health workers: a global profile 5 Table 1.1 Global health workforce, by density Health management and Total health workforce Health service providers support workers Density (per total health total health WHO region Number population) workforce er workforce 1360000 280000 Eastern Mediterranean 520000 South-East asia 7040000 4.3 4730000 672300000 Western Pacific 10070000 5.87810000 782260000 Europe 16630000 18911540000 695090000 Americas 21740000 24.812460000 9280000 38333 World 5922000 9339470000 ote: All data for latest available year. For countries where data on the number of health management and support workers were not avail- ble, estimates have been made based on regional averages for countries with complete data Data source: (3) Information has also been obtained on the relative availability of dentists and pharmacists, though fewer countries report this information. There is close to parity between the number of pharmacists and doctors in the South-East Asia Region, substantially more than in the other regions. The ratio of dentists to doctors is highest in the Region of the Americas. These data should be interpreted carefully, however, because of the difficulties involved in counting dentists and pharmacists many of whom are likely to work in the private sector Public and private sector workers Most data on the distribution of health workers between the public and private sectors describe who is the primary employer of the worker rather than where the oney to pay the salary or most of the worker's income comes from. This informa tion suggests that the majority of health service providers in low and middle income countries report their primary site of employment as the public sector: over 70% of doctors and over 50% of other types of health service providers. Insufficient infor mation is available from high income countries to allow similar analysis; it is likely, however, that the proportions officially employed by governments are lower, because many providers are officially in private practice despite much of their income coming directly from the public purse. This is also true for providers employed by faith-based and nongovernmental organizations in many settings. These broad averages hide considerable variation across countries with the same level of income or in the same geographical region. For example, while 70%of doctors in sub-Saharan Africa are officially employed in the public sector, in six countries in the region more than 60%of them are formally employed in the private ector. Furthermore, even in countries where the public sector is the predominant employer, public sector employees often supplement their incomes with private work or receive a large part of their income directly from patients rather than from the government(9-11). The data presented here on the relative importance of the public sector need, therefore, to be supplemented with information on health expenditures, as discussed below
health workers: a global profile Information has also been obtained on the relative availability of dentists and pharmacists, though fewer countries report this information. There is close to parity between the number of pharmacists and doctors in the South-East Asia Region, substantially more than in the other regions. The ratio of dentists to doctors is highest in the Region of the Americas. These data should be interpreted carefully, however, because of the difficulties involved in counting dentists and pharmacists, many of whom are likely to work in the private sector. Public and private sector workers Most data on the distribution of health workers between the public and private sectors describe who is the primary employer of the worker rather than where the money to pay the salary or most of the worker’s income comes from. This information suggests that the majority of health service providers in low and middle income countries report their primary site of employment as the public sector: over 70% of doctors and over 50% of other types of health service providers. Insufficient information is available from high income countries to allow similar analysis; it is likely, however, that the proportions officially employed by governments are lower, because many providers are officially in private practice despite much of their income coming directly from the public purse. This is also true for providers employed by faith-based and nongovernmental organizations in many settings. These broad averages hide considerable variation across countries with the same level of income or in the same geographical region. For example, while 70% of doctors in sub-Saharan Africa are officially employed in the public sector, in six countries in the region more than 60% of them are formally employed in the private sector. Furthermore, even in countries where the public sector is the predominant employer, public sector employees often supplement their incomes with private work or receive a large part of their income directly from patients rather than from the government (9–11). The data presented here on the relative importance of the public sector need, therefore, to be supplemented with information on health expenditures, as discussed below. Table 1.1 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: (3)
6 The World Health Report 2006 Sex and age of health workers Figure 1.1 illustrates the average distribution of women health service providers across countries. Insufficient information is available on the sex distribution of health management and support workers for them to be included. Men continue to dominate the medical profession, while other health service providers remain predominantly 66 female. Notable exceptions exist, however. Mongolia, the Rus- The proportion sian Federation, a number of other former Soviet republics and Sudan report more female than male doctors. Moreover, women of female doctors in are making substantial progress in some regions. The propor- ion of female doctors in Europe increased steadily during the Europe increased 1990s, as did the proportion of female students in medical steadily during schools(12). In the United Kingdom, for example, women now constitute up to 70%of medical school intakes(13) the 1990s From the limited information that exists on the ages of countries. For example, an increase in the average age of the ursing workforce over time has been noted in a number of OECD countries, including the United Kingdom and the United States(14, 15). Policies relating to the official age of retirement are considered in Chapter 5. It has not been possible to document trends over time in the mix of health professionals or their characteristics in enough countries to allow a global analysis Systems for recording and updating health worker numbers often do not exist, which presents a major obstacle to developing evidence-based policies on human resource Figure 1. 1 Distribution of women in health service professions by WHo region 0g0 83 600000 Americas South-East Asia Europe Eastem Mediterranean Pacific ■ Doctors■ Nurses Others Data source: ( 3)
The World Health Report 2006 Sex and age of health workers Figure 1.1 illustrates the average distribution of women health service providers across countries. Insufficient information is available on the sex distribution of health management and support workers for them to be included. Men continue to dominate the medical profession, while other health service providers remain predominantly female. Notable exceptions exist, however. Mongolia, the Russian Federation, a number of other former Soviet republics and Sudan report more female than male doctors. Moreover, women are making substantial progress in some regions. The proportion of female doctors in Europe increased steadily during the 1990s, as did the proportion of female students in medical schools (12). In the United Kingdom, for example, women now constitute up to 70% of medical school intakes (13). From the limited information that exists on the ages of health workers in different settings, no general patterns can be observed, though some information is available for specific countries. For example, an increase in the average age of the nursing workforce over time has been noted in a number of OECD countries, including the United Kingdom and the United States (14, 15). Policies relating to the official age of retirement are considered in Chapter 5. It has not been possible to document trends over time in the mix of health professionals or their characteristics in enough countries to allow a global analysis. Systems for recording and updating health worker numbers often do not exist, which presents a major obstacle to developing evidence-based policies on human resource development. Western Pacific Eastern Mediterranean Americas South-East Asia Europe Women (% of health service providers) Doctors 100 Africa 90 80 70 60 50 40 30 20 10 0 Nurses Others Figure 1.1 Distribution of women in health service professions, by WHO region Data source: (3). The proportion of female doctors in Europe increased steadily during the 1990s
health workers: a global profile 7 Table 1. 2 Proportion of government health expenditure paid to health workers Wages, salaries and allowances of employees as pe general government WHO region Africa 29.5 14 South-East asia 35.5 2 Europe 18 Western Pacific Americas Eastern mediterranean Note: Grouped proportions are simple averages of the country proportions showing the ratio in a typical country in the region. HOW MUCH IS SPENT ON THE HEALTH WORKFORCE? The large numbers of health workers in the world make up an important part of the total labour force. In general, the relative importance of the health workforce is higher in richer countries than in poorer ones and can account for up to 13% of the total workforce. Payments of salaries and other benefits to health workers are also a significant component of total government health expenditure(including capital costs)(Table 1.2). A typical country devotes just over 42% of total general government health expenditure to paying its health workforce, though there are regional and country variations around this average(16). For example, govemments in Africa and South-East Asia typically devote lower proportions than do those in other regions Information on the non-government (i.e. private)sector by itself is not available Data have been obtained however from 43 countries on the from all sources, government and non-government, paid in A typical country salaries and other allowances. On average, payments to the health workforce account for just under 50% of total health devotes just over none-novern ent sector make yo a higher aro ortioneiof total 42% of total general itte overlap between the43 countries described here and those government health different countries, so this information should be interpreted expenditure to paying carefully. t should also be remembered that payments made by its health workforce households directly to providers, and which are not captured in 99 official records of salaries, are not included in this analysis Trends over time(1998-2003)in the ratio of wages, salaries and allowances to government health expenditure are available for only 12 countries. Trends in the share of total health expenditure paid to health workers as wages, salaries and allowances are available for another 24. Neither set of figures shows any consistent pattern. The share rose in some countries and fell in others, and the average across all countries is remarkably stable
health workers: a global profile How much is spent on the health workforce? The large numbers of health workers in the world make up an important part of the total labour force. In general, the relative importance of the health workforce is higher in richer countries than in poorer ones and can account for up to 13% of the total workforce. Payments of salaries and other benefits to health workers are also a significant component of total government health expenditure (including capital costs) (Table 1.2). A typical country devotes just over 42% of total general government health expenditure to paying its health workforce, though there are regional and country variations around this average (16). For example, governments in Africa and South-East Asia typically devote lower proportions than do those in other regions. Information on the non-government (i.e. private) sector by itself is not available. Data have been obtained, however, from 43 countries on the share of total health expenditure (including capital costs) from all sources, government and non-government, paid in salaries and other allowances. On average, payments to the health workforce account for just under 50% of total health expenditure, suggesting that payments to health workers in the non-government sector make up a higher proportion of total expenditures than in the government sector. However, there is little overlap between the 43 countries described here and those included in Table 1.2 because of the way data are reported by different countries, so this information should be interpreted carefully. It should also be remembered that payments made by households directly to providers, and which are not captured in official records of salaries, are not included in this analysis. Trends over time (1998–2003) in the ratio of wages, salaries and allowances to government health expenditure are available for only 12 countries. Trends in the share of total health expenditure paid to health workers as wages, salaries and allowances are available for another 24. Neither set of figures shows any consistent pattern. The share rose in some countries and fell in others, and the average across all countries is remarkably stable. Table 1.2 Proportion of government health expenditure paid to health workers WHO region Wages, salaries and allowances of employees as percentage of general government health expenditure (GGHE) Number of countries with available data Africa 29.5 14 South-East Asia 35.5 2 Europe 42.3 18 Western Pacific 45 7 Americas 49.8 17 Eastern Mediterranean 50.8 5 World 42.2 64 Note: Grouped proportions are simple averages of the country proportions, showing the ratio in a typical country in the region. A typical country devotes just over 42% of total general government health expenditure to paying its health workforce
8 The World Health Report 2006 WHERE ARE THE HEALTH WORKERS? Uneven distribution across the globe Health workers are distributed unevenly (17). Countries with the lowest relative need have the highest numbers of health workers, while those with the greatest burden of disease must make do with a much smaller health Countries with the workforce. This pattern is summarized in Figure 1.2, where the vertical axis shows burden of disease the horizontal axis the Lowest relative need total health expenditure. The Region of the Americas, which have the highest includes Canada and the United States, contains only 10% of the global burden of disease, yet almost 37%of the world's numbers of health health workers live in this region and spend more than 50% of the worlds financial resources for health In contrast the workers African Region suffers more than 24% of the global burden of 99 disease but has access to only 3% of health workers and less than 1% of the world's financial resources -even with loans and grants from abroad Uneven spread within countries Within regions and countries, access to health workers is also unequal. For example, Viet Nam averages just over one health service provider per 1000 people, but this figure hides considerable variation. In fact, 37 of Viet Nams 61 provinces fall below this national average, while at the other extreme one province counts almost four health service providers per 1000(20). Similar variations exist in other countries (21) Many factors influence the geographical variation that is observed in I worker density Areas with teaching hospitals and a population that can afford to pay for health services invariably attract more health workers than regions without such facilities or financial support. As a result, health worker density is generally highest in urban centres where teaching hospitals and high incomes are most common a though the extent of urbanization increases across countries with increasing come, in countries of all income levels the proportion of health professionals living in urban areas exceeds the proportion of the general population found there. This is particularly the case for doctors, as shown in Figure 1.3, where the red dotted line shows that, while under 55% of all people live in urban areas, more than 75% of doctors over 60% of nurses and 58% of other health workers also live in urban In many countries, female health service providers are particularly scarce in rural as, a situation that may arise in part because it is unsafe for female workers to live alone in some isolated areas. The picture may well be different if traditional birth attendants and village volunteers could be included in the calculations, as these are s rarely routine available. Moreover, there are some notable exceptions. For example, Ethiopia and Pakistan are among the countries that have actively sought to recruit and train female health workers in rural areas: they are called health extension workers in Ethiopia and lady health workers and lady health visitors in Pakistan WHO is developing a tool to help countries to identify their health service resources, including where their health workers are to be found(see Box 1. 3)
The World Health Report 2006 Where are the health workers? Uneven distribution across the globe Health workers are distributed unevenly (17). Countries with the lowest relative need have the highest numbers of health workers, while those with the greatest burden of disease must make do with a much smaller health workforce. This pattern is summarized in Figure 1.2, where the vertical axis shows burden of disease, the horizontal axis the number of health workers, and the size of the dots represents total health expenditure. The Region of the Americas, which includes Canada and the United States, contains only 10% of the global burden of disease, yet almost 37% of the world’s health workers live in this region and spend more than 50% of the world’s financial resources for health. In contrast, the African Region suffers more than 24% of the global burden of disease but has access to only 3% of health workers and less than 1% of the world’s financial resources – even with loans and grants from abroad. Uneven spread within countries Within regions and countries, access to health workers is also unequal. For example, Viet Nam averages just over one health service provider per 1000 people, but this figure hides considerable variation. In fact, 37 of Viet Nam’s 61 provinces fall below this national average, while at the other extreme one province counts almost four health service providers per 1000 (20). Similar variations exist in other countries (21). Many factors influence the geographical variation that is observed in health worker density. Areas with teaching hospitals and a population that can afford to pay for health services invariably attract more health workers than regions without such facilities or financial support. As a result, health worker density is generally highest in urban centres where teaching hospitals and high incomes are most common. Although the extent of urbanization increases across countries with increasing income, in countries of all income levels the proportion of health professionals living in urban areas exceeds the proportion of the general population found there. This is particularly the case for doctors, as shown in Figure 1.3, where the red dotted line shows that, while under 55% of all people live in urban areas, more than 75% of doctors, over 60% of nurses and 58% of other health workers also live in urban areas. In many countries, female health service providers are particularly scarce in rural areas, a situation that may arise in part because it is unsafe for female workers to live alone in some isolated areas. The picture may well be different if traditional birth attendants and village volunteers could be included in the calculations, as these are the domains of women in many countries, but this information is rarely routinely available. Moreover, there are some notable exceptions. For example, Ethiopia and Pakistan are among the countries that have actively sought to recruit and train female health workers in rural areas: they are called health extension workers in Ethiopia and lady health workers and lady health visitors in Pakistan. WHO is developing a tool to help countries to identify their health service resources, including where their health workers are to be found (see Box 1.3). Countries with the lowest relative need have the highest numbers of health workers
health workers: a global profile 9 Figure 1.2 Distribution of health workers by level of health expenditure and burden of disease, by WHO region South-East Asia ss25Africa Westem Pacific 0505 Eastem mediterranean of global workforce Data sources: (3, 18, 19). ARE THERE ENOUGH HEALTH WORKERS? How important is the uneven geographical distribution of health workers within countries? Perfect equality is not feasible, and in some cases it is not even desirable. For instance, teaching hospitals must be strategically located, and a concentration of certain types of health workers around hospitals can be completely acceptable But while some degree of geographical variation in health worker numbers is appropri- ate, the question remains: to what degree? Although available data do not allow a simple response, coverage rates of key interventions are generally lower in areas with relatively low numbers of health workers, compared with those that have higher concentrations. This relationship can be observed across countries and within them. For example, researchers have recently found that countries with a higher density of health workers attain higher levels of measles vaccination and coverage with antenatal care(23-25) Figure 1.3 Rural-urban distribution of health service providers 三8 65 Line of' spatial equality Doctors Nurses Data sources: 3, 22)
health workers: a global profile Are there enough health workers? How important is the uneven geographical distribution of health workers within countries? Perfect equality is not feasible, and in some cases it is not even desirable. For instance, teaching hospitals must be strategically located, and a concentration of certain types of health workers around hospitals can be completely acceptable. But while some degree of geographical variation in health worker numbers is appropriate, the question remains: to what degree? Although available data do not allow a simple response, coverage rates of key interventions are generally lower in areas with relatively low numbers of health workers, compared with those that have higher concentrations. This relationship can be observed across countries and within them. For example, researchers have recently found that countries with a higher density of health workers attain higher levels of measles vaccination and coverage with antenatal care (23–25). Western Pacific Eastern Mediterranean Europe South-East Asia Americas % of global burden of disease 35 Africa 0 Figure 1.2 Distribution of health workers by level of health expenditure and burden of disease, by WHO region Data sources: (3, 18, 19). 0 5 10 15 20 25 30 35 40 45 % of global workforce 30 25 20 15 10 5 % in urban localities 80 Doctors 55 50 Figure 1.3 Rural–urban distribution of health service providers Data sources: (3, 22). Nurses Others Line of spatial equality (% of world population in urban localities) 75 70 65 60