10 The World Health Report 2006 n the availability of health interventions suggests that the public's health suffers when health workers are scarce(20, 21, 25-27). This raises the more fundamental issue of whether there are enough health workers. Methodologically, there are no gold standards for assessing sufficiency. The following section examines sufficiency from the perspective of Box 1.3 Where are the health workers? Service Availability Mapping To help national decision-makers obtain information rapidly, systems/serviceavailabilitymapping/en/index. htmL. WHO is working with countries to develop a tool called Ser- A rapid version of a national SAM has been applied vice Availability Mapping (SAM). Using WHO's Health Mapper in a dozen countries, providing a rich picture of services a Geographic Information System-based software pack across districts. Data on human resources include the and a questionnaire loaded on personal digital assistant density and distribution of health workers by major cadre district health teams collect critical information on health and training exposure in the last two years, unfilled posts resources, public health risks and programme implementa- and absentee rates. The figure shows the density of doc tion, in order to provide updated maps of health services. tors, clinical officers, registered and enrolled nurses and Formoreinformationseehttp://www.who.int/healthinfo/midwivescombinedper1000populationinZambia. Density of health service providers(per 1000 population) Less than 1 2 and more 260 kilometres Source: Ministry of Health, Zambia, in collaboration with WHO Map production: Public Health Mapping and GIS/WHO
10 The World Health Report 2006 The correlation between the availability of health workers and coverage of health interventions suggests that the public’s health suffers when health workers are scarce (20, 21, 25–27). This raises the more fundamental issue of whether there are enough health workers. Methodologically, there are no gold standards for assessing sufficiency. The following section examines sufficiency from the perspective of essential health needs. Box 1.3 Where are the health workers? Service Availability Mapping To help national decision-makers obtain information rapidly, WHO is working with countries to develop a tool called Service Availability Mapping (SAM). Using WHO’s Health Mapper (a Geographic Information System-based software package) and a questionnaire loaded on personal digital assistants, district health teams collect critical information on health resources, public health risks and programme implementation, in order to provide updated maps of health services. For more information, see http://www.who.int/healthinfo/ systems/serviceavailabilitymapping/en/index.html. A rapid version of a national SAM has been applied in a dozen countries, providing a rich picture of services across districts. Data on human resources include the density and distribution of health workers by major cadre and training exposure in the last two years, unfilled posts and absentee rates. The figure shows the density of doctors, clinical officers, registered and enrolled nurses and midwives, combined, per 1000 population in Zambia. Source: Ministry of Health, Zambia, in collaboration with WHO. Map production: Public Health Mapping and GIS/WHO. ��������������������������������������������������������� ����������� �������� ���������� ����� ����� ����� ����������� ������ � �� ��� ��������������
health workers: a global profile 11 Figure 1. 4 Population density of health care professionals required to ensure skilled attendance at births 品 Animum desired level of coverage 60 resold estimate per bound Doctors, nurses and midwives per 1000 population Data sources: ( 3, 30, 31) Needs-based sufficiency various estimates of the availability of health workers required to achieve a package of essential health interventions and the Millennium Development Goals(including the scaling up of interventions for HIV/AIDS) have resulted in the identification of workforce shortfalls within and across mostly low income countries. In the HIVAIDS literature, scaling up treatment with antiretrovirals was estimated to require between 0%and 50% of the available health workforce in four African countries, though less than 10% in the other 10 countries surveyed(28). In more general terms, analysts estimated that in a best case scenario for 2015 the supply of health workers would reach only 60% of the estimated need in the United Republic of Tanzania and the need would be 300% greater than the available supply in Chad(29). Furthermore, The word health report 2005 estimated that 334 000 skilled birth attendants would WHO estimates a To achieve a global assessment of shortfall, the Joint earning Initiative (JLi), a network of global health leaders shortage of more than launched by the Rockefeller Foundation, suggested that, on average, countries with fewer than 2. 5 health care professionals 4 million doctors population failed to achieve an 80% coverage rate for deliveries nurses, midwives by skilled birth attendants or for measles immunization(24) This method of defining a shortage, whether global or by and others country, is driven partly by the decision to set the minimum 99 desired level of coverage at 80% and partly by the empirical identification of health worker density associated with that level of coverage. Using a similar"threshold
health workers: a global profile 11 Needs-based sufficiency Various estimates of the availability of health workers required to achieve a package of essential health interventions and the Millennium Development Goals (including the scaling up of interventions for HIV/AIDS) have resulted in the identification of workforce shortfalls within and across mostly low income countries. In the HIV/AIDS literature, scaling up treatment with antiretrovirals was estimated to require between 20% and 50% of the available health workforce in four African countries, though less than 10% in the other 10 countries surveyed (28). In more general terms, analysts estimated that in a best case scenario for 2015 the supply of health workers would reach only 60% of the estimated need in the United Republic of Tanzania and the need would be 300% greater than the available supply in Chad (29). Furthermore, The world health report 2005 estimated that 334 000 skilled birth attendants would have to be trained globally over the coming years merely to reach 72% coverage of births (18). To achieve a global assessment of shortfall, the Joint Learning Initiative (JLI), a network of global health leaders, launched by the Rockefeller Foundation, suggested that, on average, countries with fewer than 2.5 health care professionals (counting only doctors, nurses and midwives) per 1000 population failed to achieve an 80% coverage rate for deliveries by skilled birth attendants or for measles immunization (24). This method of defining a shortage, whether global or by country, is driven partly by the decision to set the minimum desired level of coverage at 80% and partly by the empirical identification of health worker density associated with that level of coverage. Using a similar “threshold” Coverage of births by skilled birth attendants (%) 0 0 Figure 1.4 Population density of health care professionals required to ensure skilled attendance at births Data sources: (3, 30, 31). Doctors, nurses and midwives per 1000 population 1 2 3 4 Minimum desired level of coverage Lower bound (2.02) Upper bound (2.54) Threshold estimate (2.28) 100 80 60 40 20 WHO estimates a shortage of more than 4 million doctors, nurses, midwives and others
12 The World Health Report 2006 Figure 1.5 Countries with a critical shortage of health service providers (doctors, nurses and midwives) Countries with critical shortage Countries without critical shortage Data source③ method and updated information on the size of the health workforce obtained for this report, the JLl analysis has been repeated for skilled birth attendants (see Figure 1. 4). A remarkably similar threshold is found at 2.28 health care professionals per 1000 population, ranging from 2.02 to 2. 54 allowing for uncertainty The 57 countries that fall below this threshold and which fail to attain the 80% coverage level are defined as having a critical shortage Thirty-six of them are in sub-Saharan Africa( Figure 1.5). For all these countries to reach the target levels of health worker availability would require an additional 2. 4 million professionals globally(Table 1.3).(Based on the upper and lower limits of the threshold, the upper and lower limits of the estimated critical shortage are 3 million and 1.7 million, respectively. This requirement represents only three types of health service provider Multiplying the 2. 4 million shortage by 1.8, which is the average ratio of total health workers to doctors, nurses and midwives observed in all WHO regions(except Europe, where there are no critical shortages based on these criteria), the global shortage approaches 4.3 million health workers. In absolute terms, the greatest shortage occurs in South-East Asia, dominated by the needs of Bangladesh, India and Indonesia. The largest relative need exists in sub-Saharan Africa, where an increase of almost 140% is necessary to meet the hreshold These estimates highlight the critical need for more health workers in order to achieve even modest coverage for essential health interventions in the countries most in need. They are not a substitute for specific country assessments of sufficiency, nor do they detract from the fact that the effect of increasing the number of health
12 The World Health Report 2006 method and updated information on the size of the health workforce obtained for this report, the JLI analysis has been repeated for skilled birth attendants (see Figure 1.4). A remarkably similar threshold is found at 2.28 health care professionals per 1000 population, ranging from 2.02 to 2.54 allowing for uncertainty. The 57 countries that fall below this threshold and which fail to attain the 80% coverage level are defined as having a critical shortage. Thirty-six of them are in sub-Saharan Africa (Figure 1.5). For all these countries to reach the target levels of health worker availability would require an additional 2.4 million professionals globally (Table 1.3). (Based on the upper and lower limits of the threshold, the upper and lower limits of the estimated critical shortage are 3 million and 1.7 million, respectively.) This requirement represents only three types of health service provider. Multiplying the 2.4 million shortage by 1.8, which is the average ratio of total health workers to doctors, nurses and midwives observed in all WHO regions (except Europe, where there are no critical shortages based on these criteria), the global shortage approaches 4.3 million health workers. In absolute terms, the greatest shortage occurs in South-East Asia, dominated by the needs of Bangladesh, India and Indonesia. The largest relative need exists in sub-Saharan Africa, where an increase of almost 140% is necessary to meet the threshold. These estimates highlight the critical need for more health workers in order to achieve even modest coverage for essential health interventions in the countries most in need. They are not a substitute for specific country assessments of sufficiency, nor do they detract from the fact that the effect of increasing the number of health Figure 1.5 Countries with a critical shortage of health service providers (doctors, nurses and midwives) Countries without critical shortage Countries with critical shortage Data source: (3)
health workers: a global profile 13 Table 1. 3 Estimated critical shortages of doctors, nurses and midwives, by WHO region Number of countries In countries with shortages Percentage ncrease WHO region Total With shortages Total stocl shortage required Africa 36 59019 817992 Americas 5 93603 37886 South-East Asia 11623320541164001 0 Eastern Mediterranean 312613 306031 Western pacific 27260 32560 119 World 192 3355728 2358470 NA, not applicable. Data source: (3) workers depends crucially on other determinants such as levels of income and education in the community (21, 25). Furthermore, economic factors also enter the equation: shortfalls based on need can co-exist with unemployment of health workers due to local market conditions (see Chapter 6 for further discussion) ADDRESSING THE SHORTAGE HOW MUCH WILL IT COST? aking up the shortfall through training requires a significant investment. Assum- ing very rapid scaling up in which all the training is completed by 2015, the annual training costs range from a low of US$ 1.6 million per country per year to almost USS 2 billion in a large country like India. The average cost per country of USS 136 million per year is of the same order of magnitude as the estimated cost Programme(see Chapter 2). Financing it would require health expenditures to increase by USS 2.80 per person annually in the average country(the range is from USS 0.40 to just over USS 11)-an increase of approximately 11% on 2004 levels (34) The estimate is limited to doctors, nurses and midwives, the occupations for hich data on workforce numbers and training costs are most complete, so can be considered a lower limit. In the calculations, the target number of health workers has en adjusted upwards to account for population growth between 2005 and 2015 nd student intakes have also been adjusted upwards to account for attrition during and after training. Region-specific training costs that include a capital component have been used where possible, though data are limited and the results should be interpreted with caution These estimates also assume that present trends and patterns of training will continue. Other ways of helping to tackle the observed shortages, including those aimed at increasing the productivity and motivation of the current workforce, changing the skill mix of health workers, are described in subsequent chapters The additional annual cost of employing the new doctors, nurses and midwi once training has been fully scaled up is just over USS 311 million per country in 2004 prices. By 2015, to pay the salaries of the scaled-up workforce would
health workers: a global profile 13 Table 1.3 Estimated critical shortages of doctors, nurses and midwives, by WHO region WHO region Number of countries In countries with shortages Total With shortages Total stock Estimated shortage Percentage increase required Africa 46 36 590 198 817 992 139 Americas 35 5 93 603 37 886 40 South-East Asia 11 6 2 332 054 1 164 001 50 Europe 52 0 NA NA NA Eastern Mediterranean 21 7 312 613 306 031 98 Western Pacific 27 3 27 260 32 560 119 World 192 57 3 355 728 2 358 470 70 NA, not applicable. Data source: (3). workers depends crucially on other determinants such as levels of income and education in the community (21, 25). Furthermore, economic factors also enter the equation: shortfalls based on need can co-exist with unemployment of health workers due to local market conditions (see Chapter 6 for further discussion). Addressing the shortage – how much will it cost? Making up the shortfall through training requires a significant investment. Assuming very rapid scaling up in which all the training is completed by 2015, the annual training costs range from a low of US$ 1.6 million per country per year to almost US$ 2 billion in a large country like India. The average cost per country of US$ 136 million per year is of the same order of magnitude as the estimated cost of Malawi’s Emergency Human Resources Programme (see Chapter 2). Financing it would require health expenditures to increase by US$ 2.80 per person annually in the average country (the range is from US$ 0.40 to just over US$ 11) – an increase of approximately 11% on 2004 levels (34). The estimate is limited to doctors, nurses and midwives, the occupations for which data on workforce numbers and training costs are most complete, so can be considered a lower limit. In the calculations, the target number of health workers has been adjusted upwards to account for population growth between 2005 and 2015, and student intakes have also been adjusted upwards to account for attrition during and after training. Region-specific training costs that include a capital component have been used where possible, though data are limited and the results should be interpreted with caution. These estimates also assume that present trends and patterns of training will continue. Other ways of helping to tackle the observed shortages, including those aimed at increasing the productivity and motivation of the current workforce, or changing the skill mix of health workers, are described in subsequent chapters. The additional annual cost of employing the new doctors, nurses and midwives once training has been fully scaled up is just over US$ 311 million per country in 2004 prices. By 2015, to pay the salaries of the scaled-up workforce would
14 The World Health Report 2006 equire a minimum increase of US$ 7.50 per person per year in the average country This can be taken to be a lower limit cost because some level of salary increase is ikely to be necessary to retain the additional health workers in the health sector and in the country. The extent of the required increase is difficult to determine artly because salaries in the deficit countries can be up to 15 times lower than lose in countries that are popular destinations for migrants (32). The Millennium Project assumed salaries would need to double if the Millennium Development Goals vere to be achieved (33), which would increase the current annual salary cost by US$ 53 billion in the 57 countries. To put this figure into perspective, this represents an increase in the annual global wage bill for health workers of less than 5%. It would also require an increase in annual health spending by 2015 of USs 20 per person in the average country-an increase of over 75% on 2004 levels. These figures need to be interpreted with caution, particularly because labour markets for health workers are evolving rapidly as globalization increases. It is very likely, for example, that salaries in some of the countries where shortages were not identified would have to be increased as well, to ensure that their workers did not migrate to some of the deficit countries. This type of effect is difficult to predict, but the numbers reported here clearly show the need for the international community actively to support the process of strengthening human resources for health 导 Dr John Awoonor-Williams is the only doctor at Nkwanta District Hospital, Ghana, serving a population of 187 000 in a remote, vast area in the northern part of the Volta Region
14 The World Health Report 2006 require a minimum increase of US$ 7.50 per person per year in the average country. This can be taken to be a lower limit cost because some level of salary increase is likely to be necessary to retain the additional health workers in the health sector and in the country. The extent of the required increase is difficult to determine, partly because salaries in the deficit countries can be up to 15 times lower than those in countries that are popular destinations for migrants (32). The Millennium Project assumed salaries would need to double if the Millennium Development Goals were to be achieved (33), which would increase the current annual salary cost by US$ 53 billion in the 57 countries. To put this figure into perspective, this represents an increase in the annual global wage bill for health workers of less than 5%. It would also require an increase in annual health spending by 2015 of US$ 20 per person in the average country – an increase of over 75% on 2004 levels. These figures need to be interpreted with caution, particularly because labour markets for health workers are evolving rapidly as globalization increases. It is very likely, for example, that salaries in some of the countries where shortages were not identified would have to be increased as well, to ensure that their workers did not migrate to some of the deficit countries. This type of effect is difficult to predict, but the numbers reported here clearly show the need for the international community actively to support the process of strengthening human resources for health. Dr John Awoonor-Williams is the only doctor at Nkwanta District Hospital, Ghana, serving a population of 187 000 in a remote, vast area in the northern part of the Volta Region. © AFP 2005