"Although the diseases that kill attract much of the public's attention, musculoskeletal conditions are the major cause of morbidity throughout the world, having a substantial influence on health and quality of life, and inflicting an enormous burden of cost on health systems [7]."
Dr. Gro Harlem Brundtland, Director General of the WHO, January 2000
Using estimates of a world population of 6,809.7 million people of which 30% are children, and a range of rheumatic disease prevalence of 2,500 - 3,000 cases/1 million children [8–10], there are approximately 6-7 million children afflicted worldwide with rheumatic disease. Approximately 78% of these children live in Asia and Africa. To obtain an average acceptable density of 2.5 PRs/million children [8], the aggregate global demand requires ~5600 PRs. Figure 1 notes existing PR supply of the major areas defined by the United Nations [11–14]. In many circumstances, no data is available because there are no PRs in most developing nations. Currently, the total international PR workforce supply is 12% of this demand; the US possesses 40% of this total supply. The needs of these children are understandably eclipsed by the leading causes of pediatric mortality. However, the global epidemiologic shift to chronic conditions merits workforce development to meet the accompanying morbidity Dr. Brundtland described [15–17].
Among the 30 countries of the Organisation for Economic Co-operation and Development (OECD), only Canada, Finland, Poland, the United Kingdom (UK) and the US have formal credentialing processes for postdoctoral training in pediatric rheumatology. Non-OECD, European community member Bulgaria may also organize and certify this training [18]. Other European countries lack formalized certification of PR fellowship training. Both PR and internist rheumatologist physician resources in Canada are "inadequate" to fulfill requisite clinical care demands. Canadian surveys project a 64% shortfall in rheumatologists by 2026 [19, 20].
PR has been growing rapidly in Europe. In 1999, the Pediatric Rheumatology European Society (PRES) was founded. By 2005, the UK had 180 members (including allied health professionals) in its British Society for Paediatric and Adolescent Rheumatology (BSPAR) [21]. UK trainees who seek tertiary center PR positions prepare for 2-3 years in at least two different nationally recognized centers. Those who do not seek a tertiary PR position usually receive at least a year of PR training, followed by additional pediatric training to become a consultant pediatrician with a special interest in PR. UK PRs endure frustrations with inadequate MSK medicine education at UK medical schools, delays in referral and a workforce shortage. Their educational policy approach involves promoting inclusion of pediatric MSK clinical skills and knowledge in their Competency Framework for Postgraduate General Paediatrics. This approach targets medical students with adult MSK educational tools such as the Gait, Arms, Legs, Spine (GALS) screen and its pediatric equivalent (pGALS). UK training further emphasizes medical student exposure to PR to raise awareness [22, 23]. For UK physicians to whom children with MSK problems will likely present, educational research indicates their self-rated confidence in pediatric MSK assessment ranked lowest below all other bodily systems [24]. The US medical education policy approach should follow the UK PRs' lead here.
The global crisis in available human resources for health will continue to limit international development of PR. The causes of this crisis are complex. They involve insufficient production, inability to retain workers in areas of greatest need, and poor management of both health care systems and health workforce. While approximately one half of the global population lives in rural locations (defined by the OECD as communities with a population density below 150 inhabitants/km2), these areas are served by less than a quarter of the total physician workforce [25]. The WHO recommends a minimum target density of 2.3 health workers (physicians, nurses or midwives) per 1,000 population (2,300/million). This target is a simple needs-based estimate derived by the WHO. The estimate uses the percentage of births attended by trained health workers as a proxy for: 1) health needs, and 2) the numbers of workers required to achieve 80% of births attended by a trained worker [26, 27]. This recommendation does not include community and traditional health workers in specific regions or countries, e.g., the African Sahel or China, where these workers contribute extensively to routine care. Health service providers comprise two thirds of the global health workforce; the remaining third consists of health management and support workers (Figure 2) [27]. Distribution disparities exist, exemplified by the sub-Saharan African countries of Côte d'Ivoire, Mali and the Democratic Republic of Congo. These countries have a large overproduction of health workers, resulting in medical unemployment in urban areas mixed with shortages in rural areas [25]. Figure 3 portrays those countries with a critical shortage of health service providers [28].
Areas with the highest global burden of disease (especially Africa and Southeast Asia) often have the fewest health care workers per capita. The growth of health systems and the demand for health workers in wealthy nations continues to draw large numbers of skilled professionals from developing countries. Shortages in rural areas of developed countries create an incentive for health workers from developing countries to relocate disproportionately compared to resident workers. In Canada, where only 9% of the physician workforce serves rural communities, the proportion of foreign physicians in rural communities without any urban influence is 30% [29]. This "brain drain" complicates any developing country's capacity to attain the WHO's recommended workforce density. Fifty-seven countries currently fall below the minimum target [30].
Total government health expenditures for health workforce average just over 40%. Only 11% of African Union Member States (6/53) have met their pledge to allocate 15% of their budget to health. War and other causes of extreme social disruption exacerbate this limited support. For example, the total number of physicians in pre-conflict Liberia was 237, dwindling to 23 after its two civil wars (1989-96, 1999-2003) [30].
These trends profoundly affect the development of an adequate global PR workforce. Many governments have been slow to acknowledge unmet needs arising during the epidemiologic shift from infectious diseases to chronic conditions. Policy must focus on the development and funding of developing nations' health workforce plans. Specifically, developing nations should be encouraged to support a long term vision that promotes coordination and training opportunities for workers at a variety of skill levels. Aside from governmental support, international donors will need to commit their resources to achieve lasting change. For the PR community, international backing substantively constitutes donated time, academic knowledge, open access journals, telemedicine capacity, minimal registration and travel costs for educational meetings, and mentoring of identified workforce resources in developing countries, many of whom are employed as civil servants [26].
Until sufficient numbers of PRs or care extenders are available, an interim policy approach suggested is "rheumatology without borders" [31]. This strategy involves structured undergraduate MSK education, current basic and clinical research training for practitioners, and petitioning of both non-governmental and national government organizations to support developing regions' providers. In part, this will require rheumatology leaders to travel to developing nations to participate in conferences, allowing participant nations' attendees affordable costs.
The PRs of Western, developed countries share an ethical imperative to provide training, appropriate resources and professional development for those health workers in developing countries. It is critical to reward these workers for their efforts, which will in turn motivate them while they mature into their roles. Of a variety of methods, PRs can contribute meaningfully by submitting their scholarly activity to open access journals. Journal participation at regional levels may also foster provider interaction with a scholarly community and the exchange of ideas. On-line courses can be translated into many languages, providing the theoretical basis of PR to health workers. Designated international centers of excellence can provide practical training for abbreviated intervals. This approach promotes sufficient training for health workers who may possess different skill mixes than physicians to become functional PR extenders in their respective regions or countries. Regulatory reform may allow realignment of clinical responsibilities through existing certifying organizations.
Infrastructure development will remain an extraordinary challenge. Developing nations (e.g., many in Africa and Asia) may benefit from strategic alignment of their economic resources akin to the process that produced the European Union. Neither profit-based health care financing nor the privately-financed charities of non-governmental organizations are likely to result in long-term, sustainable health care systems in developing countries. When governments align with their populations' needs, their countries' rheumatic disease-afflicted children will begin to receive the vital help they need.
