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Human resources for health in fragile health systems

  • Page updated onMay 17, 2026
Health personnel
Text and photo: Bruno Abarca

If there is one thing that every health system needs, without exception, it is its health professionals. However, in low-income countries, contexts of structural fragility and humanitarian crises, both acute and protracted, health workers are often overburdened and insufficient to address the needs of the population.

Protecting the health workforce and investing in their capacity and performance is key to the resilience of health systems and the achievement of universal health coverage.

Shortage of health care workers: global causes and challenges

Lack of health personnel, especially in low-income countries

In 2020, it was estimated that there were approximately 65 million health professionals worldwide and that some 15 million more were needed (including 2.7 million doctors and more than 7 million nurses) in order to be in a position to advance towards at least 80% coverage and universal access to health services. This figure alone, however, conceals a profound inequity: high-income countries have a health workforce density 6.5 times greater than that of low-income countries (Boniol et al., 2022)(Boniol et al., 2022).

By 2030, the global shortage figure is estimated to fall to 10 million, as a result of major efforts. However, this progress is also profoundly unequal. While the gap is closing in middle- and high-income countries, the health workforce is growing more slowly in the African region and in the most fragile states (WHO Regional Office for Africa, 2026)World Health Organization Regional Office for Africa. (2026). State of the health workforce in Africa 2026: Plan, train and retain. https://www.afro.who.int/publications/state-health-workforce-africa-2026-plan-train-and-retain. It is there that more than half of the global deficit will be concentrated.

As regards the nature of this shortage, raw figures are not the only problem. In many contexts there is an inefficient distribution of the scarce workforce, and even very low levels of clinical knowledge about common maternal and child health problems, for example (Sheffel et al., 2024)Sheffel, A., Andrews, K. G., Conner, R., Di Giorgio, L., Evans, D. K., Gatti, R., Lindelow, M., Sharma, J., Svensson, J., Wane, W., & Welander Tärneberg, A. (2024). Human resource challenges in health systems: Evidence from 10 African countries. Health Policy and Planning, 39(7), 693–709. https://doi.org/10.1093/heapol/czae034.

Health worker density
(Boniol et al., 2022)

The problem of the shortage of health care workers is not easy to address

The causes of this shortage are many. These include chronic underinvestment in training, the financial inability of the public sector to absorb the available workforce, difficulties in attracting and retaining professionals in rural, poor and remote areas (resulting in inadequate distribution), lack of supervision, poorly regulated dual public-private practices, limited productivity and performance, and of course migration to wealthy countries, which further widens the asymmetry and inequality (WHO, 2021)World Health Organization. (2021). Health labour market analysis guidebook. World Health Organization. https://www.who.int/publications/i/item/9789240035546.

Overcoming these problems requires a thorough analysis of the education sector, the labour market and the factors that shape it, as well as sound planning (WHO, 2022)World Health Organization. (2022). Working for health 2022–2030 action plan. World Health Organization. https://www.who.int/publications/i/item/9789240063341. A set of public policies that go beyond "training more people" is also needed. These policies must take into account all the dynamics related to the generation of more talent by existing academic institutions (and the alignment of training programmes with health priorities and needs), the flows of staff entry and exit (determined largely by employment conditions), and the causes of inefficiency and low productivity, as well as the regulation of the private sector and its relationship with the public sector (Sousa et al., 2013)Sousa, A., Scheffler, R. M., Nyoni, J., & Boerma, T. (2013). A comprehensive health labour market framework for universal health coverage. Bulletin of the World Health Organization, 91(11), 892–894. https://doi.org/10.2471/BLT.13.118927.

Causes of the lack of health personnel
(Sousa et al., 2013)

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Challenges with healthcare workers in humanitarian crises

In humanitarian contexts the problem is even more severe and complex, as conflicts, mass forced displacement of the population and the inability of local authorities to respond are compounded by the structural weakness of existing health systems (Onvlee et al., 2023)Onvlee, O., Kok, M., Buchan, J., Dieleman, M., Hamza, M., & Herbst, C. (2023). Human resources for health in conflict affected settings: A scoping review of primary peer reviewed publications 2016–2022. International Journal of Health Policy and Management, 12, 7306. https://doi.org/10.34172/ijhpm.2023.7306.

In complex humanitarian emergencies, health workers are often the target of attacks.

Violence, insecurity and, at times, direct attacks targeting health professionals cause them to abandon their posts and migrate to more stable and secure areas (WHO, 2023)World Health Organization. (2023). Global health and care worker compact: Technical guidance compilation. World Health Organization. https://www.who.int/publications/i/item/9789240073852.

Those who stay, generally with less experience and capacity to look for options outside that place, are left working in very harsh conditions. They are forced to face enormous stress and workload, with hardly any economic and institutional support, with scarce material resources, medicines and equipment, performing tasks for which they have no preparation simply because there is no one else who can do them, without supervision or accompaniment from more experienced professionals, with enormous limitations in referring patients to higher levels of care, and without social support.

After the acute emergency, the problems with health personnel continue

In protracted humanitarian crises, the public sector continues to struggle to recover the health workforce that had left the country or gone to serve in armed forces. The impact of the crisis on staff mental health also remains to be addressed, as do the distortions introduced into the system by humanitarian actors who have recruited health personnel (Roome et al., 2014)Roome, E., Raven, J., & Martineau, T. (2014). Human resource management in post-conflict health systems: Review of research and knowledge gaps. Conflict and Health, 8, 18. https://doi.org/10.1186/1752-1505-8-18.

The effects of the interruption of training of new healthcare personnel during the crisis can be profound and long-lasting. On the one hand, during the crisis period, in the absence of accreditation systems and standards, many of the health personnel who have remained have received little in the way of continuing education or supervision. On the other hand, the education system itself may collapse, with training institutions looted or destroyed and the displacement or flight of sufficiently qualified and experienced teachers, both in higher and basic education.

Other problems are the weak governance of a health system under strong political, economic and military pressure, the possible intensification of corruption, the lack of data about the situation and needs to support decision making, or the unequal concentration of resources in areas that have already recovered better or are safer, to the detriment of the most affected areas.

International cooperation to support health personnel

Acute response and transition: ensuring continuity of services

In an acute emergency, and if local authorities are unable to sustain their health personnel, humanitarian aid is key to ensuring the continuity of essential health services. In addition, humanitarian agencies and NGOs can recruit locally or bring in additional staff from abroad to deploy mobile and emergency teams to ensure access to services where the damaged local health system cannot reach. These actions are critical to help stabilize the initial situation before a transition to recovery.

During that transition, and in the face of a critical shortage of health personnel and the need to guarantee access to essential services, task-shifting to less trained staff can be a necessary strategy. This requires precise job descriptions, competency-based training, ongoing support and an adequate supply of the necessary medical products (Mowafi et al., 2007)Mowafi, H., Nowak, K., & Hein, K. (2007). Facing the challenges in human resources for humanitarian health. Prehospital and Disaster Medicine, 22(5), 351–359. https://doi.org/10.1017/S1049023X00005057. This approach can be a realistic solution for optimising existing human talent and local capacity, as an operational bridge towards the reconstruction of the system (WHO, 2021)World Health Organization. (2021). Health labour market analysis guidebook. World Health Organization. https://www.who.int/publications/i/item/9789240035546.

Management and support to healthcare personnel in the recovery process

Alongside support to guarantee essential health services, technical and financial support for health workforce and talent management systems makes it possible to begin an effective early post-crisis recovery as soon as possible. This includes financial and non-financial incentives (such as recognition, participation in decision-making, benefits packages, opportunities for work-life balance, and professional development opportunities), supportive supervision, mentoring and tutoring programmes, in-service training and performance evaluation, without forgetting psychosocial support (WHO, 2023)World Health Organization. (2023). Global health and care worker compact: Technical guidance compilation. World Health Organization. https://www.who.int/publications/i/item/9789240073852.

All of this also requires support and training for management and coordination staff who must carry out these tasks under demanding conditions. Direct support for clinical staff who provide health services is often prioritised, without taking into account that these individuals need the backing of managers with skills in management, problem-solving, strategic planning, risk and security management, financial management, human resources management and leadership. To ensure adequate staff performance, quality management is essential, with appropriate incentivisation, clearly established roles in well-developed job descriptions, and sound organisation of work at all levels (Roome et al., 2014)Roome, E., Raven, J., & Martineau, T. (2014). Human resource management in post-conflict health systems: Review of research and knowledge gaps. Conflict and Health, 8, 18. https://doi.org/10.1186/1752-1505-8-18.

Policies and coordination to rebuild the system

It is important that efforts to support health staff in relation to supervision, training, mentoring and performance evaluation are carried out in coordination with public authorities, with regulated training curricula and guidelines, and where possible based on a sustainable system of certification and accreditation that facilitates talent management (WHO, 2005)World Health Organization. (2005). Guide to health workforce development in post-conflict environments. World Health Organization. https://www.who.int/publications/i/item/guide-to-health-workforce-development-in-post-conflict-environments.

Finally, for adequate system coordination and governance, which is key to post-crisis reconstruction and recovery, new human resources for health development policies may be necessary, even on a provisional or temporary basis. These must take into account the changes that have occurred in the context and the new needs or priorities that have now emerged. Addressing them requires intersectoral dialogue, involving the ministries of finance, education and labour, for example (WHO, 2016)World Health Organization. (2016). Global strategy on human resources for health: Workforce 2030. World Health Organization. https://www.who.int/publications/i/item/9789241511131.

New policies can help to convene new recruitment processes or update their internal procedures, include new topics (such as gender-based violence or psychosocial support) in training curricula and the competencies of new positions, determine professional categories with their roles and functions, standardize educational and continuing education programs for health personnel for their integration into the system, redistribute health personnel equitably in the different geographical areas, establish certification systems for professionals who during the crisis have developed professionally with humanitarian actors or have received unregulated training, or create mechanisms for evaluation and accreditation of health units, as they recover their functionality and capacity, where new professionals can be incorporated.

References

Health systems

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How to cite this page

Abarca, B. (May 17, 2026). Human resources for health in fragile health systems. Salud Everywhere. https://saludeverywhere.com/en/health-in-humanitarian-crises/health-workers-fragile-health-systems/

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