The report, "Human Resources for Health: Overcoming the Crisis," was sponsored by the Rockefeller Foundation, in partnership with the World Bank and the World Health Organization, with donors including the Bill & Melinda Gates Foundation, Swedish Sida and Atlantic Philanthropies. The study was conducted under the auspices of the Joint Learning Initiative (JLI). More than 100 global health leaders worldwide, coordinated through Harvard University, spent two years documenting health worker patterns and developing viable solutions.

21st C. Global Health at Stake

"At stake is nothing less than the course of global health and development in the 21st century," warns Lincoln C. Chen, MD, JLI co-chair and director of the Global Equity Initiative at Harvard University.

The equivalent of one million new health workers -- triple the current number -- are needed immediately in sub-Saharan Africa to boost collapsing health systems. Climbing rates of HIV, TB, malaria and other pathogens are highest in this region, while the density of health workers is the lowest.

Exacerbating the lean numbers are what the report terms "fatal flows," the so-called brain drain of medical professionals from poor countries to wealthy ones, and from rural to urban regions. For example, there are more Malawian doctors in Manchester, UK, than in Malawi. And a scant 50 of the 600 doctors trained in Zambia remain in that country.

In wealthy nations, foreign-trained doctors often constitute a third of working doctors. Meanwhile, even in developing countries with reasonable health worker populations, rural and urban slum communities are often left without the health care they need.

Incentives to Leave

Health workers are lured by the exponentially greater salaries and safer working conditions in richer countries or urban areas. "I have always wanted to go abroad. I am looking forward to a new life out there," said Melanie D'sa, a nurse from Bangalore, India. "We will be paid $30 an hour in the US. Here the average salary for nurses is about 6,000 rupees ($120) a month."

The JLI's recommendation to scale up the global health work force by at least 4 million refers to community health workers as well as doctors, nurses and midwives. These auxiliary workers are vital, making up 75 percent of the global health sector. They substitute for university trained professionals, and along with family members, make up the bulk of frontline health workers in poor countries.

In Uganda, there is currently 1 nurse or midwife per 11,365 people, while Liberia and Haiti have 1 per 10,000 people. The whole continent of Africa graduates a mere 5,000 doctors a year. JLI suggests a standard of at least 2.5 health providers for every 1,000 population.

Feet to the Fire

Long-term strategies to boost and balance the health work force include a call for countries to draft national plans where health human resources are prioritized.

Additionally, donor countries and organizations should coordinate efforts to earmark $400 million annually to help countries develop strategies and capacities for education, retention and recruitment of their health work force. This represents 10% of the estimated $4 billion in aid that is devoted to human resources in health. Even rich countries need to become self-sufficient in their health workforce, ending unethical recruitment from low-income nations.

JLI also recommends the creation of an Action Alliance, a short-term international body launched to bring together health care and human resource experts, to advocate for the importance of sustained attention to workforce issues and to hold responsible actors' feet to the fire.

"While resources like money and drugs become increasingly available, these inputs will be wasted without a motivated, skilled, and supported workforce," said Chen. "The lack of health workers poses perhaps the greatest threat to the achievement of the Millennium Development Goals for health by 2015."