Table 1 Global health workforce, by density Total health workforce Health service providers D Percentage of Percentage of (per 1000 total health total health WHO region Number population workforce workforce Africa 1640000 1360000 280000 Eastern Mediterranean 4.01580000 20000 South-East asia 7040000 4.34730000 672300000 Western Pacific 10070 000 5.87810000 782260000 16630000 18911540000 5090000 Americas 21740000 24.812460000 579280000 3 World 59220000 9.339470000 Note: All data for latest available year. For countries where data on the number of health management and support workers were not avail able, estimates have been made based on regional averages for countries with complete data. DatasourceWorldHealthOrganizationGlobalAtlasoftheHealthwOrkforce(http://www.who.int/globalatlas/default.asp) Driving forces: past and future Workers in health systems around the world are experiencing increasing stress and insecurity as they react to a complex array of forces- some old, some new( see Figure 2). Demographic and epidemiological transitions drive changes in popula- tion-based health threats to which the workforce must respond. Financing policies technological advances and consumer expectations can dramatically shift demands n the workforce in health systems. Workers seek opportunities and job security in dynamic health labour markets that are part of the global political economy The spreading HIV/AIDS epidemic imposes huge work burdens, risks and threats. In many countries, health sector reform under structural adjustment capped public sector employment and limited investment in health worker education, thus drying up the supply of young graduates. Expanding labour markets have intensified profes Figure 2 Forces driving the workforce Driving forces Workforce challenges Health needs Demographics Shortage/excess Disease burden Skill miⅸx Health team balance Health system Financing Distribution Technology Internal (urban/rural Consumer preferences Intemational migration Context Working conditions abour and education Compensation Public sector reforms Non-financial incentives Globalization Workplace safety
overview xvii Driving forces: past and future Workers in health systems around the world are experiencing increasing stress and insecurity as they react to a complex array of forces – some old, some new (see Figure 2). Demographic and epidemiological transitions drive changes in population-based health threats to which the workforce must respond. Financing policies, technological advances and consumer expectations can dramatically shift demands on the workforce in health systems. Workers seek opportunities and job security in dynamic health labour markets that are part of the global political economy. The spreading HIV/AIDS epidemic imposes huge work burdens, risks and threats. In many countries, health sector reform under structural adjustment capped public sector employment and limited investment in health worker education, thus drying up the supply of young graduates. Expanding labour markets have intensified profesFigure 2 Forces driving the workforce Health needs Demographics Disease burden Epidemics Driving forces Health systems Financing Technology Consumer preferences Context Labour and education Public sector reforms Globalization Numbers Shortage/excess Workforce challenges Skill mix Health team balance Distribution Internal (urban/rural) International migration Working conditions Compensation Non-financial incentives Workplace safety Table 1 Global health workforce, by density WHO region Total health workforce Health service providers Health management and support workers Number Density (per 1000 population) Number Percentage of total health workforce Number Percentage of total health workforce Africa 1 640 000 2.3 1 360 000 83 280 000 17 Eastern Mediterranean 2 100 000 4.0 1 580 000 75 520 000 25 South-East Asia 7 040 000 4.3 4 730 000 67 2 300 000 33 Western Pacific 10 070 000 5.8 7 810 000 78 2 260 000 23 Europe 16 630 000 18.9 11 540 000 69 5 090 000 31 Americas 21 740 000 24.8 12 460 000 57 9 280 000 43 World 59 220 000 9.3 39 470 000 67 19 750 000 33 Note: All data for latest available year. For countries where data on the number of health management and support workers were not available, estimates have been made based on regional averages for countries with complete data. Data source: World Health Organization. Global Atlas of the Health Workforce (http://www.who.int/globalatlas/default.asp)
xviii The World Health Report 2006 Figure 3 Countries with a critical shortage of health service providers doctors, nurses and midwives) Countries with critical shortage Countries without critical shortage DatasourceWorldHealthOrganizationGlobalAtlasoftheHealthWorkrorce(http://www.whoint/globalatls/defaultasp). sional concentration in urban areas and accelerated international migration from the poorest to the wealthiest countries. The consequent workforce crisis in many of the poorest countries is characterized by severe shortages, inappropriate skill mixes and gaps in service coverage. WHO has identified a threshold in workforce density below which high coverage of essential interventions, including those necessary to meet the health-related Mil- lennium Development Goals(MDGs), is very unlikely(see Figure 3). Based on these stimates, there are currently 57 countries with critical shortages equivalent to a global deficit of 2. 4 million doctors, nurses and midwives. The proportional shortfalls e greatest in sub-Saharan Africa, although numerical deficits are very large in South-East Asia because of its population size. Paradoxically, these insufficiencies often coexist in a country with large numbers of unemployed health professionals Poverty, imperfect private labour markets, lack of public funds, bureaucratic red tape and political interference produce this paradox of shortages in the midst of underutilized talen Skill mix and distributional imbalances compound today 's problems. In many countries, the skills of limited yet expensive professionals are not well matched to the local profile of health needs. Critical skills in public health and health policy and management are often in deficit. Many workers face daunting working environments poverty-level wages, unsupportive management, insufficient social recognition and weak career development. Almost all countries suffer from maldistribution char- acterized by urban concentration and rural deficits, but these imbalances are per- haps most disturbing from a regional perspective. The WHO Region of the Americas
xviii The World Health Report 2006 Figure 3 Countries with a critical shortage of health service providers (doctors, nurses and midwives) Countries without critical shortage Countries with critical shortage Data source: World Health Organization. Global Atlas of the Health Workforce (http://www.who.int/globalatlas/default.asp). sional concentration in urban areas and accelerated international migration from the poorest to the wealthiest countries. The consequent workforce crisis in many of the poorest countries is characterized by severe shortages, inappropriate skill mixes, and gaps in service coverage. WHO has identified a threshold in workforce density below which high coverage of essential interventions, including those necessary to meet the health-related Millennium Development Goals (MDGs), is very unlikely (see Figure 3). Based on these estimates, there are currently 57 countries with critical shortages equivalent to a global deficit of 2.4 million doctors, nurses and midwives. The proportional shortfalls are greatest in sub-Saharan Africa, although numerical deficits are very large in South-East Asia because of its population size. Paradoxically, these insufficiencies often coexist in a country with large numbers of unemployed health professionals. Poverty, imperfect private labour markets, lack of public funds, bureaucratic red tape and political interference produce this paradox of shortages in the midst of underutilized talent. Skill mix and distributional imbalances compound today’s problems. In many countries, the skills of limited yet expensive professionals are not well matched to the local profile of health needs. Critical skills in public health and health policy and management are often in deficit. Many workers face daunting working environments – poverty-level wages, unsupportive management, insufficient social recognition, and weak career development. Almost all countries suffer from maldistribution characterized by urban concentration and rural deficits, but these imbalances are perhaps most disturbing from a regional perspective. The WHO Region of the Americas
with 10% of the global burden of disease, has 37% of the worlds health workers spending more than 50% of the worlds health financing, whereas the African Region has 24% of the burden but only 3%of health workers commanding less than 1% of world health expenditure. The exodus of skilled professionals in the midst of so much unmet health need places Africa at the epicentre of the global health workforce This crisis has the potential to deepen in the coming years. Demand for service providers will escalate markedly in all countries- rich and poor. Richer countries face a future of low fertility and large populations of elderly people, which will cause a shift towards chronic and degenerative diseases with high care demands. Tech nological advances and income growth will require a more specialized workforce even as needs for basic care increase because of families' declining capacity or willingness to care for their elderly members Without massively increasing training of workers in this and other wealthy countries, these growing gaps will exert even greater pressure on the outflow of health workers from poorer regions. In poorer countries, large cohorts of young people(1 billion adolescents) will joir an increasingly ageing population, both groups rapidly urbanizing. Many of these countries are dealing with unfinished agendas of infectious disease and the rapid emergence of chronic illness complicated by the magnitude of the HIv/AIDS epi demic. The availability of effective vaccines and drugs to cope with these health threats imposes huge practical and moral imperatives to respond effectively. The chasm is widening between what can be done and what is happening on the ground Success in bridging this gap will be determined in large measure by how well the workforce is developed for effective health systems. These challenges, past and future, are well illustrated by considering how the workforce must be mobilized to address specific health challenges a The MDGs target the major poverty-linked diseases devastating poor popula- tions, focusing on maternal and child health care and the control of HIV/AIDS, tuberculosis and malaria. Countries that are experiencing the greatest difficul- ties in meeting the MDGs, many in sub-Saharan Africa, face absolute shortfalls in their health workforce. Major challenges exist in bringing priority disease programmes into line with primary care provision, deploying workers equitably for universal access to HIV/AIDS treatment, scaling up delegation to community workers, and creating public health strategies for disease prevention Chronic diseases, consisting of cardiovascular and metabolic diseases, can- cers, injuries, and neurological and psychological disorders, are major burdens affecting rich and poor populations alike. New paradigms of care are driving a shift from acute tertiary hospital care to patient-centred, home-based and team-driven care requiring new skills, disciplinary collaboration and continuity of care-as demonstrated by innovative approaches in Europe and North America. Risk reduction, moreover, depends on measures to protect the environment and the modification of lifestyle factors such as diet, smoking and exercise through behaviour change. Health crises of epidemics, natural disasters and conflict are sudden, often un expected, but invariably recurring. Meeting the challenges requires coordinated planning based on sound information, rapid mobilization of workers, command- and-control responses, and intersectoral collaboration with nongovernmental rganizations, the military, peacekeepers and the media. Specialized workforce capacities are needed for the surveillance of epidemics or for the reconstruction
overview xix with 10% of the global burden of disease, has 37% of the world’s health workers spending more than 50% of the world’s health financing, whereas the African Region has 24% of the burden but only 3% of health workers commanding less than 1% of world health expenditure. The exodus of skilled professionals in the midst of so much unmet health need places Africa at the epicentre of the global health workforce crisis. This crisis has the potential to deepen in the coming years. Demand for service providers will escalate markedly in all countries – rich and poor. Richer countries face a future of low fertility and large populations of elderly people, which will cause a shift towards chronic and degenerative diseases with high care demands. Technological advances and income growth will require a more specialized workforce even as needs for basic care increase because of families’ declining capacity or willingness to care for their elderly members. Without massively increasing training of workers in this and other wealthy countries, these growing gaps will exert even greater pressure on the outflow of health workers from poorer regions. In poorer countries, large cohorts of young people (1 billion adolescents) will join an increasingly ageing population, both groups rapidly urbanizing. Many of these countries are dealing with unfinished agendas of infectious disease and the rapid emergence of chronic illness complicated by the magnitude of the HIV/AIDS epidemic. The availability of effective vaccines and drugs to cope with these health threats imposes huge practical and moral imperatives to respond effectively. The chasm is widening between what can be done and what is happening on the ground. Success in bridging this gap will be determined in large measure by how well the workforce is developed for effective health systems. These challenges, past and future, are well illustrated by considering how the workforce must be mobilized to address specific health challenges. The MDGs target the major poverty-linked diseases devastating poor populations, focusing on maternal and child health care and the control of HIV/AIDS, tuberculosis and malaria. Countries that are experiencing the greatest difficulties in meeting the MDGs, many in sub-Saharan Africa, face absolute shortfalls in their health workforce. Major challenges exist in bringing priority disease programmes into line with primary care provision, deploying workers equitably for universal access to HIV/AIDS treatment, scaling up delegation to community workers, and creating public health strategies for disease prevention. Chronic diseases, consisting of cardiovascular and metabolic diseases, cancers, injuries, and neurological and psychological disorders, are major burdens affecting rich and poor populations alike. New paradigms of care are driving a shift from acute tertiary hospital care to patient-centred, home-based and team-driven care requiring new skills, disciplinary collaboration and continuity of care – as demonstrated by innovative approaches in Europe and North America. Risk reduction, moreover, depends on measures to protect the environment and the modification of lifestyle factors such as diet, smoking and exercise through behaviour change. Health crises of epidemics, natural disasters and conflict are sudden, often unexpected, but invariably recurring. Meeting the challenges requires coordinated planning based on sound information, rapid mobilization of workers, commandand-control responses, and intersectoral collaboration with nongovernmental organizations, the military, peacekeepers and the media. Specialized workforce capacities are needed for the surveillance of epidemics or for the reconstruction ■ ■ ■
xx The World Health Report 2006 of societies torn apart by ethnic conflict. The quality of response, ultimately, depends upon workforce preparedness based on local capacity backed by timely international support These examples illustrate the enormous richness and diversity of the workforce needed to tackle specific health problems. The tasks and functions required are xtraordinary demanding, and each must be integrated into coherent national health systems. All of the problems necessitate efforts beyond the health sector. Effective strategies therefore require all relevant actors and organizations to work together STRATEGIES: WORKING LIFESPAN OF ENTRY-WORKFORCE-EXIT In tackling these world health problems, the workforce goal is simple to get the right workers with the night skills in the night place doing the night things / -and in so doing to retain the agility to respond to crises, to meet current gaps, and to the fu A blueprint approach will not work, as effective workforce strategies must be matched to a country s unique history and situation. Most workforce problems are deeply embedded in changing contexts, and they cannot be easily resolved. These problems can be emotionally charged because of status issues and politically loaded because of divergent interests. That is why workforce solutions require stakeholders to be engaged in both problem diagnosis and problem solving This report lays out a"working lifespan"approach to the dynamics of the work force. It does so by focusing on strategies related to the stage when people enter the workforce, the period of their lives when they are part of the workforce, and the point at which they make their exit from it. The road map(see Figure 4)of training, sustain ing and retaining the workforce offers a worker perspective as well as a systems pproach to strategy. Workers are typically concerned about such questions as: How do i get a job? What kind of education do I need? How am I treated and how well am I paid? What are my prospects for promotion or my options for leaving From policy and management perspectives, the framework focuses on modulating the roles of both labour markets and state action at key decision-making junctures Entry: preparing the workforce through strategic investments in education and effective and ethical recruitment practices. Workforce: enhancing worker performance through better management of work a Exit: managing migration and attrition to reduce wasteful loss of human re- sources Entry: preparing the workforce A central objective of workforce development is to produce sufficient numbers of skilled workers with technical competencies whose background, language and social attributes make them accessible and able to reach diverse clients and populations To do so requires active planning and management of the health workforce pro duction pipeline with a focus on building strong training institutions, strengthening professional regulation and revitalizing recruitment capabilities. a Building strong institutions for education is essential to secure the numbers and qualities of health workers required by the health system. Although the vari ations are enormous among countries, the world's 1600 medical schools, 6000
xx The World Health Report 2006 of societies torn apart by ethnic conflict. The quality of response, ultimately, depends upon workforce preparedness based on local capacity backed by timely international support. These examples illustrate the enormous richness and diversity of the workforce needed to tackle specific health problems. The tasks and functions required are extraordinarily demanding, and each must be integrated into coherent national health systems. All of the problems necessitate efforts beyond the health sector. Effective strategies therefore require all relevant actors and organizations to work together. Strategies: working lifespan of entry–workforce–exit In tackling these world health problems, the workforce goal is simple – to get the right workers with the right skills in the right place doing the right things! – and in so doing, to retain the agility to respond to crises, to meet current gaps, and to anticipate the future. A blueprint approach will not work, as effective workforce strategies must be matched to a country’s unique history and situation. Most workforce problems are deeply embedded in changing contexts, and they cannot be easily resolved. These problems can be emotionally charged because of status issues and politically loaded because of divergent interests. That is why workforce solutions require stakeholders to be engaged in both problem diagnosis and problem solving. This report lays out a “working lifespan” approach to the dynamics of the workforce. It does so by focusing on strategies related to the stage when people enter the workforce, the period of their lives when they are part of the workforce, and the point at which they make their exit from it. The road map (see Figure 4) of training, sustaining and retaining the workforce offers a worker perspective as well as a systems approach to strategy. Workers are typically concerned about such questions as: How do I get a job? What kind of education do I need? How am I treated and how well am I paid? What are my prospects for promotion or my options for leaving? From policy and management perspectives, the framework focuses on modulating the roles of both labour markets and state action at key decision-making junctures: Entry: preparing the workforce through strategic investments in education and effective and ethical recruitment practices. Workforce: enhancing worker performance through better management of workers in both the public and private sectors. Exit: managing migration and attrition to reduce wasteful loss of human resources. Entry: preparing the workforce A central objective of workforce development is to produce sufficient numbers of skilled workers with technical competencies whose background, language and social attributes make them accessible and able to reach diverse clients and populations. To do so requires active planning and management of the health workforce production pipeline with a focus on building strong training institutions, strengthening professional regulation and revitalizing recruitment capabilities. Building strong institutions for education is essential to secure the numbers and qualities of health workers required by the health system. Although the variations are enormous among countries, the world’s 1600 medical schools, 6000 ■ ■ ■ ■
Figure 4 Working lifespan strategies ENTRYA Preparing the workforce Planning WORFORCE PERFORMANCE WORKFORCE. Responsiveness Compensation Productivity EXIR Systems supports Managing attrition Lifelong learning nursing schools and 375 schools of public health in aggregate are not producing ufficient numbers of graduates. Addressing shortfalls will require building new institutions and ensuring a more appropriate mix of training opportunities-for example, more schools of public health are needed. Commensurate with the shift in expectations of graduates from " know-all to"know-how", improving education calls for attention to both curricular content and pedagogical learning methods. Teaching staff, too, require training as well as more credible support and career incentives so that a better balance with the competing demands of research and service can be achieved greater access to education at lower cost can be achieved by regional pooling of resources and expanding the use of formation technologies such as telemedicine and distance education a Assuring educational quality involves institutional accreditation and professional regulation(licensing, certification or registration). Rapid growth of the private sector in education calls for innovative stewardship to maximize the benefits of private investments while strengthening the state's role in regulating the quality of education. Too often lacking or ineffective in low income countries, structures for regulation are rarely developed sufficiently to ensure quality, responsiveness and ethical practice. State intervention is necessary in order to set standards protect patient safety, and ensure quality through provision of information, finan cial incentives and regulatory enforcemer a Revitalizing recruitment capabilities is necessary in order to broker more ef- fectively demands from the labour market that often overlook public health needs Recruitment and placement services should aim not only to get workers with the right skills to the right place at the right time but also to achieve better social compatibility between workers and clients in terms of gender, language, ethnicity
overview xxi nursing schools and 375 schools of public health in aggregate are not producing sufficient numbers of graduates. Addressing shortfalls will require building new institutions and ensuring a more appropriate mix of training opportunities – for example, more schools of public health are needed. Commensurate with the shift in expectations of graduates from “know-all” to “know-how”, improving education calls for attention to both curricular content and pedagogical learning methods. Teaching staff, too, require training as well as more credible support and career incentives so that a better balance with the competing demands of research and service can be achieved. Greater access to education at lower cost can be achieved by regional pooling of resources and expanding the use of information technologies such as telemedicine and distance education. Assuring educational quality involves institutional accreditation and professional regulation (licensing, certification or registration). Rapid growth of the private sector in education calls for innovative stewardship to maximize the benefits of private investments while strengthening the state’s role in regulating the quality of education. Too often lacking or ineffective in low income countries, structures for regulation are rarely developed sufficiently to ensure quality, responsiveness and ethical practice. State intervention is necessary in order to set standards, protect patient safety, and ensure quality through provision of information, financial incentives and regulatory enforcement. Revitalizing recruitment capabilities is necessary in order to broker more effectively demands from the labour market that often overlook public health needs. Recruitment and placement services should aim not only to get workers with the right skills to the right place at the right time but also to achieve better social compatibility between workers and clients in terms of gender, language, ethnicity ■ ■ Figure 4 Working lifespan strategies ENTRY: Preparing the workforce Planning Education Recruitment WORKFORCE: Enhancing worker performance Supervision Compensation Systems supports Lifelong learning EXIT: Managing attrition Migration Career choice Health and safety Retirement Availability Competence Responsiveness Productivity WORFORCE PERFORMANCE