A major thought piece in today’s New England Journal of Medicine looks at the global supply of healthcare professionals. The review article is by two of the very grand figures in global heath: Lord Nigel Crisp (former head of the UK National Health Service and current senior adviser on health and development to the UK government) and Lincoln Chen (former vice-president of the Rockefeller Foundation, chair of CARE and current President of the China Medical Board — another philanthropic legacy of John D Rockefeller).

You would expect a piece from great thinkers in the world’s leading medical journal to be measured and careful. It is but it is surprisingly blunt on a few points.

Chen and Crisp say that around the world, many doctors refuse to work where they are needed most and instead focus on the affluent and worried well. “Remote rural and poor populations are often not able to attract or retain health professionals … The obverse of this rural neglect is excessive urban concentrations of health professionals, which can generate other problems, such as unnecessary, wasteful, and costly medical procedures.” This is almost as true in the United States (think of the Appalachians versus Manhattan) as it is in India (rural Bihar versus Mumbai). Maybe we shouldn’t blame the doctors but we also should be careful of accepting the special pleading by trade bodies such as the British Medical Association which often argue that doctors are not just another profession seeking to extract the maximum rent possible from society.

There are shortages of healthcare professionals (doctors, nurses and midwives) everywhere and they are likely to get worse, say Chen and Crisp. “There is growing demand and competition for health workers globally … Although there is no consensus on the subject, some researchers in the United States are projecting shortages of 85,000 doctors by 2020 and 260,000 nurses by 2025 … Countries with fast-growing economies, such as India, China, Brazil, and South Africa, want more trained health workers, and critical shortages remain in the world’s poorest countries,” they write. Of course, rich countries often respond to this shortage by luring away doctors and nurses from poor countries without reimbursing any of the costs of training the professionals. The authors hint at requiring that those who enjoy years of state-subsidised schooling should have an obligation to work, at least for a while, in areas that actually need them.

Chen and Crisp have consolidated a number of suggestions on how to cope with the problems. Using workers with specific training to do many of the jobs currently reserved to doctors would help (expect continued dire warnings from the doctors’ unions over this one despite evidence that nurses and “barefoot doctors” actually do some jobs better) . Distance learning as teams of professionals might make things better too. The article is worth reading as every country needs to consider at least some of these steps.

The authors are careful to avoid a couple of trickier global trends. Most doctor visits are probably unnecessary: we know this anecdotally but we can see it starkly by looking at the variations between rich countries in the number of times a year the average person sees a doctor. The average Slovak sees a doctor four times as often as the average Swede but is certainly not four times healthier. We could divert many of these visits to cheaper pharmacists, nurses, social workers or even clergy but doctors are ruthless in protecting their privileges: why, for example, are hypertension medicines on tightly-controlled prescription regimes despite having no abuse potential and very few adverse events?

There is also a lot of evidence that many doctors around the world do not actually work very hard once they have finished their training. It is not just the frequent stories of clinics in India that allegedly employ a doctor or nurse but which are always unstaffed. An excellent 2006 paper in the Journal of Economic Perspectives reports that “enumerators made unannounced visits to … health clinics in Bangladesh, Ecuador, India, Indonesia, Peru and Uganda and recorded whether they found .. health workers in the facilities. Averaging across the countries about … 35 percent of health workers were absent.” At Hyderus, we have been asking UK sales professionals working for pharma companies to estimate how many hours they think the average GP works a day. Remember that these are people whose jobs involve knowing when to visit doctors at work. It is far from a structured study but the rough average estimate is about six hours a day. British GPs earn more than any other GPs in Europe.

nejm physician map