A well built health system is essential. Health workers are the definitive resource achieves such health system (WB, 1993a; Anand and Bärnighausen, 2004). Higher worker density and better work quality, joining other social determinants of health, improve population-based health and human survival (Navarro and Shi, 2001). Physicians and nurses density in particular has been found to correlate significantly with lower mortality rates and higher life expectancy (El-Jardali et al., 2007). Consequently, the density of health workers can make an enormous difference in achieving the Millennium Development Goals (WHO, 2004).
At the global level, the most critical issue facing healthcare systems is the shortage of the workforce (WHO, 2003). The World Health Organization (WHO) estimates the current health workforce at 59 million and its global shortage at 4.3 million, with a critical shortage in 57 countries worldwide (WHO, 2006a; Anyangwe and Mtonga, 2007). Challenges with respect to human resources vary greatly between and within countries and are associated with the political, economical and social perspectives of a country. Conspicuously, the gaps in the workforce do not generally relate to doctors but to nurses and other classes of health workers. Nowadays, as a result of globalization, doctors and nurses are increasingly on the move within their countries, within regions, and across the international labour market. The health workforce migration is caused by the absence of remunerative and professionally rewarding work opportunities in low income countries and a growing demand for skilled workers in high income countries due to aging population and increase of the chronic diseases prevalence (Pruitt and Epping-Jordan, 2005). This migration is of growing concern worldwide because of its impact on health systems in developing countries and developed countries alike. It is estimated that more than 20% of physicians working in Australia, Canada and the US come from other countries (Diallo, 2004). Health workforce migration affects service provision, care quality and staff distribution across administrative units and countries. The serious issue of global maldistribution of health workers reflects inequities that are even more marked than inequities in health status (Anyangwe and Mtonga, 2007). The difficulties caused by low staff numbers are compounded by morale problems, skill imbalances, geographical maldistribution, poor work environment and weak knowledge base, most of which are related to poor human resource management (Dussault and Dubois, 2003; Chen et al., 2004; Wyss, 2004). Furthermore, the present practice of physicians/nurses is taking place within a context of globalization, heightened public demand and expectation for better healthcare services, advanced research and technology, rising healthcare costs and limited financial resources. Therefore, developments of strategies to meet current and future challenges in human resources are urgently needed.
The WHO Report 2006 launched the Health Workforce Decade (2006–2015), with high priority given for countries to develop effective workforce strategies that include three core elements: improving recruitment, helping the existing workforce perform better and slowing down the rate at which workers leave the health workforce. The report emphasized human resources management and planning as major strategic priorities for goals achievement (WHO, 2006a).
This paper will discuss the supply of health professionals (physicians and nurses) in the UAE, stopping at how the physicians'/nurses' supply is challenged by demographic transition, aging population, growing shortages, poor recruitment and retention strategies, including out migration of health professionals, low salaries, limited education and training capacities, skill-mix imbalance, maldistribution, poor human resources planning, absence of a reliable database, poorly informed policy decisions and slow health system reform (El-Haddad, 2006; EMRO, 2006).
The UAE has undergone a profound transformation from an impoverished region of small desert principalities to a modern state with a high standard of living (Codrai, 1990; EMRO, 2006). Therefore, the UAE health system is currently operating within an environment of rapid social, economical and technological change. Health system is also under continuous scrutiny by planners and purchasers. The UAE consumer expectations have grown proportionately with the rising wealth of the population, resulting in strong societal pressure to adopt policies that satisfy heightened consumer expectations (Margolis et al., 2003). Hence, for the UAE Ministry of Health (MOH) to achieve the overall goals of good health, it is important to identify the critical health challenges facing health development.
Demographic trend and aging-population challenge
The huge expansion and the progressive aging of the UAE population is a crucial challenge to the health system stewardship. The demographic trends within the country are driven primarily by the emirates' reliance on foreigners to provide the workforce for their growing economy (EMRO, 2006; WHO, 2006b). The population of the UAE was only 180 000 people in 1968. Over 27 years, the population increased by 13-fold; 1.4 million by 1986 (Kronfol, 1999). Since then, the total population grew at an average annual rate of 10% to just over 8 million by 2010 with local nationals making up around 20% of the population (UAE-National.statistics, n.d.). Recent United Nation estimates suggest that the population could double by 2029. Furthermore, the improvement in the health status resulted in increase of life expectancy to an average of 77 years and to a decrease in leading cause of death from infectious diseases to a mortality picture that resembles the industrialized country patterns, with a predominance of cardiovascular-related deaths (Bener et al., 1993; Kronfol, 1999; WB, 2012). Additionally, cardiovascular diseases and other non-communicable diseases, notably, cancers, diabetes and accidents, have been the leading causes of morbidity. Therefore, the UAE demographic and epidemiological transition calls for more physicians/nurses workforce to cope with the expansion/aging population and with the increasing chronic diseases comorbidity (Qutub, 1983).
Despite the fact that a remarkable increase took place in the number of workers in the MOH, there is still a shortage in availability of trained physicians/nurses, especially local professionals. Additionally, health facilities in the UAE have high turnover rates and retention problem (EMRO, 2006). In numbers, 82% of the total health workers are expatriates. The physicians account for 20% of the total health workforce. The nationals constitute 19% of total physicians and 8% of nurses (MOH, 2012). The number of medical doctors reached 2304 in the public sector, with an average of 1 doctor for every 1629 people and 1 nurse for every 650 people (EMRO, 2006).
Numerous factors work together in exacerbating the shortage problem; the country does not have bilateral agreements for recruitment of foreign trained health workers, a sizeable proportion of national personnel working in the health field are engaged in administrative duties even if they are qualified as a physicians or nurses, employment is difficult, and the official rules and regulations are lengthy even when a vacancy is available (El-Haddad, 2006; EMRO, 2006). Moreover, the local physicians typically migrate overseas (mainly to Canada, US and UK) to complete speciality training, but some choose to remain in their destination country or take more than needed time to return back to the UAE (WHO, 2008a). Nurses migration has reached substantial rates of one of every five nursing migrating on annual rate (WHO, 2008a). The high turnover rate of expatriate nurses occurs as a result of unfavourable UAE immigration policies. Consequently, nurses move to countries with better immigration policies.
Moreover, although it has been widely acknowledged that there are more Emirati women in higher education than there are men, with female to male ration for enrolment in tertiary education 3.16 (World-Economic-forum, 2012), the female to male participation in the workforce remains low. Female to male ration is 0.46 for labour workforce participation, 0.11 for legislators, senior officials and managers, and 0.28 for professional and technical workers (World-Economic-forum, 2012). Among the medical profession, women (both local and foreigners) constitute 43% of total physicians and 85% of total nurses (MOH, 2012). Recent published estimate of total number of local female physicians is 15%, which not much different than the proportion they occupy among the nursing profession (8%) (MOH, 2012). It has been claimed that the struggle by nurses in the UAE to achieve professional status is complicated by the dependent role of women and their low status in the society (El-Haddad, 2006). Hence, this leads to the region's dependence on a foreign nursing workforce (92% out of total nurses in the UAE) (MOH, 2012). Moreover, the prosperous lifestyle of UAE nationals, the sociocultural norms and religious values are barriers to retaining indigenous nurses in the nursing profession because of the embarrassment caused by working with other male healthcare professionals (which conflicts with the gender-separation policy of Arab/Islamic cultures) or undertaking nightshift duties (El-Haddad, 2006). Furthermore, culturally, nurses are considered maids for patients and assistants for physicians (Al-Jarallah et al., 2009).
The limited number of native physicians/nurses raises the concern as to whether language barriers, religion and sociocultural differences between the majority expatriates who come from diverse educational and cultural backgrounds, and their patients would affect the quality of health care (Al-Jarallah et al., 2009). It has been demonstrated that health conceptions of healthcare professionals that differ substantially from the cultural groups they serve often lead to confusion, conflicting health promotion goals and low adherence to treatment regimes (Daly, 1994). Expatriate healthcare providers most often impose their own cultural values on their clients (El-Haddad, 2006). According to Daly et al, expatriate healthcare professionals impose their own values and provide ‘ethnocentric health care’. Furthermore, clients experiencing health care, which is incongruent with their own values, norms and customs, may not comply fully with their recommended treatment protocols and may experience cultural conflict, stress and ethical or moral dilemmas (Daly, 1994).
Other major factors that challenge physicians/nurses are the limited education and training capacities and the low salaries. Lack of financial and non-financial incentives were identified as key elements to address to improve health workforce recruitment and retention (WHO, 2008a). In their review of human resources management in health services, Martinez et al. pointed out the reality for many health workers in developing countries is to be ‘underpaid, poorly motivated and increasingly dissatisfied’ (Martinez and Martineau, 1998). In the UAE, despite good individual outcomes in general, the physicians'/nurses' salaries are relatively low compared with other jobs, even if it is compared with the lowest professions and to those with fewer qualifications. For example, a salary of a police/military services personnel with a primary education can be as high as a physician's salary and by far better than any nurse's outcome. Youniese et al. looked at the preferred rewards the UAE physicians would want to achieve; result shows that the monetary rewards rank high as a first priority (Younies et al., 2008). Additionally, it has been reported that the reward and incentive system is the most important for recruiting and retaining health workers in the UAE and that the rewards need to be advertised in advance of any programme implementation (McLean and Van Wyk, 2006). Furthermore, health workers suffer from heavy workloads and excess overtime duties, with no extra hour subsidies (El-Haddad, 2006). Extra hours work with low payment (relatively) resulted in a daunting task facing health system managers to motivate the health employees. This necessitates the need to review the compensation programmes available for the health employees.
Moreover, the rapid advances in medicine and technology is changing the mixture of skills required to respond to current and emerging health needs (Allegrante et al., 2001). Additionally, matching the skill mix of health workers with the needs of diverse populations is a key requirement of successful health education and training (EMRO, 2006). Yet the education cycle of preparation for health workers is long, and response to loss of human capital from the health workforce is not usually fast or flexible (Stilwell et al., 2003). In the UAE, medical training is recent but lacks the necessary funds; the career development activities are uncoordinated, and there is no systematic performance appraisal (el Matri, 1990). Although the number of national nurses graduated (from five nursing institutes across the country) increased from 32 national nurses in 1989 to 207 in 2006 and a medical school graduates (from two medical schools across the country) reached 114 physicians in 2007 (EMRO, 2006). The continuing education programmes are episodic and often unplanned. The quality of care offered by the physicians and nurses is thus bound to deteriorate with time. Hence, the morale sags as well. This climate does not encourage the recruitment of much needed professionals who are concerned with maintaining their professional growth and updating their skills and knowledge. Stilwell et al. reported that among the reasons for increased professional migration is a convergence towards international standards of education and skills acquisition (Stilwell et al., 2003). In the UAE, the opportunity to receive training and education was of great importance to the physicians, and it came after the material rewards as the highest priority (Younies et al., 2008). Among nurses, it has been found that contributing factors related to high migration and less involvement in nursing profession are the variations in basic nursing programmes and the lack of educational resources in Arabic. Although the official language of hospitals is English, many nurses have a poor command of the language. Therefore, lack of educational resources in the national language and lack of standardization of nursing programmes continue to compromise the quality of nursing education (Tumulty, 2001).
Maldistribution and skill mix imbalance
The geographic maldistribution between urban and rural areas and the imbalance in the number of different categories of professionals represent another dimension of the problem. The enumerated professionals are severely maldistributed between regions. The UAE cities generally have higher physician–population ratio than rural areas (Bener et al., 1993). The maldistribution is worsened by unplanned migration of the expatriate physicians/nurses. Improving within country equity requires attracting and retaining health workers to rural and marginal communities (Younies et al., 2008). Additionally, there is a discrepancy between nursing education and community needs for service. The hospital population, which represents the smallest proportion of the populace, receives the highest proportion of the nursing service, whereas rural communities, health centres and health posts receive the smallest proportion of services (WHO, 2008b). Furthermore, nearly all the emirates have skill imbalances, which create huge inefficiencies. In some, the skill mix depends too much on specialists. In most, population-based public health is neglected (EMRO, 2006). The estimates show that specialists increased from about 31% of total physicians in 1990 to 41% in 2012, which shows the inclination towards appointment of specialists at the expense of family physicians (MOH, 2012). Department of planning revealed that while some specialties suffer from oversupply of doctors/specialist, others hardly have a handful number (MOH, 2005). Losing part of the professional mix in the health workforce may result in either an absence of some services or in professionals having to adapt their roles to deliver services commonly outside their scope of practice (Stilwell et al., 2003).
Absence of a reliable database
The development of structured quality assurance programmes and ongoing evaluation of health outcomes has lagged behind, leaving limited information for decision making by policy makers (Kronfol, 1999; Margolis et al., 2003). Most data categorize the workforce as a homogeneous group and are silent on key attributes, such as quality and sex, geographical distribution and types of skills (Kronfol, 1999; Egger et al., 2000; WHO, 2002a; MOH, 2005; EMRO, 2006). This weak knowledge based on the health workforce hampers planning, policy development and programmes operation.
Attention to human resources
Human resource management do not compete well for policy attention with macro-economic issues in the Arabic world (Makhoul and El-Barbir, 2006). As a result, human resources rank low on the health policy agenda. Health workforce have been particularly neglected and adversely affected by severe underinvestment. Moreover, reform of the health sector has not fully addressed the necessary human infrastructure, and the fiscal discipline depends on restriction of staff numbers; with staff salaries now consuming 60–80% of the health sector's budget (Salvatore et al., 2000; Rigoli and Dussault, 2003).
Driven by financial limitations, workforce planning has been unable to match staff requirements, the needs of the population and the health system as a whole (Martinez and Martineau, 1998). The qualities of the work environment are deteriorating, and educational and training institutions are starved of funds (El-Haddad, 2006). Moreover, globalization has resulted in an increase in movement of internationally competitive professionals, among whom nurses and doctors rank high, which resulted in supply–demand imbalance (ILO, 1999). Additionally, a major focus of recent studies is the effect of various human resource policies on the success or failure of health systems (Hammer and Jack, 2001). Analyses of how to improve personnel management practices in bureaucratic public systems have rarely included the health sector workforce (WB, 1993b).
Therefore, management of human resources should no longer be viewed as a simple matter of workforce planning or expanding professional education. New factors have fundamentally altered the scene and, correspondingly, demand new strategies for their implementation. In approaching the challenges to human resources, consideration should be given to at least three aspects of workforce development—supply, demand and mobility, and should be directed at the promotion of equity in health and health care. Traditional approaches to human resources are mostly supply-oriented; they focus on the production of appropriately trained workers. Training capacity, however, is poor in the UAE, as have been mentioned earlier. Moreover, the precise nature of the problem is difficult to ascertain because data on physicians/nurses come mostly from unreliable administrative statistics, and little information is available on key categories of health personnel.
Approaches that focus on the training of individuals, which do not take into account the work environment and worker mobility, can have only limited success (Smith, 2006). Increase production alone cannot compensate for weak motivation, high attrition and increasing mobility. Therefore, the health care system needs to be conceptualized in a way that illuminates its relation with the political, economic and social environment. Hence, some of the solutions should be derived from outside the health sector (Navarro and Shi, 2001; Moeller and Sonntag, 2002). Although governments are the power points for workforce development because they set policies, secure financing, support education and operate the public sector while regulating the private sector (WHO, 2000; WHO, 2004). Others such as finance, health and education ministries, academic leaders, professional associations and educational institutions—all having different aims, capabilities and interests—must be involved in setting national goals, designing strategies, drawing up plans and implementing policies and programmes.
MOH should develop a national workforce strategic plan to guide investments in human resources as the core component of strengthening national health systems. Moreover, national health and finance policy makers must work together to ensure a fiscal environment that enables workforce development. The attention should be given to the physicians/nurses shortage and to the high turnover rate and retention problem. Hence, there is a need to develop strategies to mobilize, retain and train national health workers and support the recruitment and retention of the expatriate professionals (WHO, 2008a). The attention to the shortage/high turnover problem should be occurring in parallel with more equitable geographical distribution and more balanced skill mix. Additionally, recruitment and placement policies should aim to ensure the acceptability and accessibility of health workers, especially in terms of gender, language and ethnic compatibility (Fleet et al., 2008). Furthermore, to guide the training of a sufficient pool of health workers with appropriate skills mix, the plan needs to focus on optimizing public and private investments in education and training, and on managing labour market. To achieve the education/training target, educational medical/nursing bodies should increase the annual intake of indigenous students without compromising the study quality. Access for local and international education and training programmes should be increased, and opportunities for promotion and career development should be enhanced. Likewise, the MOH and the Ministry of Higher Education should launch public education programmes through mass media to educate the community regarding the essential role played by nurses and female physicians in the healthcare system. The women work in health profession should earn its due respect. This may help in minimizing the negative perception of nursing (and to some extent female physicians) and increase the number of Emirati who wish to enter the health profession. In addition, further research needs to be undertaken to address issues related to the working conditions of physicians/nurses in the UAE and their relationship to recruitment and retention. Research is also required to explore further the factors contributing to the small number of nationals in the healthcare profession. The UAE should be self-reliant with respect to the supply of physicians/nurses. It is important to increase the proportion of indigenous health worker so that culturally appropriate healthcare can be delivered (Aldossary et al., 2008). Furthermore, the MOH and other health employers should give further attention to improving the working conditions and retention via improvement of salaries, benefits and overtime, and reducing the workload. It has been reported that improvement in pay and conditions act as incentives to health workers to stay in their country (Van Lerberghe et al., 2002). Improved pensions, childcare, educational opportunities and recognition are also known to be important (Van Lerberghe et al., 2002). Finally, the effective action needs solid information, reliable analyses and a firm knowledge base. The UAE should strengthen its national data, information and analysis. All workers should be counted, and their social attributes and work functions should be collated to improve planning, policy and programmes implementations.
In conclusion, the performance of healthcare systems is closely related to the numbers, distribution, knowledge, skills and motivation of its workforce, particularly of those individuals delivering the services (WHO, 2002b). The UAE health system is challenged by physicians/nurses shortage, especially the national personnel, high turnover rate and retention problem, skill-mix imbalance, maldistribution, negative work environment, weak knowledge base and inadequate investment in human resources. Therefore, health workforce development is a long-term challenge for the UAE health system stewardship, needing years of steady investment but yielding high and sustained returns. Decision makers should begin now, first by recognizing the problem and second by fixing it through the immediate implementation of potentially effective strategies that includes strengthening the organization of health services, health financing, health resources and health education.