2.1 Global Health Workforce
The global health workforce, comprising doctors, nurses, dentists, and other healthcare professionals, is a critical determinant of health system performance and population health outcomes. According to The Global Strategy on Human Resources for Health: Workforce 2030 (GSHRH, 2022) highlighted a projected health workforce shortage of 18 million health workers by 2030, with the most severe shortages occurring in low- and middle-income countries (LMICs) (WHO, 2021). This gap poses significant challenges to achieving universal health coverage (UHC) and meeting the health-related Sustainable Development Goals (SDGs) (Campbell et al., 2013, Scheffler et al., 2018).
The distribution of the health workforce is highly uneven. High-income countries (HICs) generally have a higher density of healthcare workers compared to LMICs. For instance, the United States and countries in Western Europe have approximately 3-4 healthcare workers per 1,000 people, while sub-Saharan Africa has fewer than 1 healthcare worker per 1,000 people(WHO, 2021, OECD, 2020) (The Organisation for Economic Co-operation and Development). This disparity is not only a matter of numbers but also reflects differences in training, resource allocation, and healthcare infrastructure. Recent data highlight that 22% of the world’s population has access to 47% of the global health workforce, underscoring significant inequities in workforce distribution (Boniol et al., 2022).
Table1 Projected Stock of SDG3.c Health Workers by WHO Region (in millions) for 2030 by occupation
(WHO, 2017)
|
|
2013
|
2020
|
2030 (projected)
|
|
Dentists
|
0.49
|
0.26
|
0.22
|
|
Medical Doctors
|
3.05
|
2.66
|
1.94
|
|
Midwifery personnel
|
0.36
|
0.41
|
0.31
|
|
Nursing personnel
|
9.89
|
7.07
|
4.50
|
|
Pharmacists
|
0.33
|
0.29
|
0.19
|
|
Other occupations
|
6.02
|
4.69
|
3.08
|
|
Total
|
20.15
|
15.37
|
10.23
|
Table 2 Estimation of the Global Health Workforce Shortage (in millions) by Occupation
(GSHRH, 2022)
|
year
|
dentist
|
Medical Doctors
|
Midwifery personnel
|
Nursing personnel
|
Pharmacists
|
Other occupations
|
Total
|
|
2013
|
0.49
|
3.05
|
0.36
|
9.89
|
0.33
|
6.02
|
20.15
|
|
2020
|
0.26
|
2.66
|
0.41
|
7.07
|
0.29
|
4.69
|
15.37
|
|
2030
|
0.22
|
1.94
|
0.31
|
4.50
|
0.19
|
3.08
|
10.23
|
While global progress in expanding the health workforce is evident, regional disparities and specific challenges in certain regions underscore the need for targeted strategies and dedicated support. Addressing these gaps is crucial for achieving global health goals and ensuring equitable access to health services across all regions.
2.1.1 Regional and Country-Specific Issues
Sub-Saharan Africa:
Sub-Saharan Africa faces the most acute shortages of healthcare workers. The region has only 3% of the world’s health workforce but bears 24% of the global disease burden (WHO, 2020). Factors contributing to these shortages include high rates of attrition due to migration, poor working conditions, and limited opportunities for professional development. The outmigration of healthcare professionals, often termed "brain drain," exacerbates the issue, with many seeking better pay and working conditions in HICs (Dovlo, 2005, Naicker et al., 2009)
South Asia:
In South Asia, countries like India and Pakistan struggle with uneven distribution of healthcare workers, particularly between urban and rural areas. Rural regions are often underserved, leading to disparities in healthcare access and outcomes. The Indian government has implemented several initiatives to address these disparities, such as incentivising rural postings for healthcare workers and investing in rural health infrastructure (Rathod et al., 2017, Kumar and Kumar, 2018).
Latin America:
Latin American countries, including Brazil and Mexico, have made significant strides in increasing their health workforce densities. However, challenges remain in ensuring the quality and equitable distribution of healthcare services. Brazil's Family Health Program has been a model for integrating community health workers into the healthcare system, improving access and outcomes in underserved areas (Paim et al., 2019)
High-Income Countries:
High-income countries like the United States and those in Western Europe face their own set of challenges. While they generally have higher densities of healthcare workers, issues such as an aging workforce, burnout, and increasing demands for healthcare services are significant concerns. In the U.S., for example, the growing aging population is expected to increase the demand for healthcare services, leading to potential shortages despite the higher workforce density (Auerbach et al., 2013, OECD, 2020),(Organisation for Economic Co-operation and Development).
2.1.2 Workforce Distribution and Density
The variations in workforce density and distribution are stark across different regions and income levels. HICs, with their more robust economies and healthcare systems, can afford to train and retain more healthcare professionals. In contrast, LMICs often struggle with limited resources, leading to lower workforce densities and higher rates of healthcare worker migration【WHO, 2021】【Scheffler et al., 2018】.
Efforts to address these disparities include global initiatives like the WHO’s Global Strategy on Human Resources for Health: Workforce 2030, which aims to strengthen health systems by improving workforce planning, training, and retention strategies worldwide(WHO, 2020). Additionally, national policies such as the Bucharest Declaration on the Health and Care Workforce highlight the importance of supportive work environments and adequate compensation to improve retention and distribution of healthcare workers (Bucharest, 2023).
2.2 Health Workforce Retention
Health workforce retention is a multifaceted challenge affecting countries worldwide. In developing countries, retention difficulties are primarily due to inadequate infrastructure, limited professional development opportunities, and low financial incentives, contributing to high turnover rates and the migration of skilled workers (Karma T, 2020; WHO, 2017). Conversely, high-income countries like the UK face retention challenges such as job stress, burnout, and professional dissatisfaction (NHS Employers 2020). Region-specific retention strategies are needed to address these unique economic, cultural, and professional landscapes.
2.2.1 Ethical Issues and International Recruitment
International recruitment of health professionals is a common practice aimed at addressing workforce shortages in high-income countries (HICs) and enhancing career opportunities for health workers from low- and middle-income countries (LMICs). However, this practice raises several ethical concerns, particularly when it exacerbates health workforce shortages in source countries. To ensure ethical international recruitment, guidelines and codes of conduct have been established to promote fairness and sustainability in global health workforce management.
Ethical Issues:
2.2.1.a Brain Drain:
One of the most significant ethical concerns is the "brain drain" phenomenon, where the migration of skilled health professionals from LMICs to HICs depletes the already limited workforce in the source countries. This exacerbates healthcare disparities and undermines health systems in countries that can least afford to lose their healthcare workers (Tankwanchi et al., 2019, WHO, 2014)
The impact of brain drain is particularly severe in sub-Saharan Africa, where the loss of healthcare professionals to more affluent countries can lead to a critical shortage of essential health services (WHO, 2020).
2.2.1.b. Inequity and Fairness:
The recruitment of health workers from LMICs often involves inequities, as HICs can offer significantly higher salaries, better working conditions, and more career development opportunities. This creates a situation where wealthier nations benefit at the expense of poorer countries, leading to an imbalance in global health workforce distribution (Aluttis et al., 2014),Ensuring that recruitment practices do not exploit disparities between countries is crucial for maintaining fairness and equity.
2.2.1.c. Ethical Recruitment Practices:
Ethical recruitment involves adhering to principles of transparency, fairness, and respect for the rights and interests of both health professionals and source countries. This includes providing accurate information about employment conditions and ensuring that recruitment does not adversely affect the source country's health system (Edge and Hoffman, 2021).
2.2.1.d. Codes of Conduct
The World Health Organization (WHO) established the Global Code of Practice on the International Recruitment of Health Personnel in 2010 to guide ethical recruitment practices. The Code provides a framework for international cooperation and aims to balance the interests of source and destination countries while protecting the rights of migrant health workers (WHO, 2010).
Key principles include the promotion of voluntary agreements between countries, support for health workforce development in source countries, and ensuring that recruitment practices do not deplete health resources in vulnerable regions.
2.2.1.e. National and Regional Guidelines:
Various countries and regions have developed their own guidelines to complement the WHO Code. For instance, the UK’s Department of Health and Social Care has established ethical recruitment guidelines to ensure that international recruitment practices align with global standards and do not negatively impact source countries (Department of Health, 2023).
The European Union has also adopted measures to promote ethical recruitment and support health workforce sustainability within its member states and beyond (European, 2017).
2.3 Current Workforce Issues Post-Pandemic
The COVID-19 pandemic has profoundly impacted healthcare systems worldwide, exacerbating pre-existing workforce challenges and creating new pressures. The pandemic highlighted critical vulnerabilities in the global health workforce, such as staffing shortages, increased workload, and mental health strain. These issues have underscored the urgent need for robust strategies to support and sustain the health workforce in the post-pandemic era (WHO, 2022).
In Europe, the Healthcare Workforce in Europe Report, adopted in Tel Aviv in 2022, provides a comprehensive analysis of the challenges and pressures faced by European healthcare workers post-pandemic. The report emphasizes several key issues, including increased workload and burnout, staffing shortages, and mental health and wellbeing (Rafila et al., 2022)European healthcare workers experienced unprecedented levels of stress and burnout due to the high patient volumes and extended working hours during the pandemic, leading to increased turnover rates and a pressing need for mental health support and resilience-building programs. The pandemic also intensified pre-existing staffing shortages, particularly in critical care and specialized fields, necessitating efforts to recruit and retain healthcare workers to ensure the resilience of healthcare systems. Additionally, the psychological impact of the pandemic on healthcare workers has been significant, with many experiencing anxiety, depression, and post-traumatic stress, highlighting the need for support systems, including counselling and peer support programs.
The WHO's "Time to Act" paper underscores the necessity of immediate and sustained actions to strengthen the global health workforce (WHO, 2021). Key recommendations include improving working conditions by reducing workloads, providing adequate rest periods, and ensuring safe working conditions; offering competitive compensation to attract and retain talent, addressing pay disparities, and ensuring timely remuneration; and creating clear pathways for career progression and professional development through continuous education and training programs to keep the workforce skilled and adaptable.
The Bucharest Declaration, revised in 2023, specifically addresses the post-pandemic challenges facing the European healthcare workforce (Bucharest Declaration, 2023). It highlights priorities such as addressing the ageing workforce through strategies to retain experienced professionals and attract younger talent, including phased retirement options and mentorship programs; adapting to digital transformations by training healthcare workers to effectively use digital health technologies; reducing administrative burdens by streamlining processes and reducing unnecessary paperwork; and supporting the dental workforce by addressing unique challenges like the impacts of an ageing workforce and the need for digital adaptation to ensure the sustainability of dental services.
WHO guidelines emphasize the necessity of improving working conditions, offering competitive compensation, and creating opportunities for career advancement to make the health profession more attractive and sustainable (WHO, 2021). These guidelines, reflected in follow-up articles in leading medical journals such as BMJ and The Lancet, highlight the importance of these measures in sustaining the healthcare workforce post-pandemic. Key recommendations include implementing measures to improve job satisfaction and reduce burnout, such as flexible working hours and supportive management practices; ensuring healthcare workers are adequately compensated for their work, with regular salary reviews and performance-based incentives; and providing ongoing training and career development opportunities to help healthcare workers advance in their careers and stay updated with the latest medical practices.
The COVID-19 pandemic has brought to light the critical challenges facing the global healthcare workforce. In Europe, specific measures outlined in the Healthcare Workforce in Europe Report, the WHO's "Time to Act" paper, and the Bucharest Declaration emphasize the need for comprehensive strategies to support healthcare workers. Improving working conditions, offering competitive compensation, and creating career advancement opportunities are essential steps to ensure the sustainability and resilience of the healthcare workforce in the post-pandemic world.
2.4 Global Oral Health Workforce
The global oral health workforce faces significant challenges in terms of distribution and sufficiency, particularly in low-income countries and regions like Africa, where the demand for oral health services exceeds the available professional capacity (Gallagher et al., 2023). Workforce retention emerges as a critical concern across the health sector, with disparities in retention highlighting systemic issues and regional variances. The urgency of these challenges is amplified in the context of global crises such as the COVID-19 pandemic, which has further stressed healthcare systems and professionals alike.
2.5 Dental Workforce Retention
Research has documented the dynamics of the dental workforce, particularly in the United Kingdom, which boasts one of the most professionalized dental workforces globally. All workforce members are registered with the General Dental Council, emphasizing a structured and regulated professional environment (Gallagher, 2019; Gallagher, 2022). Despite this, the dental profession, including dental nurses—who constitute more than half of this workforce—faces profound retention challenges exacerbated by gender disparities and significant professional stress (GDC et al., 2022). The pressures on dental professionals have been well recognized even before the pandemic, with studies highlighting the intense professional demands placed on dentists and clinical dental care professionals (Colonio-Salazar Sipiyaruk et al., 2019; Gallagher Colonio-Salazar et al., 2021). Furthermore, a rapid review of dental care professionals conducted in 2021 revealed similar retention challenges among dental hygienists and therapists, underscoring the need for a focused investigation into their well-being and professional satisfaction (Kaki Kc et al., 2022).
The retention of the dental workforce in England appears to be influenced by a blend of intrinsic and extrinsic factors ranging from macro to micro levels suggesting that retention strategies at the country level must be multi-faceted, incorporating economic incentives, professional development opportunities, and supportive work environments, highlighting the urgent need for multi-level action to enhance workplace conditions and regulate dentistry to support professional fulfilment and career retention, especially in the post-COVID-19 era, which has added layers of complexity to the existing challenges (Gallagher Colonio-Salazar et al., 2021). At the macro level, professional regulation and healthcare systems like the NHS play pivotal roles in England. Meso-level factors include workplace environments and job specifications, while micro-level influences encompass professional career trajectories, personal relationships, and individual life circumstances.
Dental Workforce Retention in Different Regions
High-Income Countries:
In high-income countries like Australia and Canada, dental workforce retention is influenced by factors such as job satisfaction, professional autonomy, work-life balance, and the rural-urban divide. In Australia, rural areas struggle to attract and retain dental professionals due to isolation and lack of career development opportunities (Woolley et al., 2020). In Canada, retention is linked to job satisfaction and professional development, with a focus on providing a supportive work environment and opportunities for career progression (Baker et al., 2019).
Middle-Income Countries:
In middle-income countries, the challenges are often related to economic incentives, career advancement opportunities, and professional support. In Brazil, for instance, dental workforce retention is impacted by socio-economic disparities and the distribution of healthcare resources. Programs like Brazil's Family Health Program have been implemented to integrate dental services into primary care and improve retention by providing better working conditions and community support (Paim et al., 2011). In South Africa, retention is affected by issues such as workplace environment, workload, and the availability of resources, with many dental professionals seeking opportunities abroad due to better pay and working conditions (Naicker et al., 2009).
Low-Income Countries:
Low-income countries face significant challenges in retaining their dental workforce due to inadequate infrastructure, limited professional development opportunities, and financial constraints. In countries like India and Nigeria, dental professionals often migrate to high-income countries for better career prospects and living conditions (Patel et al., 2018; Naicker et al., 2009). These countries struggle with a lack of investment in healthcare infrastructure and training, which hampers efforts to improve retention. Addressing these challenges requires comprehensive policies that focus on improving working conditions, providing adequate compensation, and investing in professional development.
2.7 Theoretical Frameworks
The retention of the dental workforce is influenced by a complex interplay of factors at macro, meso, and micro levels. Understanding these dynamics requires drawing from various theoretical frameworks such as job satisfaction, motivation, and organizational commitment. These frameworks provide insights into how systemic factors, workplace environments, and individual career trajectories affect retention decisions.
2.7.1Macro-Level Factors: Professional Regulation and Healthcare Systems
At the macro level, professional regulation and healthcare systems play crucial roles in influencing dental workforce retention. For example, the General Dental Council (GDC) mandates strict professional standards and continuous education, ensuring a highly professionalized workforce capable of meeting evolving healthcare needs (Gallagher, 2019; Gallagher, 2022). However, aligning these regulatory standards with practice conditions often impacts professional satisfaction and retention as dental professionals working under NHS contracts may experience significant pressures due to high workloads and the business-driven nature of many practices. This environment can lead to feelings of reduced autonomy and conflict between business priorities and patient care, which are detrimental to professional satisfaction and retention (Gallagher Colonio-Salazar et al., 2021).
2.7.2 Meso-Level Factors: Workplace Environment and Job Specifications
At the meso level, the workplace environment and job specifications significantly impact retention. Factors such as supportive management practices, a positive workplace culture, and opportunities for professional development are critical. Organizational psychology theories, such as those related to job satisfaction and organizational commitment, suggest that workplace recognition, career development opportunities, and professional autonomy contribute significantly to job satisfaction and retention within healthcare settings (Krawczyk et al., 2018).
2.7.3. Micro-Level Factors: Personal Career Development and Relationships
At the micro level, individual career trajectories, personal relationships, and life circumstances play a crucial role. Personal career development opportunities, professional growth, and the ability to balance personal and professional life contribute to retention decisions. Theoretical frameworks on motivation and job satisfaction emphasize the importance of intrinsic and extrinsic motivators in retaining dental professionals. Intrinsic motivators include personal growth and professional fulfillment, while extrinsic motivators encompass financial incentives and work-life balance (Krawczyk et al., 2018).
2.8 Policy Context
While there are countries which have effective policies like Australia, Canada, Brazil, South Africa, India, and New Zealand focus on improving working conditions, providing financial incentives, supporting professional development, and enhancing the integration of dental services into broader healthcare systems, but there countries with some policies and systemic issues can drive them to leave their countries. This migration, often referred to as "brain drain," can exacerbate workforce shortages in the countries of origin, p Inadequate Compensation and Incentives:
In many countries, dental professionals face inadequate compensation, lack of financial incentives, and poor working conditions, driving them to seek better opportunities abroad.
In India, many dental professionals migrate due to low salaries, limited career progression opportunities, and better financial prospects abroad. The National Health Mission's inability to provide competitive salaries and incentives compared to international standards contributes to this migration (Patel et al., 2018).
Limited Professional Development Opportunities:
Lack of opportunities for continuing education, specialization, and professional growth can push dental professionals to move to countries with better career development prospects.
In Nigeria, the scarcity of advanced training programs and continuing professional development opportunities leads many dental professionals to migrate to countries with more robust educational systems and career advancement prospects (Naicker et al., 2009).
Poor Working Conditions and Infrastructure:
Inadequate healthcare infrastructure, high patient loads, and insufficient support staff can create a stressful work environment, prompting dental professionals to leave.
Despite the Rural Allowance Program, many dental professionals in South Africa migrate due to poor working conditions, lack of resources, and overwhelming workloads in public healthcare facilities (George et al., 2017).
Political instability, economic downturns, and uncertain futures can drive healthcare professionals, including dentists, to seek stability and security in other countries.
In Venezuela, the political and economic crisis has led to a mass exodus of healthcare professionals, including dentists. The lack of basic supplies, deteriorating healthcare infrastructure, and safety concerns have forced many to seek opportunities in more stable countries (Page et al., 2019).
Health policies that limit the scope of practice, impose burdensome regulations, or fail to protect the rights of dental professionals can also contribute to migration.
In Egypt, restrictive health policies and excessive bureaucratic regulations have led to dissatisfaction among dental professionals, prompting many to migrate to countries with more flexible and supportive regulatory environments (El-Sherbiny et al., 2019).
High-income countries often engage in active recruitment of dental professionals from lower-income countries to fill their workforce gaps, offering attractive packages that are hard to resist.
The UK has been known to recruit dental professionals from countries like India and South Africa by offering higher salaries, better working conditions, and career development opportunities. While this helps address workforce shortages in the UK, it exacerbates shortages in the source countries (Buchan et al., 2013).
Some high-income countries do not adhere to ethical recruitment guidelines, leading to aggressive poaching of dental professionals from countries already struggling with workforce shortages.
The United States has recruited dental professionals from the Philippines and other developing countries without always considering the impact on the healthcare systems in those countries. This practice contributes to the depletion of skilled professionals in the source countries (Tankwanchi et al., 2015).
2.9 Economic Impact of Dentist Retention
Economically, the retention of dentists is crucial for maintaining adequate workforce numbers and achieving sustained quality of care and economic stability in oral health services. Continuity in the dental workforce leads to more efficient use of healthcare resources, reducing financial waste and improving the quality of care, thereby enhancing patient outcomes and satisfaction (WHO, 2023). This structured literature review provides a comprehensive overview of the challenges and factors influencing the retention of the dental workforce, particularly in the context of the UK and global health crises.