Let's talk further about maldistribution. In addition to an overall shortage, there is also the problem of maldistribution of health workers. Like many people, skilled health workers tend to enjoy the advantages of living in urban areas where there are good schools for their children, educational opportunities for themselves, increased availability of jobs for their spouses, better housing, and so on. Thus, many rural areas may be underserved because they are hard to reach, poverty-stricken, and lack the amenities of cities. This graph indicates the scope of the problem of the urban-rural maldistribution. The y-axis indicates the percent of doctors, nurses and other healthcare workers who work in urban areas. The dotted line along the x-axis indicates the percent of the world's population that lives in urban areas. You can see that a much larger percent of healthcare workers live in urban areas compared with the population, and this is especially true for doctors. More than 75% of them are in urban areas compared with less than 55% of the population. Urban rural male distribution of healthcare workers is especially a problem for pregnant women living in rural areas, who may live a long distance from medical facilities and skilled birth attendants. Although they may have access to antenatal care, they may not have access to skilled healthcare should they have a life-threatening complication during labor and delivery. Delivering at home without a skilled birth attendant is associated with a much higher rate of maternal and infant mortality and morbidity. Let's take a look at the country of Kenya as an example of maldistribution. This map of Kenya is divided into the 47 counties that make up the country. The colors indicate the distribution of nurses per 100,000 population in the public and faith-based health sectors. The dark green areas represent the counties with the most nurses per population, while the pink areas are those that have the least number of nurses per population. As you can see, the distribution varies widely and there are many remote areas, particularly in the eastern and northwestern parts of the country, here in Mandera, Wajir and Turkana counties, that are poorly served. Part of the reason for maldistribution is the fact that nurse training schools are often located in more urban areas. Note this map of Kenya again now that shows the location of nurse training schools. Note the same counties with the greatest shortage of nurses have few training schools. Mendera and Wajir counties have no training schools and Turkana has only one, while most training schools are located in the southern part of the country. The colors of the counties indicate the number of newly trained nurses according to their county of residence. As you can see, Kenya trains very few nurses per population from these remote counties. Special incentives and resources are needed to encourage and support young people from these remote areas to attend nurse training and then go on to serve in these remote areas. Another problem that contributes to maldistributiion is the migration of skilled health workers from developing countries, that is, areas of the greatest shortage, to the more developed countries such as Europe and the United States. An Emory University study in Kenya in 2007 found that for every four nurses Kenya trains, one of them will apply to migrate out of the country. In addition, the nurses who choose to migrate are often the most highly trained nurses. Note the bar graph in this slide. The grey part of the bars represent those newly trained nurses that intend to migrate out of the country. And the red part of the bar represents those newly trained nurses who intend to remain in the country. You can see that 27% percent of bachelors trained and 35% of registered nurses intend to migrate. So, why do healthcare workers tend to migrate to urban areas or to more developed countries? You can think of the reasons as push and pull factors. For example, if you were a highly trained nurse midwife assigned to a remote area in rural Kenya, why might you want to leave? Take a moment to think about some reasons. Likewise, if you are a highly trained nurse working in Kenya, why might you want to migrate to the United States? Take a moment to think about some reasons. Note some of the reasons listed on this slide as to why healthcare workers may not want to go to rural areas or may want to migrate to more developed countries. For example, poor nurse to population ratios means that nurses in these areas are often overworked and along with low wages, they are often underpaid. Rural areas often lack social amenities, such as good housing and good schools. Lack of educational opportunities also contributes, as many workers want to upgrade their education. A high HIV/AIDS prevalence and lack of resources such as gloves and protective clothing can increase their risk of occupational exposure. In addition, many leave because of unstable political areas in governments that can increase violence. What are some of the pull factors? Shortages in developed countries may result in aggressive recruitment practices that may encourage workers to migrate. Better educational opportunities, more resources for patient care and better compensation also contribute.
