This week in our continuing series looking at the health care system in Jamaica, we will look at human resources in Jamaica, particularly in the light of current manpower shortages and continuing recruitment from more advanced economies.

Issues of human capital have been an ongoing problem in the Jamaican health care environment for several decades. Despite the fact that we have been able to train personnel for most of our local health care needs, the public and private health care systems are often critically short staffed in many areas.

The deficits can be seen in the ratio of physicians and nurses to the population. World Health Organization (WHO) numbers from 2018 find that Jamaica has 0.807 nurses and midwives per 1,000 population. This compares with 17.6 nurses and midwives per 1000 population in the United States and an average of 14.6 nurses and midwives per 1,000 in other developed countries.

When looking at physician numbers the situation is not as dire with 1.31 physicians per 1,000 population in Jamaica, compared to 2.6 physicians per 1,000 population in the United States and 2.9 physicians per 1,000 population in the United Kingdom. It is important to note that these numbers are per thousand population and do not consider the deficits in specialised nurses and physicians, for example, nurses who work in intensive care, midwifery and operating theatres or specialist physicians who have advanced training in areas such as infectious disease, rheumatology, radiation oncology, advanced cardiac imaging, advanced heart failure management or plastic/reconstructive surgery.

Why do we still have severe health worker shortages in Jamaica?

Given the fact that we have a long history of training physicians and nurses locally, what accounts for the shortages that we experience? The simple answer is that of migration of large numbers of our health care personnel and inability to retain foreign health care workers due to lack of enabling environment and burdensome bureaucracy. A study from 2016 estimated that 50 per cent of physicians who had graduated since 1991 have left Jamaica. For nurses, the authors found that two out of three nurses that had been trained in Jamaica had also left the country. This is not a problem unique to Jamaica but is seen in most low- and middle-income developing country but particularly acute in Jamaica. Unfortunately, addressing the issue of nursing and physician migration does not have an easy solution. The factors underlying this migration are complex and exert a strong pull on our educated population overall.

Developed countries in general are experiencing an increasing need for health care personnel, particularly nurses but also physicians. For example, The Economist reports that that National Health Service in the United Kingdom entered the novel coronavirus epidemic with 40,000 nursing vacancies and estimates that within a decade the number of vacancies could reach 100,000.

In the United States the Bureau of Labor Statistics estimates the need for an additional 1.1 million new nurses by 2022 to avoid nursing shortages secondary to increasing need and nursing retirement.

Global health care workforce demand and impact on local health care delivery

Developed countries are currently unable to meet the increasing needs from training within their borders and as such have turned to overseas recruitment. The health care needs of developed countries have large impact on the workforce of low- and middle-income economies, as most cannot produce physicians and nurses in quantities that would allow for significant migration while ensuring adequate numbers remain to provide health care at home. Notable exceptions include the Philippines and India who have taken the innovative approach of developing nursing schools with a view to export the talent of nurses.

In the face of this global demand for health care workers, what are the additional local factors that lead our nurses and physicians to emigrate? Probably the most important is economic — nurses and physicians can command significantly higher salaries in developed countries. Unfortunately for most low- and middle-income countries such as Jamaica, we are not able to compete on purely monetary terms.

There are, however, other factors which push health care workers to emigrate. These include working conditions. One cascading effect of emigration is the fact that this results in those who remain having increased workloads both in terms of patients to be seen but also increased frequency of call and need for overtime work. Nursing shortages result in higher patient-to-nurse ratios in Intensive care units and medical/surgical floors. Over time, this results in great difficulty in providing or maintaining optimal or even adequate levels of care and increasing frustrations among health care providers and decreasing the quality of care patients receive.

Other issues include inadequate infrastructure, equipment, and shortages of medical disposables. An important factor for physicians is that of professional advancement with positions in the public sector being difficult to acquire, particularly at the consultant and senior registrar levels. More recently there have been issues in terms of placing interns after graduation from medical school. Other factors encouraging emigration include the availability of continuing medical education, issues of crime and violence and family reunification.

How do we mitigate health care worker migrations?

In the face of these issues, what can we do to try to limit our health care workers from migrating? It is unlikely that in the near term we will be able to offer salaries in the public sector that will be able to compete with those offered in more developed countries.

We can, however, try to ensure that the compensation that is offered allows an adequate standard of living, realising that given current budgetary constraints even this may be challenging. Paying attention to infrastructure needs and trying to improve as best as we can; working conditions within our hospitals and clinics is not only a question of financial resources.

We should look at developing innovative systems and approaches and try to improve efficiencies in health care delivery. Other countries have had success in creating cadres of allied health care professionals who can do some of the lower skilled nursing and physician tasks allowing physicians and nurses to focus on work that uniquely requires their talents. At a societal level solving the vexing problem of crime and violence and creating a Jamaica that we would be happy to raise our children in.

Some low- and middle-income countries have taken the approach of recruiting nurses and physicians from other underdeveloped countries. In Jamaica, we have had nurses and physicians from Cuba, India, Southeast Asia, and the African continent. They have played a valuable role in supplementing our workforce, sometimes in niche areas.

We, however, do need to streamline these processes to make them more efficient and more welcoming if we are to be competitive with developed countries with obvious comparative advantages. A comparison can be made between nursing recruitment in the United Kingdom and Jamaica. Currently, given the nursing needs in the United Kingdom, visa processing with a work permit approval can be completed in five days. Visa processing fees have been reduced and the passing English proficiency score needed for work permit approval has been lowered. The effect of this is to maximise the influx of foreign nurses at a time of great need.

This new policy in UK was necessitated by their perceived nursing shortages and projected impact on their ability to deliver adequate health care for their citizens and residents. The impact has been devastating on low- and middle-income countries that have failed to adjust their policies to respond to a global health care workforce shortage.

In the past month alone, Jamaica has lost dozens of expatriate nurses working here in highly specialised areas where we do not have adequate local capacity to fill. This is a case of a country like the UK adjusting its policies and doing what it needed to do in its best interest to preserve the health and lives of their citizens. Contrast this with Jamaica. Despite our severe shortages in critical areas of nursing, in Jamaica it can take six months each for nursing registration and for approval of a work permit.

Visa application fees have recently been increased. We do not in any way suggest that we should employ unqualified candidates. We believe, however, that it is in our national interest to significantly improve the efficiency of the credentialing and licensing process and issuance of work permits for qualified and eligible health care workers to be competitive in the global marketplace. Failure to do so puts the lives of Jamaicans at risk.

Another approach to consider would be that of increasing the number of health care workers that we train (particularly nurses) realising that many will still seek work in more developed economies. This approach has been tried in the Philippines and India. We should also encourage the development of more private medical schools in Jamaica, not impede the process. This will help in increasing the physician workforce.

We have advantages of a native English-speaking population and a reputation for well-trained nurses and physicians. It may be possible to reach arrangements with more developed countries for financial compensation for recruitment or more flexibility in working arrangements that would allow part-time work in Jamaica.

Unfortunately, it is likely that issues of manpower shortage in health care will continue to be an issue in the years ahead, unless we tackle the identified friction points. As a nation we must understand that we are competing in a global marketplace and so must do what we must do in our national interest to maintain and improve sustainable high-quality health care for Jamaicans at home.

Dr Ernest Madu, MD, FACC and Dr Paul Edwards, MD, FACC are Consultant Cardiologists at Heart Institute of the Caribbean (HIC) and HIC Heart Hospital

Dr Madu is a main TED Speaker whose TED talk has been translated into 19 languages, seen, and shared by more than 500,000 viewers. He has received the Distinguished Cardiologist Award, the highest award from the American College of Cardiology and has been named among the 100 most influential people in health care and among the 30 most influential in public health. Dr Madu is also a recipient of the Global Health Champion Award from the University of Pennsylvania.

Correspondence to info@caribbeanheart.com or call 876-906-2107