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Roselyne Sachiti

Features Editor

Primary healthcare is the cornerstone of universal health coverage in any country. Globally, health workers like nurses provide patient care, quality control, coordination, problem solving, education and being an agent of connectivity.

With the world battling the 2019 novel coronavirus disease (Covid-19), nurses are among health workers at the forefront.

Risking their lives, working under extremely anxious moments as they attend to Covid-19 cases, women and men in the nursing profession continue to do their jobs without hesitation.

According to the World Health Organisation (WHO), nurses account for more than half of all the world’s health workers, yet there is an urgent shortage worldwide.

Over 5,9 million more nurses are still needed, especially in low and middle-income countries.

“The Covid-19 pandemic is a stark reminder of the vital role nurses play. Without nurses and other health workers, we will not win the battle against outbreaks, we will not achieve the Sustainable Development Goals or universal health coverage,” said WHO recently.

WHO encouraged countries to ensure the occupational safety and health of nurses and all health workers, including notably, unhindered access to personal protective equipment so they can safely provide care and reduce infections in health care settings.

Governments, WHO said, should make sure that nurses and all health care workers have access to mental health support, timely pay, sick leave and insurance; as well as access to the most up-to-date knowledge and guidance required to respond to all health needs, including outbreaks.

Furthermore, it urged countries to ensure that nurses were given the financial support and other resources required to help respond to and control Covid-19 and future outbreaks.

In April, WHO and its partners, the International Council of Nurses and the global Nursing Now campaign, and with the support of governments and wider partners launched the first ever State of the Worlds’ Nursing Report.

The report provides a snapshot of the global nursing workforce, as well as highlights the scale of the challenge they face and provides feasible policies for governments to invest in nursing so that Health for All can become a reality.

For the first time in WHO history, data on the nursing workforce for over 190 countries based on a set of standardised indicators and one data reporting process, following the National Health Workforce Accounts (NHWA) approach.

Data for 30 indicators including availability, composition, distribution, education and training, skills, management, regulation, financing, and leadership of the nursing workforce were collected and analysed.

The data collection efforts included various stakeholders.

The report looked at the nursing workforce availability, composition and distribution with data for 191 countries indicating a global stock of almost 28 million nursing personnel, comprising both the public and private sectors.

Data from 191 countries indicate a global nursing stock of approximately 28 million in 2018, predominantly (69 percent) professional nurses.

There was a 4,7 million actual increase globally in nursing stock between 2013 and 2018, even after accounting for better availability and quality of data, the report points out.

Professional and associate professional nurses represent approximately 59 percent of health professionals (medical doctors, nursing personnel, midwifery personnel, dentists, pharmacists) in 172 countries with available data.

The report states that nine out of 10 nurses globally are female, with important regional variations: in the African Region the female–male ratio is 3:1. Male nurses outnumber females in 13 countries.

There are also large variations in distribution within regions. In the region of the Americas, more than eight out of 10 nurses work in three countries (Brazil, Canada and the United States), which host 57 percent of the population.

In the African and Eastern Mediterranean regions, the nurse density per population varies 100-fold across countries, according to the report.

One out of six of the world’s nurses are expected to retire in the next 10 years; this percentage is substantially higher in the Region of the Americas (24 percent), posing a further replenishment challenge.

With regards to equity in availability of and access to the nursing workforce, the report revealed that around 81 percent of the world’s nurses are found in the American, European and Western Pacific regions, which account for 51 percent of the world’s population.

In 76 countries with available data, 75 percent of nurses are employed in the public sector, with the remaining 25 percent in the private sector.

Nearly all countries reported on indicators for regulation of nursing education, and more than 50 percent of countries responded positively to each of the nine related indicators.

The existence of regulatory mechanisms and processes was reported as high in the African, American and European regions.

A total of 88 countries, mostly from South-East Asia and Europe, reported data on the number of nursing workforce graduates per year.

Regions with the lowest density of nurses (African, Eastern Mediterranean and South-East Asia regions) also had the lowest graduation rates (7.7, 7.1 and 12.2 per 100 000 population, respectively).

Relative to their population, the region of the Americas had 10 times more graduates than the African and Eastern Mediterranean regions.

Among countries reporting data, the average duration of nursing professional education in the African and Western Pacific regions was two to three years for approximately 75 percent of countries, while it was four to five years for over half of the countries in the American, South-East Asia and Eastern Mediterranean regions.

The African, American, European and Eastern Mediterranean regions reported high levels of existence of regulatory mechanisms relating to working conditions for nurses.

Some countries, mostly in the South-East Asia and Western Pacific regions, but also in the African Region and South America, reported lower levels of these regulations, says the report.

The existence of an advanced nursing role (reported by 53 percent of the 95 responding countries) is more frequent in countries with a low density of medical doctors, suggesting that more professional autonomy for nurses might be a policy response to mitigate the shortages of medical doctors.

The future development of the nursing profession requires strong nursing leadership and governance.

Of the 115 and 76 responding countries, respectively, 71 percent reported having a government chief nursing or midwifery officer position and 53 percent a nursing leadership development programme, the report adds.

The report estimated a shortage of 5,9 million nurses comparing 2018 data with benchmark values defined in the Global Strategy on Human Resources for Health; the gaps are mostly (89 percent) concentrated in low- and lower middle-income countries.

“If all countries maintain their current level of production of graduate nurses, the nurse headcount is projected to increase from nearly 28 million in 2018 to approximately 36 million in 2030; 70 percent of this projected increase, however, is expected to occur in upper middle and high-income countries and not where gaps are greatest,” reads the report.

Taking into account projected population growth and the ageing of the nursing workforce, the African, South-East Asia and Eastern Mediterranean regions are projected to remain in 2030 with a density below 25 nurses per 10 000 population.

Density in the African region is projected to improve only marginally.

Addressing the shortage of nursing personnel in low-density countries would require an average increase in the number of yearly graduates of 8.8 percent from 2018 to 2030 (range: 0.2–13.4 percent), and improving absorption capacity to at least 70 percent, according to the findings.

Scaling up education of nurses to address gaps may cost approximately US$10 per capita for the period 2018–2030 in affected low- and lower middle-income countries.

The report further spells out the pivotal role played by nurses as part of teams managing epidemics that threaten health across the globe, including severe acute respiratory syndrome (SARS) in 2003, the Middle East respiratory coronavirus (MERS-CoV) outbreak in 2015, Zika virus disease in 2016, Ebola virus disease in 2014 and the COVID-19 outbreak that began in 2019.

Through the WHO Emergency Medical Teams Initiative, the report adds, nurses and other health workers are trained to better support their own countries’ capacity to respond to future disaster and emergency situations.

The report also found out that a growing number of governments in eastern and southern Africa are investing in a specialist nurse role for children’s health as part of strategies to reduce child mortality.

There are approximately 3 650 registered children’s nurses in the ESAR region, including approximately 750 in Kenya, Malawi, Uganda and Zambia, and 2900 in South Africa.

The 12 different educational programmes (the majority in South Africa) graduate around 205 children’s nurse specialists annually.

Three more programmes in Botswana, United Republic of Tanzania and Zimbabwe are in development, the report reveals.

As nurses work on the front lines, we should celebrate their heroic efforts to fight the COVID-19 crisis.

[email protected], [email protected], @RoselyneSachiti