Labour Research May 2020


Crisis sharpened by global nursing shortage

In this, the International Year of the Nurse and Midwife, the coronavirus crisis has highlighted the importance of union campaigns to end the worldwide shortage of nurses.

Last month, the PSI global public services union federation, the largest international organisation representing all categories of nurses, welcomed a new World Health Organisation (WHO) report, The state of the world’s nursing 2020.

This revealed a global shortage of almost six million nurses. This report is significant, according to PSI health and social services officer Baba Aye, because it is the first time such a report has been published. The study is based on responses from 191 WHO member states.

It sets out that there are just under 28 million nurses worldwide and they account for more than half of all the world’s health workers. Although nursing numbers increased between 2013 and 2018, this still leaves a global shortfall of 5.9 million.

The report also shows that more than 80% of the world’s nurses work in countries that are home to half the world’s population, and one in every eight nurses practices in a country other than the one in which they were born or trained.

Many high-income countries, it says, “appear to have an excessive reliance on international nursing mobility due to low numbers of graduate nurses or existing shortages vis-à-vis the number of nursing jobs available and the ability to employ new graduate nurses in their health system”.

Ageing also threatens the nursing workforce, the WHO reports, with one in six nurses expected to retire over the next 10 years.

To address the shortage in all countries by 2030, the total number of nurse graduates would need to increase by 8% per year on average, alongside improved capacity to employ and retain these graduates. This would cost just 10 US dollars per head of population per year, according to the WHO.

The biggest gaps revealed by the report are in countries in Africa, South East Asia and the Eastern Mediterranean region — this includes Cyprus, Iran, Pakistan and Egypt — as well as some parts of Latin America.


But according to Luca Scarpiello, secretary for healthcare at the EPSU European public services union federation, an extra million health workers, including nurses, are also needed in Europe. EPSU has been calling for a coordinated effort to recruit healthcare workers right across Europe, from the Nordic countries including Sweden, down to Italy, Greece and Spain. This is critically important in the context of the current coronavirus crisis.

“The situation is not the same across Europe, but the key message is that the challenges in responding to the outbreak are the results of financial restraint and austerity cuts right across Europe,” he told Labour Research.

“The capacity of healthcare systems to cope with the outbreak has been undermined everywhere.”

In Italy, for example, which was the epicentre in Europe in the early weeks of the crisis, there were 900 intensive care beds for every 10,000 inhabitants in 1983. Today, that figure has plummeted to 279.

The reasons for the shortages of nurses and other healthcare workers, he says, include austerity and fiscal consolidation at both European level and in individual member states; the undervaluing and undermining of public healthcare systems; and increased privatisation of public healthcare.

Even in Nordic countries like Sweden and Finland, known for providing universal access to health care: “The state has been withdrawing from healthcare systems”, Scarpiello said.

Underfunding of healthcare

The trade union movement has been warning about the consequences of these developments over many years, but it has taken a pandemic for people to see how important healthcare workers are and how badly we treat them.

“Internationally, we can see that healthcare systems do not have the staff to cope with demand during this crisis as countries recruit recently-retired doctors and nurses and students,” he added.

Doctors, nurses and other healthcare workers are now working around the clock. While countries have increased the number of hospital beds, and there is additional help from these recent recruits, it remains the case that health workers are overloaded and there are high levels of stress, understaffing and fatigue.

It is the same story across many parts of the world, according to Aye. And as bad as things are now, he says the likelihood of them getting worse, particularly in the global south, is very high. Brazil, for example, is expecting a steep surge in coronavirus cases in a few weeks’ time, as is South Africa.

He says there are grossly inadequate levels of testing — even in countries like the UK. And while the lack of testing is not directly linked to the shortage of nurses, it is symptomatic of the same logic of underfunding.

“It is already clear that there could be a series of catastrophes, and inability to cope, not least because of the shortage of nurses and other healthcare workers,” he said.

“Countries have prioritised the impact on the economy over the impact on life. Likewise, putting profit before people for decades is also a major contributor as to why we have a shortage of nurses during the pandemic today.”

Healthcare is considered a fundamental human right in 110 countries who include this in their constitutions. They should not need prompting to employ enough nurses, midwives and other healthcare workers, says Aye.

However, the international financial institutions — including the World Bank and the International Monetary Fund — have put conditions on loans, particularly in the global south, but also increasingly in European countries including Greece, Portugal and Spain.

These cap the level of public sector pay and the level of public sector employment and have impacted on countries’ levels of preparedness to deal with the current crisis.

“There are not enough nurses, not enough testing, and governments have not adequately put people before profit,” he concludes.

Union demands

At both European and international level, unions have very immediate and longer-term demands in relation to the shortage of nurses, particularly in response to the current crisis.

“We are clear that part of the crisis has been down to the fact that, in particular, workforce planning has been dire,” said Scarpiello.

EPSU’s main demand, both during the crisis and for the future, is for coordinated action to increase staffing levels.

“There needs to be investment to increase the capacity of healthcare systems,” he said.

“There must be a recovery plan with funding to cope, not only with the current emergency, not just opening 10,000 intensive care wards for six months for example, but also a vision of how to run healthcare systems that really are able to cope with the challenges of the aftermath of this crisis and future crises.”

He makes clear that we must be ready for more global pandemics, the response must be coordinated, and it must include participation of the social partners — there can be no planning without worker involvement.

And governments must also address the low level of pay of healthcare workers. “Healthcare workers are risking their lives for 1500 euros a month — and they are lucky if they get that much,” he said.

“The first demand is for personal protective equipment, but workers must also be properly compensated for their efforts during this emergency.”

PSI’s Safe Workers Save Lives campaign calls for urgent action to ensure nurses and other healthcare workers have access to adequate personal protective equipment (PPE) and improved training and working conditions so they can stay healthy while saving lives.

Lack of PPE is a global problem

Like UK unions representing nurses and other healthcare workers, unions around the world are fighting for them to have proper personal protective equipment (PPE) to protect against infection from the coronavirus. Many report this is often not available.

The World Health Organization (WHO) has published and is regularly updating guidance on the Rational use of personal protective equipment for coronavirus disease (COVID-19) and considerations during severe shortages.

Guidance issued in April 2020 sets out guidance on the type of PPE used when caring for COVID-19 patients. This will vary according to the setting, type of personnel and activity and further details are provided.

The guidance covers the type of PPE that should be issued to healthcare workers involved in the direct care of patients.

Specifically, for aerosol-generating procedures and support treatments, health care workers should use respirators, eye protection, gloves and gowns; aprons should also be used if gowns are not fluid-resistant.

In early March 2020, the WHO reported that shortages are leaving doctors, nurses and other frontline workers “dangerously ill-equipped to care for COVID-19 patients”. It reported prices for PPE surging, with a six-fold increase for surgical masks. The price of N95 respirators trebled and that of gowns doubled.

It called on industry and governments to act quickly to boost supply, ease export restrictions and put measures in place to stop speculation and hoarding. Governments should develop incentives for industry to ramp up production, it added.

Meanwhile, increasing numbers of healthcare workers on the frontline of the pandemic have become infected with coronavirus and many have died.

The global union federation PSI reported that in Italy, by 19 March 2020, 2,629 health workers were infected, more than 8% of the total number (35,713) of cases in the country.

Later that month, the International Council of Nurses’ chief executive officer, Howard Catton, said it had seen reports of a figure of 12% in Spain and heard of the deaths of nurses in Indonesia and Iran, as well as Italy and Spain.

In the UK, The Guardian had recorded 56 deaths among NHS staff by 17 April 2020.

Longer term, Aye says governments must tackle structural and systemic issues and deliver on the commitments they have made.

In 2016, the United Nations (UN) High-Level Commission on Health Employment and Economic Growth, of which PSI general secretary Rosa Pavanelli was a member, issued a report calling for massive increases to health funding and the health workforce.

It made a series of recommendations, which were adopted in 2017 by the World Health Assembly, a body of the WHO, to address a predicted shortfall of 18 million health workers by 2030.

Governments across the world committed to implement the recommendations, beginning with immediate action to kick off a five-year action plan running from 2016 to 2021.

“But member states went back and forgot about the recommendations and carried on business as usual,” said Aye.

“It is critical for all member states of the WHO to implement the plan and endorse the recommendations of the UN High-Level Commission.”

Commission recommendations

The 2016 UN High-Level Commission on Health Employment and Economic Growth set out 10 recommendations to secure “an expanded, transformed, interdependent and sustainable health workforce to accelerate inclusive economic growth and to ensure healthy lives, well-being, equity and economic security for all”. These are:

• educational reform: countries must begin to establish transformational reform of health worker education and training programmes to equip them with the skills to provide community-centred public health services and person-centred, continuous and integrated clinical care;

• workforce innovation: all countries should initiate ambitious scaling up of health worker education and training to produce sufficient numbers of the full range of health workers needed;

• technological transformation: all countries must initiate programmes to enable health workers to use appropriate technologies for optimally delivering a wide range of health services and efficient and sustainable health information systems;

• health workforce for growth: particularly low- and middle-income countries must guarantee and implement strategies to employ sufficient numbers of health workers to deliver quality universal health coverage and access progressively, by better anticipating future health workforce requirements;

• prioritising women: women’s central role in providing health care must be recognised and fully rewarded and countries must invest in opportunities for increasing women’s participation in the health workforce;

• guaranteeing rights: countries must reform regulatory frameworks to secure decent jobs and labour rights for healthcare workers and non-medical workers, paying special attention to fair pay, social protection, gender equity, safe and healthy working environments, and a voice for health workers and their organisations;

• transforming aid: greater proportions of donor assistance must be invested into the health workforce while ensuring the predictability of finance;

• international migration: countries must address the push and pull factors driving the loss of skilled health workers from countries with the most serious health worker shortages, including a global mechanism to strengthen the accountability of destination and sending countries;

• humanitarian crises: the international community must establish global strategies for the deployment of health workers during war, post-conflict, natural disaster and other humanitarian or complex crises; and

• information and accountability: countries and partners should implement a data revolution for human resources for health, monitoring, tracking and reporting progress on scaling up the health workforce.

As PSI’s recent Public health once and for all statement makes clear, investing in extending the healthcare workforce will not only provide new and decent jobs and fair pay for health workers, it will also have a multiplier effect on the economy.

In the midst of this current crisis, there is real public support for healthcare workers, and Scarpiello says the challenge for unions is to turn that support into concrete action that will benefit both them and the people they care for. “It is not enough, particularly on the part of governments, to commend nurses, midwives and other healthcare workers for putting their lives at stake on the frontline of the COVID response,” said Aye.

They must make PPE available, train healthcare workers — with a sense of urgency — and help them avoid becoming burned out.

“They are people with friends and families who want to carry on living,” he added. “These gruelling circumstances are impacting on bodies and minds.”

And while they welcome people across the world coming out to clap from balconies, windows and doors to show their appreciation, “it’s not enough just to come out and clap”.

He emphasised: “We want everyone to add their voice to our demands for testing, PPE and training now to help us save lives and defeat this pandemic.

“Write to your MPs and governments and make demands. Do everything you can to add your voice to help us. Everyone has a part to play in this global response.”

WHO, The state of the world’s nursing 2020 (

UN High-Level Commission on Health Employment and Economic Growth, Final report of the expert group (

PSI, Public Health, Once and for All! - concept note (

WHO, Rational use of personal protective equipment for coronavirus disease (COVID-19) and considerations during severe shortages (

Guardian, Doctors, nurses, porters, volunteers: the UK health workers who have died from Covid-19 (