The loss of frontline health workers dying of Covid around the globe, is being compounded in the hospitals of developing nations by trained medical staff leaving to help in the pandemic effort abroad, according to experts. With new Covid waves in Africa, and with Latin America and Asia facing unrelenting health emergencies, the number of health worker deaths from Covid-19 in May was at least 115,000, according to the World Health Organization. Its director-general, Tedros Adhanom Ghebreyesus, acknowledged data is “scant” and the true figure is likely to be far higher. In richer countries, the share of foreign-trained or foreign-born doctors and nurses has been rising for two decades. But the pandemic’s double blows of death and migration are leaving behind knowledge gaps in already fragile health systems, where poor pay and conditions are driving staff to leave, say advocates and health workers. Global health specialists are launching initiatives to protect medical staff, and incentivise them not to be enticed abroad. Women in Global Health, an international network advocating for equality, has jointly launched what it calls “a new social contract for women in the health and care workforce”. The Gender Equal Health and Care Workforce Initiative, a partnership between the WHO, Women in Global Health and the French government, aims to strengthen policy investing in and protecting workers. “Health workers are exhausted, many want to leave. We cannot afford to lose one single worker at this time,” says Dr Roopa Dhatt, executive director of Women in Global Health. “Investing in women is the best investment we can make for all our futures and the future of health security.” The world is reliant on women to deliver health and care services, Ghebreyesus told the Generation Equality Forum, where the first round of commitments to the initiative was announced on 1 July. Women account for about 90% of nurses and midwives, close to 50% of all doctors, and make up 70% of all health and care workers worldwide. “This reliance demands that we ask ourselves tough questions on workplace conditions and equity, including how we value and reward women in the health and care workforce,” Ghebreyesus said. “And how we guarantee that workplaces are free from discrimination, violence, sexual exploitation and abuse.” As governments – including those of Mexico, Pakistan, the Democratic Republic of Congo and Liberia – commit to the gender policy initiative, Dhatt said that millions of health and care workers were unpaid or underpaid and had no access to Covid vaccines. “We must provide incentives for women to stay,” said Dhatt. The global south has long supplied many of the human resources for health systems in the northern hemisphere. And as the UK, the US and Europe have struggled under the weight of their respective pandemics, demand for imported medical expertise has intensified. Across the world’s wealthiest countries, nearly 25% of doctors and 16% of nurses were born abroad, according to a brief from the Organisation for Economic Co-operation and Development (OECD). Published in May, it examined how rich countries have sought to attract staff from developing countries in response to the pandemic. It acknowledged that nations from where staff were being enticed “were already facing severe shortages of skilled health workers before the Covid-19 pandemic”. The UK launched its own incentive – a fast-track Health and Care Visa in 2020 to attract more health workers from developing countries – even as the government drastically reduced its foreign aid budget from 0.7% to 0.5% of national income, against OECD advice and putting global health systems at risk, according to academics. The Philippines is the largest contributor of nurses to wealthy countries, OECD data shows. India provides the highest number of doctors, and the second-highest number of migrant nurses. Mitigating push factors for professionals to leave their countries requires policy to “reinforce international cooperation, notably overseas development assistance and technical assistance, to help less advanced countries build up a sufficient health workforce and to strengthen their health systems”, the OECD brief said. The Filipino Nurses Association UK has raised concerns about the disproportionately high rate of deaths among NHS and social care staff from the Philippines, saying that the nationality had the highest mortality of all ethnicities, at about 20%. The group set up a special helpline for Filipino health workers and their families as a result. In the US, more than 30% of nurses who have died of Covid were Filipino, though they make up just 4% of the country’s registered nurses, according to the National Nurses United union. In the Philippines, two prominent specialists died of Covid in March 2020: paediatric surgeon Leandro Resurreccion III and Salvacion “Sally” R Gatchalian, the president of the Philippine Paediatric Society. Gatchalian helped create the Philippines Coalition Against Tuberculosis and led a children’s TB initiative, while Resurreccion was lauded for having returned from Australia to dedicate himself to the Philippines’ health service. Highly skilled researchers are scarce in low- and middle-income countries, said Glenda Gray, president of the South African Medical Research Council, adding: “Any loss of scientists, either through death or migration, is a concern.” In fragile health systems, lost knowledge when a community health worker or highly trained medical expert dies can have a long-term impact. And research suggests physician migration costs low and middle income countries $16bn (£11.5bn) annually and lost medical knowledge contributes to excess deaths. With emigration rates of doctors and nurses as high as 50% from some African and Latin American countries, it can mean that more doctors born in these countries are working in the OECD area than in their countries of origin. Africa’s research community lost renowned HIV scientist Gita Ramjee to Covid in March 2020. “Gita was fundamental and inextricably linked to the endeavours to find solutions to prevent HIV in women. She was tireless in this pursuit, her tenacity will never be forgotten,” Gray said. Winnie Byanyima, executive director of UNAIDS, said Ramjee’s loss was “when the world needs her most”. “The psychological impact of deaths, infections and [increased workloads] prompted many doctors to request leave and, in the event of management refusal, some resorted to resigning from governmental hospitals,” Egyptian physician Abdel Hamid Mahmoud said. Johan Fagan, an ear, nose and throat disease specialist at the University of Cape Town in South Africa, said policies such as the UK’s fast-track visa would spur further migration. “These countries aren’t training enough of their own healthcare professionals and are exploiting the workforce in developing countries,” Fagan said. “In a pandemic, this has a significant impact on our health systems and how we’re able to deliver care.” Algerian Dr Al Arabi Bin Hara predicted a new exodus of skilled workers from his country, saying: “Last year and at the beginning of this year, there was the smallest number recorded in doctors’ immigration because of the closed borders as [a result] of the measures imposed by the pandemic. “The post-Covid phase will witness a mass flight of doctors, as long as the situation remains as it is and the suffering continues.” What hurts, said Bin Hara, is that hospitals and clinics in Europe – particularly in France – were attracting Algerian doctors with critical specialisations. In Zimbabwe, a country with one of the highest doctor emigration rates, Dr Charles Moyo said Africa would face a healthcare crisis if the tide of health worker losses was not stemmed. “The healthcare system is already strained by limited resources and by Covid. If more manpower is lost, the entire healthcare system could collapse,” he said. The International Council of Nurses (ICN), which has backed the Gender Equal Health and Care Workforce Initiative, celebrated the World Health Assembly’s adoption of the WHO’s updated global nursing and midwifery strategy, which presents policy priorities to support midwives and nurses. ICN chief Howard Catton said the message was clear, adding: “We must invest now in nursing education, leadership, jobs and practice, and we need member states to own their new strategy and implement it now. “Of course, the tragic irony is that if we had done this before, we would have had a better protected healthcare workforce, and fewer of our colleagues would have died.”