The World Health Organization’s Eastern Mediterranean region comprises twenty-two countries that do not have access to the same healthcare workers: between the best-equipped and the least-equipped, physician density varies by a factor of thirteen. Two-thirds of these countries experienced service disruptions linked to staffing during the pandemic, according to the WHO’s 2025-2028 Investment Case. Training healthcare workers without retaining them means financing your neighbor’s health capacity.
The Essentials
- In the WHO Eastern Mediterranean region, the density of doctors, nurses, and midwives ranges from 8 to 108 per 10,000 inhabitants depending on the country (WHO EMRO, Investment Case 2025-2028).
- Two-thirds of countries in the region experienced service disruptions linked to staffing during the pandemic.
- The migration of healthcare workers trained in low-density countries to high-density countries, or outside the region, structurally worsens the gaps.
- Documented approaches include investment, scaling up and retaining staff, adapting training, and establishing a regional collaboration mechanism.
- The scenario of a regional shared competency space depends on collective political will that nothing guarantees today.
A Gap of Thirteen Between Regional Neighbors
The gap between 8 and 108 per 10,000 inhabitants has concrete effects. This ratio measures the probability that a child will be born with a qualified midwife, that an emergency will be treated, that a vaccination program will be supervised. At 8 per 10,000, there is no margin. The slightest epidemic wave or political crisis is enough to collapse the service.
These gaps have known causes. Low-density countries suffer from a combination of historical underinvestment in training, insufficient salaries to retain graduates, and less geographic attractiveness for practice. High-density countries, meanwhile, have both the means to train and the means to attract, including healthcare workers trained elsewhere.
This mechanism is not unique to the region. Northern European countries have been recruiting nurses trained in Central and Eastern Europe for twenty years. But in the Eastern Mediterranean region, the combination of persistent armed conflicts, economic crises, and institutional fragilities makes the phenomenon even more destructive. A healthcare worker who leaves Yemen or Somalia to practice in Oman or the United Arab Emirates does not easily return. The loss is often permanent.
The Pandemic Tested Systems
Two-thirds of countries in the region experienced service disruptions linked to staffing during the Covid-19 pandemic. This figure describes emergency rooms closed for lack of personnel, deliveries without qualified assistance, vaccination campaigns interrupted.
The pandemic functioned as an involuntary stress test. Systems with staffing margins bent; those that had none broke. These margins are built over decades of training, retention, and planning.
Human resources are an essential pillar of health systems, among other indispensable capacities. A hospital without qualified healthcare workers is a building. This observation, documented in the WHO’s Investment Case for the region, structures the regional response planned for 2025-2028.
Training Without Retention: An Investment for Others
This imbalance perpetuates itself because no mechanism interrupts it. The training country has insufficient resources to raise salaries to the level of host countries, and there is no general international obligation for compensation, although the WHO recommends agreements providing benefits for countries of origin. Investment in training thus becomes a factor of further impoverishment: it mobilizes scarce public resources without producing the expected effect on local density. An increase in training must be accompanied by employment and retention policies to limit the effects of departures, because voluntary WHO frameworks exist but do not create an automatic compensation mechanism.
The economic logic of healthcare worker migration is simple and cruel. A poor country trains a doctor over ten years, at the cost of considerable public investment. This doctor leaves to practice in a richer country upon obtaining their diploma. The host country benefits from a competency without having borne the cost. The training country absorbs the expense without seeing a return.
This dynamic is particularly marked for nurses and midwives, who represent the heart of primary care. The question of who finances healthcare worker training and who benefits from it is fundamentally a question of political power: countries with the means to attract impose their rules in fact, without any agreement compelling them to do so.
Competency transfers flow structurally from South to North and from poor countries to rich countries, within the region itself. Low-density countries lack mechanisms to transform their investment into sustainable capacity.
Two Instruments That Could Change Things
The Investment Case identifies four groups of interventions to strengthen health personnel. The first group of interventions consists of facilitating investment in health personnel. A recognition agreement can reduce certain administrative obstacles according to rules established by the States concerned. The second group of interventions aims at increasing, employing, and retaining primary care and public health personnel.
Mutual recognition is not a new idea. The European Union built it over several decades, with resistance and persistent asymmetries. In the Eastern Mediterranean region, obstacles are more complex: heterogeneity of educational systems, different training languages, varying legal statuses of professionals from country to country, and above all, mistrust between States, some of which are in conflict.
Without agreements and solid data systems, monitoring and shared benefits from mobility may be insufficient. A regional framework can structure this mobility and contribute to its regulation. Without cooperation mechanisms, training countries risk not receiving benefits proportionate to mobility.
The documented instrument is a regional mechanism for collaboration and partnership. Recruitment agreements can stipulate that high-density countries provide compensation to training countries, but the WHO recommends above all that negotiated agreements define benefits for the health systems of both parties. This mechanism exists partially in certain bilateral agreements on a global scale, but the Eastern Mediterranean Region has a regional framework for health personnel development, even if it does not necessarily constitute a specific regional mechanism for regulating mobility.
Two Trajectories by 2030
The region is at a documented tipping point. Two trajectories are open to it, and signals in the coming years will allow them to be distinguished.
In the first scenario, member countries adopt a common framework for recognition of qualifications and collectively fund a training and retention fund. Healthcare worker mobility then becomes a regional asset: a Yemeni nurse can practice in Jordan according to rules known to both parties, with compensation paid to Yemen. Density gaps gradually narrow, not because migrations cease, but because they are balanced by organized flows of training and financing. This scenario relies on instruments that have worked elsewhere, provided there is sufficient political will.
In the second scenario, nothing changes in the structure. Each country continues to recruit individually, without a collective mechanism. Healthcare workers trained in low-density countries continue to migrate to high-density countries or outside the region, attracted by incomparable salaries and working conditions. During the next crisis—pandemic, conflict, climate disaster—the service disruptions documented during the Covid-19 pandemic recur. Two-thirds may become three-quarters.
The difference between these two trajectories hinges on two observable signals. The first: the number of countries in the region that sign, by 2028, a bilateral or regional agreement on mutual recognition of qualifications, existing agreements being today fragmented and partial. The second: the change in the gap between the best-equipped and the least-equipped country between 2025 and 2030, measurable through WHO annual data on national health personnel.
These two trajectories coexist in regional discussions. WHO Eastern Mediterranean has made reducing this gap an explicit priority of its Investment Case. But an institutional priority is not a funding mechanism. It creates a framework for action, not the resources to act.
Expected Concessions From Rich Countries in the Region
Mobility agreements can help mitigate the effects of international recruitment. The WHO also plans investments in training, increasing personnel, retaining them, and transforming training. Several countries recruit healthcare workers from other regions of the world. Recruitments are not subject to automatic compensation, but the WHO recommends negotiated benefits for countries of origin.
This observation is not intended to moralize. It describes a mutual dependence that Gulf States have an interest in recognizing. The next pandemic will not stop at borders. If neighboring health systems collapse, migration pressures, epidemic risks, and humanitarian costs will spill over into high-density countries as well. Regional solidarity on healthcare workers is a security investment, not only an ethical obligation.
The economic argument is there too. Training healthcare workers in low-income countries in the region costs less than recruiting them from the Philippines or India with high salary packages. A regional fund that finances training in Yemen or Somalia and guarantees a portion of these graduates to Gulf countries for five or ten years after their training would be mutually advantageous. The model exists in other forms in other regions of the world.
Measurement as a Condition for Progress
The absence of a reliable registry can create an information asymmetry that favors host countries. Host countries generally control the regulatory acceptance of practitioners, but do not necessarily know precisely who is actually recruited and employed. Origin countries, meanwhile, often do not know how many of their graduates practice abroad and under what conditions. This asymmetry risks weakening their position in negotiations on mobility or compensation agreements. Building a shared data infrastructure could help rebalance information asymmetries between training countries and host countries.
No policy to retain healthcare workers can be evaluated without data. The WHO publishes annual accounts of national health personnel, which make it possible to track densities by country and professional category. This data is the basic condition for regional governance.
But data exists in fragments. Some countries in the region do not have reliable national registries of healthcare professionals. Mutual recognition requires reliable mechanisms for verifying and comparing qualifications; national data on practitioners can facilitate it without necessarily being an absolute prerequisite. This technical requirement is often neglected in political discussions, which jump directly to mobility agreements without building the data infrastructure that would make them work.
The fragility of care systems can also be read in access to treatments. A regional registry of qualifications, coupled with reliable workforce data, constitutes the starting point for a measurable, correctable, and improvable policy. Without adequate data and monitoring mechanisms, agreements risk being difficult to implement and evaluate, but they can nonetheless contain operational commitments.
By 2030, member states of the WHO Eastern Mediterranean region will have to decide whether they share their workforce data in a common registry, including when this data reveals migrations that some governments would prefer not to document.
Sources
- World Health Organization, Eastern Mediterranean Regional Office, All for Health, Health for All: Eastern Mediterranean Investment Case 2025-2028
- WHO, National Health Workforce Accounts 2026 (annual database of health personnel by country)
