Systemic and political determinants of the global nursing and midwifery shortages: A discussion based on human resources for health data

Abstract

Background Nurses and midwives constitute a substantial proportion of the global health workforce and are essential to universal health coverage, maternal and newborn health, and health-system resilience. Despite workforce expansion, persistent shortages, maldistribution, gender inequities, poor working conditions, leadership gaps, and migration pressures continue to undermine both professions. The Global Burden of Disease 1990–2023 Human Resources for Health estimates provide an opportunity to examine these challenges across three decades. Aim This discussion paper reframes global nursing and midwifery shortages as outcomes of systemic, political, economic, and gendered determinants rather than solely numerical workforce deficits. Sources of evidence The paper draws on Global Burden of Disease 1990–2023 Human Resources for Health estimates and integrates contemporary evidence from nursing and midwifery workforce research, global health, migration, gender equity, maternal and newborn health, and health policy literature. Discussion Although the global nursing and midwifery workforces have expanded, growth has not produced equitable distribution or sufficient workforce capacity. In 2023, published estimates indicated approximately 33.30 million nurses and 3.32 million midwives globally. These figures require cautious interpretation because national definitions of professional nurses, associate-professional nurses, midwives, and nurse-midwives vary, limiting cross-country comparability. The midwifery estimate is also higher than figures reported in other global analyses and may reflect differences in occupational classification, source data, and modelling assumptions. Shortages and low workforce densities remain concentrated in low- and middle-income countries, where limited education capacity, constrained public financing, insufficient funded positions, weak retention systems, regulatory limitations, and outward migration interact with structural inequities. These challenges are particularly consequential for midwifery because of its contribution to sexual, reproductive, maternal, newborn, and adolescent health. Both professions remain highly feminised, with women comprising approximately 85% of nurses and 98% of midwives. Gendered labour structures and negative cultural norms influence remuneration, professional recognition, working conditions, leadership representation, and policy authority. International migration further reflects unequal relationships between source and destination countries, particularly when wealthier health systems recruit from countries already experiencing workforce constraints. Conclusion Global nursing and midwifery shortages are not only workforce-planning failures but manifestations of interconnected political, economic, institutional, and gendered inequities. This paper contributes by synthesising three decades of workforce estimates through an integrated political economy and gender-responsive framework linking workforce planning, financing, education, employment, regulation, migration, leadership, and structural disadvantage. Sustainable progress requires coordinated investment in education, funded employment, retention, ethical mobility, workforce data, professional regulation, and stronger nursing and midwifery leadership in health policy.