health wol
health workers: a global profile
chapter one a global profile 1 Who are the health workers? 4 How many health workers are there? 7 How much is spent on the health workforce? 8 Where are the health workers? Health workers are people whose job it is to 9 Are there enough health workers? protect and improve the health of their com- 13 Addressing the shortage-how much will it cost? munities. Together these health workers, in 15 Conclusio all their diversity, make up the global health workforce. This chapter gives an overview of what is known about them It describes the size and distribution of the workforce, and some of its characteristics, including how much it costs. It shows that there is a substantial shortage of health workers to meet health needs, but that shortages are not universal, even across low income countries. The chapter then considers how much it would cost to scale up training to meet this shortfall and pay health workers subsequently The data used in this chapter are drawn from many different WHO ARE THE HEALTH WORKERS? sources,with varying degrees of completeness by country and by This report defines health workers to be all people en- year. WHO supplemented this information with written requests to gaged in actions whose primary intent is to enhance numerous agencies as well as with special country surveys request- health. This meaning extends from WHO's definition of ing information about the numbers and types of health workers the health system as comprising activities whose pri- and training institutions. Substantial gaps remain, however, in the mary goal is to improve health. Strictly speaking, this nformation, and the picture painted here is based on incomplete means that mothers looking after their sick children data which means that it needs to be interpreted carefully. and other unpaid carers are in the health workforce
health workers: a global profile Health workers are people whose job it is to protect and improve the health of their communities. Together these health workers, in all their diversity, make up the global health workforce. This chapter gives an overview of what is known about them. It describes the size and distribution of the workforce, and some of its characteristics, including how much it costs. It shows that there is a substantial shortage of health workers to meet health needs, but that shortages are not universal, even across low income countries. The chapter then considers how much it would cost to scale up training to meet this shortfall and pay health workers subsequently. The data used in this chapter are drawn from many different sources, with varying degrees of completeness by country and by year. WHO supplemented this information with written requests to numerous agencies as well as with special country surveys requesting information about the numbers and types of health workers and training institutions. Substantial gaps remain, however, in the information, and the picture painted here is based on incomplete data which means that it needs to be interpreted carefully. Who are the health workers? This report defines health workers to be all people engaged in actions whose primary intent is to enhance health. This meaning extends from WHO’s definition of the health system as comprising activities whose primary goal is to improve health. Strictly speaking, this means that mothers looking after their sick children and other unpaid carers are in the health workforce. health workers: a global profile chapter one in this chapter 1 Who are the health workers? 4 How many health workers are there? 7 How much is spent on the health workforce? 8 Where are the health workers? 9 Are there enough health workers? 13 Addressing the shortage – how much will it cost? 15 Conclusion Jean Mohr/WHO
2 The World Health Report 2006 They make important contributions and are critical to the functioning of most health systems. However, the data available on health worker numbers are generally limited to people engaged in paid activities, so the numbers reported in this chapter are limited to such workers 66 Even then, the definition of a health action for classifying This report defines paid workers is not straightforward. Consider a painter health workers to be all improve health, though the actions of the painter' s employer people engaged a mining company to care for its employees: the actions of the in actions whose doctor improve health, though the actions of the employer do not. a classification system that considers the actions of the primary intent is to individual alone, or those of the employer alone, cannot place them both in the health workforce enhance health In principle, the report argues that the actions of the 99 dividual are most important, so that the painter is not a health worker while the mine's doctor is. However, in practice, it is not yet possible to fully apply this rule because much of the data on health worker numbers do not provide sufficient detail to allow people directly engaged in improving health to be separated from other employees (1). For this reason, the report takes a pragmatic approach and includes all paid workers employed in organizations or institutions whose primary intent is to improve health well as those whose personal actions are primarily intended to improve health but who work for other types of organizations. This means that the painter working for a hospital is included as is the doctor working for a mine. WHO is working to devise a more detailed, standard classification system for health workers that should permit the gold standard definition to be applied in the future(see Box 1. 1). The system of counting used in this chapter allows two types of health workers to be distinguished. The first group comprises the people who deliver services whether personal or non-personal-who are called"health service providers"; the second covers people not engaged in the direct provision of services, under the term health management and support workers"(details are given in Box 1.1; see also Box 1.2). The report sometimes presents information for different types of health service providers, although such detail is often available only for doctors and nurses. Further explanation of the sources of the data, classification issues, and the triang and harmonization applied to make the data comparable across countries is in the statistical Annex The available data do not allow reporting on the people working for a part of their time to improve health, such as social workers who work with mentally ill patients. In addition, the report has chosen not to include workers in other types of occupations who contribute in vital ways to improving population health, if their main function lies elsewhere. This category includes, for instance, police officers who enforce seat-belt laws. Finally, current methods of identifying health workers do not allow unpaid carers of sick people or volunteers who provide other critical services to be counted. This exclusion is simply because of a lack of data, and all these valuable contributions are acknowledged in subsequent chapters. Furthermore, official counts of the health workforce often omit people who deliver services outside health organizations, for example doctors employed by mining companies or agricultural firms, because they classify these employees under the
The World Health Report 2006 They make important contributions and are critical to the functioning of most health systems. However, the data available on health worker numbers are generally limited to people engaged in paid activities, so the numbers reported in this chapter are limited to such workers. Even then, the definition of a health action for classifying paid workers is not straightforward. Consider a painter employed by a hospital: the painter’s own actions do not improve health, though the actions of the painter’s employer, the hospital, do. Then take the case of a doctor employed by a mining company to care for its employees: the actions of the doctor improve health, though the actions of the employer do not. A classification system that considers the actions of the individual alone, or those of the employer alone, cannot place them both in the health workforce. In principle, the report argues that the actions of the individual are most important, so that the painter is not a health worker while the mine’s doctor is. However, in practice, it is not yet possible to fully apply this rule because much of the data on health worker numbers do not provide sufficient detail to allow people directly engaged in improving health to be separated from other employees (1). For this reason, the report takes a pragmatic approach and includes all paid workers employed in organizations or institutions whose primary intent is to improve health as well as those whose personal actions are primarily intended to improve health but who work for other types of organizations. This means that the painter working for a hospital is included as is the doctor working for a mine. WHO is working to devise a more detailed, standard classification system for health workers that should permit the gold standard definition to be applied in the future (see Box 1.1). The system of counting used in this chapter allows two types of health workers to be distinguished. The first group comprises the people who deliver services – whether personal or non-personal – who are called “health service providers”; the second covers people not engaged in the direct provision of services, under the term “health management and support workers” (details are given in Box 1.1; see also Box 1.2). The report sometimes presents information for different types of health service providers, although such detail is often available only for doctors and nurses. Further explanation of the sources of the data, classification issues, and the triangulation and harmonization applied to make the data comparable across countries is found in the Statistical Annex. The available data do not allow reporting on the people working for a part of their time to improve health, such as social workers who work with mentally ill patients. In addition, the report has chosen not to include workers in other types of occupations who contribute in vital ways to improving population health, if their main function lies elsewhere. This category includes, for instance, police officers who enforce seat-belt laws. Finally, current methods of identifying health workers do not allow unpaid carers of sick people or volunteers who provide other critical services to be counted. This exclusion is simply because of a lack of data, and all these valuable contributions are acknowledged in subsequent chapters. Furthermore, official counts of the health workforce often omit people who deliver services outside health organizations, for example doctors employed by mining companies or agricultural firms, because they classify these employees under the This report defines health workers to be all people engaged in actions whose primary intent is to enhance health
health workers: a global profile 3 Box 1.1 Classifying health workers The third version of the International Standard Classification used to define the different types of economic activity in a of Occupations(ISCO), an international classification sys- country In ISIC, health is considered a separate industry tem agreed by members of the International Labour Orga- Vast numbers of workers with different training and oc nization, was adopted in 1987 and is known as ISC0-88 (2). cupational classifications are found in the health industry: Many national occupational classifications, and most cen- many more than the health service providers themselves. suses and labour force surveys, use one of the three Isco These include professionals such as statisticians, com versions. Because the system is used to classify all types of puter programmers, accountants, managers and admin- workers, the breakdown provided for health workers is not istrators and also various types of clerical staff as well as very detailed, so many ministries of health have developed support staff such as drivers, cleaners, workers their own classification systems. WHO is now working on a and kitchen staff. Examples of the various types of occu process to devise a more detailed, standard classification pations included for the health industry classification in ystem for health workers that is consistent with the ISCo. the South African census are provided below This work coincides with the update of ISCo-88, which is Some health service providers work in industries other The table below shows the health-specific occupation- ly, for this report, health workers include all occupations al classification used in the South African census of 2001, listed under the health industry, plus people in occupa which is typical of many countries using a three-digit Isco tional groups 1-5 working in other industries. coding system( four-digit codes break down each of the The report groups health workers into two categories categories listed into subcategories). Note that traditional that map directly into the ISCO codes. People covered by healers are part of the official occupational classification occupational codes for groups 1-5 in the table are"health and are included in counts in this report where data are service providers"; other workers in the health industry are called"health management and support workers At the same nother internationally agreed clas- This is shown in the figure, where health workers make sification syster Classification of all Economic Activities(SIC)-is commonly Occupational classifications for the health industry, South African census, 2001 IScO groups of health service providers Type 1. Health professionals(except nursing 2. Nursing and midwifery professionals Professionals 4. Nursing and midwifery associate professionals 5. Traditional medicine practitioners and faith healers 324 Examples of other occupations involved in the health industry 6. Computing professionals 7. Social science and related professionals Professionals 244 8. Administrative associate professionals Associates 9. Secretaries and keyboard operating clerks 10. Painters, building structure cleaners and related trades workers Craft and related trades workers Data source: (2) Health workers in all sectors Sector Health sector All other sectors Health workforce Occupation Health service Health management and support workers All others Professionals e.g. phsc e.g. adminstrative professional in a hospial Other community .Support staf e.g.denial workers, drivers in a hospit Craft and trade workers
health workers: a global profile The third version of the International Standard Classification of Occupations (ISCO), an international classification system agreed by members of the International Labour Organization, was adopted in 1987 and is known as ISCO-88 (2). Many national occupational classifications, and most censuses and labour force surveys, use one of the three ISCO versions. Because the system is used to classify all types of workers, the breakdown provided for health workers is not very detailed, so many ministries of health have developed their own classification systems. WHO is now working on a process to devise a more detailed, standard classification system for health workers that is consistent with the ISCO. This work coincides with the update of ISCO-88, which is expected to be ready in 2008. The table below shows the health-specific occupational classification used in the South African census of 2001, which is typical of many countries using a three-digit ISCO coding system (four-digit codes break down each of the categories listed into subcategories). Note that traditional healers are part of the official occupational classification and are included in counts in this report where data are available. At the same time, another internationally agreed classification system – the International Standard Industrial Classification of all Economic Activities (ISIC) – is commonly Box 1.1 Classifying health workers Health workers in all sectors Sector Occupation Health workforce • Professionals e.g. doctor, nurse • Associates e.g. laboratory technician • Other community e.g. traditional practitioner • Professionals e.g. accountant in a hospital • Associates e.g. administrative professional in a hospital • Support staff e.g. clerical workers, drivers in a hospital • Craft and trade workers e.g. painter in a hospital e.g. physician employed in mining company Health service providers Health management and support workers Health sector Health service providers All others All other sectors Occupational classifications for the health industry, South African census, 2001 ISCO groups of health service providers Type ISCO code no. 1. Health professionals (except nursing) Professionals 222 2. Nursing and midwifery professionals Professionals 223 3. Modern health associate professionals (except nursing) Associates 322 4. Nursing and midwifery associate professionals Associates 323 5. Traditional medicine practitioners and faith healers Associates 324 Examples of other occupations involved in the health industry 6. Computing professionals Professionals 213 7. Social science and related professionals Professionals 244 8. Administrative associate professionals Associates 343 9. Secretaries and keyboard operating clerks Clerks 411 10. Painters, building structure cleaners and related trades workers Craft and related trades workers 714 Data source: (2). used to define the different types of economic activity in a country. In ISIC, health is considered a separate industry. Vast numbers of workers with different training and occupational classifications are found in the health industry: many more than the health service providers themselves. These include professionals such as statisticians, computer programmers, accountants, managers and administrators and also various types of clerical staff as well as support staff such as drivers, cleaners, laundry workers and kitchen staff. Examples of the various types of occupations included for the health industry classification in the South African census are provided below. Some health service providers work in industries other than health, such as mining or manufacturing. Accordingly, for this report, health workers include all occupations listed under the health industry, plus people in occupational groups 1–5 working in other industries. The report groups health workers into two categories that map directly into the ISCO codes. People covered by occupational codes for groups 1–5 in the table are “health service providers”; other workers in the health industry are called “health management and support workers”. This is shown in the figure, where health workers make up the first three of the four occupational boxes
4 The World Health Report 2006 The global health industries that employ them. An accurate count of such workers is difficult to obtain, but they make up between 14% and 37% workforce is of all health service providers in countries with available census data. Excluding them from official counts results in a substantial conservatively underestimation of the size of the health workforce and its potential to improve health. Such undercounting also prevents estimated to be just consideration of the complex labour market links between over 59 million different sectors that could inform planning, recruitment retention and career paths workers.. HOW MANY HEALTH WORKERS ARE THERE? The work undertaken for this report allowed wHO to update the information contained in its Global Atlas of the Health Workforce ( 3)for some countries and to find previously unavailable data for others. Data are generally more complete for health service providers than for health management and support work- ers but, using the best available information from various sources, a conservative stimate of the size of the health workforce globally is just over 59 million workers (see Table 1. 1). This figure is conservative in so far as it is likely to undercount health workers outside the health industry in countries where census information is not Health service providers account for 67% of all health workers globally, though only 57% in the Region of the Americas. a breakdown by the level of national income in a country shows that health management and support workers slightly outnumber health service providers in high income countries, while the opposite is the case in low and middle income settings where health service providers typically constitute over 70% of the total health workforce Within the category of health service providers, attention is often focused on the ratio of nurses(and midwives) to doctors, though the exact numbers and mix necessary for a health system to run efficiently and effectively remains unclear (4-8). The number of nurses per 1000 doctors for a typical country is highest in the WHO African Region, partly because of the very low number of doctors per 1000 population in that region. The ratio is lowest in the Western Pacific Region. There is also considerable heterogeneity among countries within regions. For example, there are approximately four nurses per doctor in Canada and the United States of America while some other countries in the Region of the Americas, such as Chile, El Salvador Mexico and Peru, have more doctors than nurses. Similarly, in the European Region there is nearly one physician for every nurse in Bulgaria, Portugal and Turkey, but around five nurses for each physician in Norway and the United Kingdom Box 1.2 The invisible backbone of the health system: management and support workers People who help the health system to function but do not whole Health management and support workers provide provide health services directly to the population are often an invisible backbone for health systems; if they are not gotten in discussions about the health workforce. These present in sufficient numbers and with appropriate skills, individuals perform a variety of jobs, such as distributing the system cannot function -for example, salaries are medicines, maintaining essential buildings and equipment, not paid and medicines are not delivered nd planning and setting directions for the system as a
The World Health Report 2006 industries that employ them. An accurate count of such workers is difficult to obtain, but they make up between 14% and 37% of all health service providers in countries with available census data. Excluding them from official counts results in a substantial underestimation of the size of the health workforce and its potential to improve health. Such undercounting also prevents consideration of the complex labour market links between different sectors that could inform planning, recruitment, retention and career paths. How many health workers are there? The work undertaken for this report allowed WHO to update the information contained in its Global Atlas of the Health Workforce (3) for some countries and to find previously unavailable data for others. Data are generally more complete for health service providers than for health management and support workers but, using the best available information from various sources, a conservative estimate of the size of the health workforce globally is just over 59 million workers (see Table 1.1). This figure is conservative in so far as it is likely to undercount health workers outside the health industry in countries where census information is not available. Health service providers account for 67% of all health workers globally, though only 57% in the Region of the Americas. A breakdown by the level of national income in a country shows that health management and support workers slightly outnumber health service providers in high income countries, while the opposite is the case in low and middle income settings where health service providers typically constitute over 70% of the total health workforce. Within the category of health service providers, attention is often focused on the ratio of nurses (and midwives) to doctors, though the exact numbers and mix necessary for a health system to run efficiently and effectively remains unclear (4–8). The number of nurses per 1000 doctors for a typical country is highest in the WHO African Region, partly because of the very low number of doctors per 1000 population in that region. The ratio is lowest in the Western Pacific Region. There is also considerable heterogeneity among countries within regions. For example, there are approximately four nurses per doctor in Canada and the United States of America, while some other countries in the Region of the Americas, such as Chile, El Salvador, Mexico and Peru, have more doctors than nurses. Similarly, in the European Region, there is nearly one physician for every nurse in Bulgaria, Portugal and Turkey, but around five nurses for each physician in Norway and the United Kingdom. People who help the health system to function but do not provide health services directly to the population are often forgotten in discussions about the health workforce. These individuals perform a variety of jobs, such as distributing medicines, maintaining essential buildings and equipment, and planning and setting directions for the system as a Box 1.2 The invisible backbone of the health system: management and support workers whole. Health management and support workers provide an invisible backbone for health systems; if they are not present in sufficient numbers and with appropriate skills, the system cannot function – for example, salaries are not paid and medicines are not delivered. The global health workforce is conservatively estimated to be just over 59 million workers