62481 Working together for health The World Health Report 2006 WHO Library Cataloguing-in-Publication Data World Health Organization. The world health report 2006: working together for health. 1. World health – trends. 2. Health personnel – education. 3. Education, Medical. 4. Health manpower. 5. National health programs – organization and administration. 6. World Health Organization. I. Title. II. Title: Working together for health. ISBN 92 4 156317 6 (NLM classi�cation: WA 530.1) ISBN 978 92 4 156317 8 ISSN 1020-3311 © World Health Organization 2006 All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 3264; fax: +41 22 791 4857; email: bookorders@who.int). 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Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Information concerning this publication can be obtained from: World Health Report World Health Organization 1211 Geneva 27, Switzerland E-mail: whr@who.int Copies of this publication and the full report can be ordered from: bookorders@who.int This report was produced under the overall direction of Tim Evans (Assistant Director-General, Evidence and Information for Policy). The principal authors were Lincoln Chen, David Evans, Tim Evans, Ritu Sadana, Barbara Stilwell, Phyllida Travis, Wim Van Lerberghe and Pascal Zurn, assisted by Christie Aschwanden and Joanne McManus. Organizational supervision of the report was provided by Manuel M. Dayrit and Carmen Dolea. The Managing Editor of the report was Thomson Prentice. Valuable inputs in the form of contributions, peer-review, suggestions and criticisms were received from the Director-General's Of�ce, and from Maia Ambegaokar, Dina Balabanova, James Buchan, Gilles Dussault, Martin McKee and Barbara McPake. Signi�cant contributions to the analytical work were received from Mario Dal Poz, Sigrid Draeger, Norbert Dreesch, Patricia Hernandez, Yohannes Kinfu, Teena Kunjumen, Hugo Mercer, Amit Prasad, Angelica Souza and Niko Speybroek. Additional help and advice were kindly provided by Regional Directors and members of their staff. Other contributors were Sabine Ablefoni, Taghreed Adam, Alayne Adams, Chris Afford, Alan Leather, Fariba Aldarazi, Ghanim Al'Sheick, Ala Alwan, Sarah Barber, Kisalaya Basu, Jacques Baudouy, Robert Beaglehole, Habib Benzian, Karin Bergstrom, Isa Bogaert, Paul Bossyns, Jean-Marc Braichet, Hilary Brown, Paul Bunnell, Francisco Campos, Eleonora Cavagnero, Xuanhao Chan, Amélina Chaouachi, Ottorino Cosivi, Nadia Danon-Hersch, Khassoum Diallo, Alimata Diarra, Marjolein Dieleman, Dela Dovlo, Nathalie Drew, Sambe Duale, Steeve Ebener, Dominique Egger, JoAnne Epping-Jordan, Marthe-Sylvie Essengue, Edwige Faydi, Paulo Ferrinho, Noela Fitzgerald, Martin Fletcher, Helga Fogstad, Gilles Forte, Kathy Fritsch, Michelle Funk, Charles Godue, Sandy Gove, Alexandre Griekspoor, Steffen Groth, Anil Gupta, Piya Hanvoravongchai, Hande Harmanci, Lisa Hinton, Sue Ineson, Anwar Islam, Anna Iversen, PT Jayawickramarajah, Patrick Kadama, Hans Karle, Julia Karnaukhova, Guy Kegels, Meleckidzedeck Khayesi, Mireille Kingma, Stephen Kinoti, Etienne Krug, Yunkap Kwankam, Chandrakant Laharyia, Gaert Laleman, Jean Pierre Lokonga, Ana Lopes Temporão, Alessandro Loretti, Pat McCarty, Judith Mandelbaum- Schmid, Annick Manuel, Bruno Marchal, Tim Martineau, Liz Mason, Zoe Matthews, Sandra McGinnis, Abdelhay Mechbal, Remo Meloni, Nata Menabde, Phillipa Mladovski, Dominic Montagu, Jean Moore, Krishnan Natarajan, Mwansa Nkwane, John Norcini, Ezekiel Nukoro, Isabelle Nuttal, Jennifer Nyoni, Cornelius Oepen, Judith Oulton, Francis Omaswa, Mary O'Neill, Ariel Pablos-Mendez, Fred Peccaud, Margie Peden, Galina Per�lieva, Bob Pond, Raymond Pong, Amit Prasad, Usha Raman, Tom Ricketts, Robert Ridley, Arjanne Rietsema, Felix Rigoli, Barbara Rijks, Salif Samake, Benedetto Saraceno, Shekhar Saxena, Robert Scherpbier, Lee-Martin Shook-Pui, Kit Sinclair, Alaka Singh, Ronald Skeldon, Susan Skillman, Ajay Tandon, Tessa Tan-Torres Edejer, Linda Taw�k, Michel Thieren, Anke Tijstma, Nicole Valentine, Wim Van Damme, Dirk Van der Roost, Mark van Ommeren, Paul Verboom, Marko Vujicic, Lis Wagner, Eva Wallstam, Diane Whitney, Marijke Wijnroks, Paul Wing, Christiane Wiskow, Tana Wuliji, Jean Yan, Sandy Yule, Manfred Zahorka, Diana Zandi, and Lingling Zhang. Contributors to statistical tables not already mentioned were Endre Bakka, Dorjsuren Bayarsaikhan, Ties Boerma, Eduard Bos, Thomas Buettner, Veneta Cherilova, Trevor Croft, Driss Zine Eddine Elidrissi, Anton Fric, Charu Garg, Peter Ghys, Amparo Gordillo, Eleanor Gouws, Attila Hancioglu, Kenneth Hill, Chandika Indikadahena, Mie Inoue, Gareth Jones, Joses Kirigia, Jan Klavus, Joseph Kutzin, Eduardo Levcovitz, Edilberto Loaiza, Doris Ma Fat, François Pelletier, Ravi Rannan-Elyia, Hossein Salehi, Cheryl Sawyer, Kenji Shibuya, Karen Stanecki, Rubén Suárez, Emi Suzuki, Nathalie Van de Maele, Jakob Victorin, Neff Walker, Tessa Wardlaw, Charles Waza, Jens Wilkens, John Wilmoth, and many staff in WHO country of�ces, governmental departments and agencies, and international institutions. The report was edited by Leo Vita-Finzi, assisted by Barbara Campanini. Editorial, administrative and production support was provided by Shelagh Probst and Gary Walker, who also coordinated the photographs. Figures and tables were provided by Gael Kernen who also was responsible for the web site version, and other electronic media. Proofreading was by Marie Fitzsimmons. The index was prepared by June Morrison. Cover photo: © AFP 2005. © AFP 2005 and © Médecins Sans Frontières: courtesy of the World Medical Association. The World Medical Association (WMA) licenses the use of selected photographs of the Caring Physicians of the World campaign, sponsored by the P�zer Medical Humanities Initiative. The material is taken from Caring physicians of the world (WMA web site www.wma.net). Design: Reda Sadki Layout: Steve Ewart and Reda Sadki Figures: Christophe Grangier Printing coordination: Raphaël Crettaz Printed in France iii contents Message from the Director-General xiii Overview xv Why the workforce is important xv Picture of the global workforce xvi Driving forces: past and future xvii Strategies: working lifespan of entry–workforce–exit xx Entry: preparing the workforce xx Workforce: enhancing performance xxii Exit: managing migration and attrition xxii Moving forward together xxiii An imperative for action xxiii National leadership xxiii Global solidarity xxiv Plan of action xxv Moving forward together xxvi Chapter 1 Health workers: a global pro�le 1 Who are the health workers? 1 How many health workers are there? 4 Public and private sector workers 5 Sex and age of health workers 6 How much is spent on the health workforce? 7 Where are the health workers? 8 Uneven distribution across the globe 8 Uneven spread within countries 8 Are there enough health workers? 9 Needs-based suf�ciency 11 Addressing the shortage – how much will it cost? 13 Conclusion 15 iv Chapter 2 Responding to urgent health needs 19 High priority services: human resources for health and the MDGs 19 Epidemics of in-service training 20 Overburdened district staff 21 Two tiers of salaries 21 Strategy 2.1 Scale up workforce planning 22 Strategy 2.2 Capitalize on synergies across priority programmes 23 Strategy 2.3 Simplify services and delegate appropriately 23 Strategy 2.4 Secure the health and safety of health workers 24 Preparing the workforce for the growing burden of chronic diseases and injuries 24 New paradigms of care require a workforce response 25 Strategy 2.5 Deploy towards a continuum of care 25 Strategy 2.6 Foster collaboration 27 Strategy 2.7 Promote continuous learning for patient safety 28 Mobilizing for emergency needs: natural disasters and outbreaks 29 Preparedness plans can help 29 Strategy 2.8 Take a “command and control� approach 30 Strategy 2.9 Help remove sector boundaries 30 Strategy 2.10 Train appropriate health staff for emergency response 31 Strategy 2.11 Develop an emergency deployment strategy for different kinds of health workers 32 Strategy 2.12 Ensure adequate support for front-line workers 32 Working in conflict and post-conflict environments 34 Strategy 2.13 Obtain and maintain strategic information 34 Strategy 2.14 Invest in advanced planning and focused interventions 34 Strategy 2.15 Protect what works 35 Strategy 2.16 Repair and prepare 35 Strategy 2.17 Rehabilitate when stability begins 35 Conclusion 36 Chapter 3 Preparing the health workforce 41 Workforce entry: the right mix 41 The “pipeline� for recruitment 42 Training: the right institutions to produce the right workers 43 Governance 44 Getting the right balance of schools and graduates 44 Strategy 3.1 Encourage training across the health care spectrum 45 Accreditation: promoting competence and trust 46 Managing admissions to enhance diversity 46 Strategy 3.2 Develop admissions policies to reflect diversities 47 Retaining students through to graduation 47 Educational services 47 Strategy 3.3 Ensure quality and responsive curricula 47 Acquiring competencies to learn 48 Workforce of teachers 48 v Strategy 3.4 Encourage and support teaching excellence 50 Financing 50 Infrastructure and technology 52 Strategy 3.5 Find innovative ways to access teaching expertise and materials 54 Information for policy-making 54 Strategy 3.6 Evaluate institutional performance, policy options and actions 54 Rethinking recruitment: gateway to the workforce 54 Imperfect labour markets 56 Strategy 3.7 Improve recruitment performance 58 Conclusion 59 Chapter 4 Making the most of existing health workers 67 What is a well-performing health workforce? 67 What determines how health workers perform? 70 What influences health workers’ performance? 71 Job-speci�c levers 72 Strategy 4.1 Develop clear job descriptions 72 Strategy 4.2 Support norms and codes of conduct 72 Strategy 4.3 Match skills to tasks 73 Strategy 4.4 Exercise supportive supervision 75 Basic support systems 75 Strategy 4.5 Ensure appropriate remuneration 75 Strategy 4.6 Ensure adequate information and communication 80 Strategy 4.7 Improve infrastructure and supplies 81 An enabling work environment 82 Strategy 4.8 Promote lifelong learning 82 Strategy 4.9 Establish effective team management 84 Strategy 4.10 Combine responsibility with accountability 86 How are levers linked to the four dimensions of health workforce performance? 86 Availability 86 Competence 87 Responsiveness 87 Productivity 88 Conclusion 89 Chapter 5 Managing exits from the workforce 97 Ebbs and flows of migration 98 Why are health workers moving? 99 Impacts of migration 101 Strategies to manage migration 101 Source country strategies 102 Strategy 5.1 Adjust training to need and demands 102 Strategy 5.2 Improve local conditions 103 Receiving country strategies 103 vi Strategy 5.3 Ensure fair treatment of migrant workers 103 Strategy 5.4 Adopt responsible recruitment policies 103 Strategy 5.5 Provide support to human resources in source countries 104 International instruments 104 Occupational risks to health workers 105 Violence 105 Strategy 5.6 Develop and implement tactics against violence 106 Other risks 106 Strategy 5.7 Initiate and reinforce a safe work environment 107 Illness and death from HIV/AIDS 107 Change of occupation or work status 107 Choosing a reduced work week 107 Strategy 5.8 Accommodate workers’ needs and expectations 107 Health workers not employed in their �eld 108 Strategy 5.9 Target health workers outside the health sector 108 Absentees and ghost workers 108 Strategy 5.10 Keep track of the workforce 109 Retirement 109 Retirement rates and the risk of shortages 109 Health workforce ageing 110 Strategy 5.11 Develop the capacity and policy tools to manage retirement 111 The need for knowledge transfer 111 Strategy 5.12 Develop succession planning 111 Conclusion 112 Chapter 6 Formulating national health workforce strategies 119 Building trust and managing expectations 120 Strategy 6.1 Design and implement a workforce strategy that fosters trust 120 Fair and cooperative governing 121 Self-regulation 121 “Muddling through� and command-and-control 122 Watchdogs and advocates 123 A model for effective governance 123 Strategy 6.2 Ensure cooperative governance of national workforce policies 124 Strong leadership 125 Strengthening strategic intelligence 126 Strategy 6.3 Obtain better intelligence on the health workforce in national situations 126 Extent and nature of the national workforce problem 126 Action taken and further options 126 National politics around the health workforce 126 Reactions of health workers and their employers 127 Investing in workforce institutions 127 Learning from microinnovations 128 Scenario building and planning 129 Conclusion 129 vii Chapter 7 Working together, within and across countries 135 Catalysing knowledge and learning 135 A �rm foundation for information 136 Generation and management of knowledge 139 Pooling of expertise 141 Striking cooperative agreements 143 Responding to the health workforce crisis 143 An extraordinary global response is needed 144 Coalitions around emergency plans 144 Towards more worker-friendly practices 144 The imperative of suf�cient, sustained �nancing 145 A global guideline for �nancing 146 Moving forward together 147 National leadership 148 Global solidarity 149 Plan of action 150 Joint steps to the future 151 Statistical Annex Explanatory notes 155 Annex Table 1 168 Annex Table 2 178 Annex Table 3 186 Annex Table 4 190 Index 201 Figures – Overview Figure 1 Health workers save lives! xvi Figure 2 Forces driving the workforce xvii Figure 3 Countries with a critical shortage of health service providers (doctors, nurses and midwives) xviii Figure 4 Working lifespan strategies xxi Figure 5 Global stakeholder alliance xxvi Figures – Chapters Figure 1.1 Distribution of women in health service professions, by WHO region 6 Figure 1.2 Distribution of health workers by level of health expenditure and burden of disease, by WHO region 9 Figure 1.3 Rural–urban distribution of health service providers 9 viii Figure 1.4 Population density of health care professionals required to ensure skilled attendance at births 11 Figure 1.5 Countries with a critical shortage of health service providers (doctors, nurses and midwives) 12 Figure 2.1 From massive deprivation to marginal exclusion: moving up the coverage ladder 20 Figure 2.2 Optimal mix of mental health services 26 Figure 2.3 Global distribution of psychiatrists 27 Figure 3.1 Getting the mix right: challenges to health workforce production 42 Figure 3.2 Pipeline to generate and recruit the health workforce 42 Figure 3.3 Relationship of education, labour and health services markets with human resources 56 Figure 3.4 Projected time to recuperate student investments in education, Colombia, 2000 57 Figure 4.1 Patients’ perception of respectful treatment at health facilities in 19 countries 69 Figure 4.2 Levers to influence the four dimensions of health workforce performance 71 Figure 5.1 Exit routes from the health workforce 98 Figure 5.2 Health workers’ reasons to migrate in four African countries (Cameroon, South Africa, Uganda and Zimbabwe) 99 Figure 5.3 Occupations at risk of violence, Sweden 105 Figure 5.4 Ageing nurses in the United States of America 110 Figure 5.5 Age distribution of doctors 111 Figure 6.1 Organizations influencing the behaviour of health workers and the health institutions 124 Figure 7.1 Health information system (HIS) performance 136 Figure 7.2 Immunization coverage and density of health workers 139 Figure 7.3 Country priorities for health systems strengthening 145 Figure 7.4 Global stakeholder alliance 151 ix Boxes – Chapters Box 1.1 Classifying health workers 3 Box 1.2 The invisible backbone of the health system: management and support workers 4 Box 1.3 Where are the health workers? Service Availability Mapping 10 Box 2.1 Health workers and the Millennium Development Goals 21 Box 2.2 An emergency programme for human resources in Malawi 22 Box 2.3 Task shifting in the health care workforce 24 Box 2.4 Core competencies for long-term patient care 25 Box 2.5 Patient safety 28 Box 2.6 Responding to infectious disease outbreaks – SARS 29 Box 2.7 Thailand’s response to epidemics and disasters 31 Box 2.8 Protecting health systems and biomedical practice during conflicts 36 Box 3.1 Is the future of academic medicine in jeopardy? 43 Box 3.2 The public health movement in South-East Asia: regional initiatives and new schools 45 Box 3.3 Rapid growth in private education of health professionals 46 Box 3.4 Practice-based teaching, problem-based learning, and patient-focused practice all go together 49 Box 3.5 Faculty development programmes: training trainers in professional health education 50 Box 3.6 From in-service to pre-service training: Integrated Management of Childhood Illness (IMCI) 51 Box 3.7 Regionalization of training for health professionals: University of the South Paci�c and the University of the West Indies 53 Box 3.8 The evidence base to enhance performance of health educational institutions 55 Box 3.9 Pakistan’s Lady Health Workers: selection and development of new cadres 59 x Box 4.1 Infant mortality and health worker density, Viet Nam 68 Box 4.2 Differences in performance of male and female health service providers 70 Box 4.3 Job-related challenges to improving health worker performance 74 Box 4.4 Differences in salaries between countries, professions, sectors and sexes 76 Box 4.5 Incentives to enhance health workers’ performance 78 Box 4.6 Using modern communication technology to improve data, services and productivity 80 Box 4.7 What sort of training works best? 82 Box 4.8 Quality assurance, supervision and monitoring in Uganda 83 Box 4.9 Changing tasks and therefore skill needs 84 Box 4.10 The importance of management and leadership 85 Box 5.1 Turning brain drain into brain gain – the Philippines 101 Box 5.2 Recruitment agencies and migration 102 Box 5.3 Bilateral agreement between South Africa and the United Kingdom 104 Box 5.4 Strategies in action: examples of exit management 106 Box 5.5 Measures for a safe work environment: HIV/AIDS 108 Box 6.1 Self-regulation opportunities 122 Box 6.2 Human resources for health observatories in Latin America 128 Box 7.1 Seeking a common technical framework for human resources for health: a public good useful to all countries? 137 Box 7.2 Research priorities related to community health workers 140 Box 7.3 Tools for health workforce assessment and development 141 Box 7.4 Technical skills for human resource policy-making 142 xi Tables – Overview Table 1 Global health workforce, by density xvii Table 2 Ten-year plan of action xxv Tables – Chapters Table 1.1 Global health workforce, by density 5 Table 1.2 Proportion of government health expenditure paid to health workers 7 Table 1.3 Estimated critical shortages of doctors, nurses and midwives, by WHO region 13 Table 2.1 Deployment of state-employed health personnel in response to avian influenza outbreak in Turkey 33 Table 3.1 Functions of health educational institutions to generate the health workforce 44 Table 3.2 Health professional training institutions, by WHO region 44 Table 4.1 Dimensions of health workforce performance 68 Table 4.2 Human resource indicators to assess health workforce performance 71 Table 4.3 Pharmaceutical situations in public health facilities in Africa and South-East Asia 81 Table 4.4 Approaches to professional development and performance 83 Table 4.5 An aid to thinking through potential effects of levers on health workforce performance 87 Table 4.6 Health workforce performance: provisional assessment of implementation and effects of levers 88 Table 5.1 Doctors and nurses trained abroad working in OECD countries 98 Table 5.2 Doctors trained in sub-Saharan Africa working in OECD countries 100 Table 5.3 Nurses and midwives trained in sub-Saharan Africa working in OECD countries 100 Table 5.4 Statutory pensionable age 110 Table 7.1 Short description of results of three Cochrane systematic reviews on human resources for health 138 Table 7.2 Ten-year plan of action 150 xiii Message from the Director-General In 2003, before I took up the position of Director-General, I asked many leaders and decision-makers in health what they saw as the most important issues in their countries. One common theme, whether in developed or developing countries, was the crisis in human resources. There is a chronic shortage of well-trained health workers. The shortage is global, but most acutely felt in the countries that need them most. For a variety of reasons, such as the migration, illness or death of health workers, countries are unable to educate and sustain the health workforce that would improve people’s chances of survival and their well-being. People are a vital ingredient in the strengthening of health systems. But it takes a considerable investment of time and money to train health workers. That investment comes both from the individuals and from institutional subsidies or grants. Countries need their skilled workforce to stay so that their professional expertise can bene�t the population. When health workers leave to work elsewhere, there is a loss of hope and a loss of years of investment. The solution is not straightforward, and there is no consensus on how to proceed. Redressing the shortages in each individual country involves a chain of cooperation and shared intent between the public and private sector parties which fund and direct educational establishments; between those who plan and influence health service staf�ng; and between those able to make �nancial commitments to sustain or support the conditions of service of health workers. This report aims to provide clarity through presentation of the evidence gathered, as a �rst step towards addressing and resolving this urgent crisis. Dr LEE Jong-wook Director-General World Health Organization working together xv overview for health “We have to work together to ensure access to a motivated, WHY THE WORKFORCE IS IMPORTANT skilled, and supported In this �rst decade of the 21st century, immense health worker by every advances in human well-being coexist with person in every village extreme deprivation. In global health we are wit- nessing the bene�ts of new medicines and tech- everywhere.� LEE Jong-wook nologies. But there are unprecedented reversals. High-Level Forum, Paris, November 2005 Life expectancies have collapsed in some of the poorest countries to half the level of the richest – attributable to the ravages of HIV/AIDS in parts of sub-Saharan Africa and to more than a dozen “failed states�. These setbacks have been accompanied by growing fears, in rich and poor countries alike, of new infectious threats such as SARS and avian influenza and “hidden� behavioural conditions such as mental disorders and domestic violence. The world community has suf�cient �nancial resources and technolo- At the heart of each and every health system, gies to tackle most of these health challenges; yet today many national the workforce is central to advancing health. There health systems are weak, unresponsive, inequitable – even unsafe. is ample evidence that worker numbers and quality What is needed now is political will to implement national plans, together are positively associated with immunization cov- with international cooperation to align resources, harness knowledge erage, outreach of primary care, and infant, child and build robust health systems for treating and preventing disease and maternal survival (see Figure 1). The quality of and promoting population health. Developing capable, motivated and doctors and the density of their distribution have supported health workers is essential for overcoming bottlenecks to been shown to correlate with positive outcomes achieve national and global health goals. Health care is a labour-inten- in cardiovascular diseases. Conversely, child sive service industry. Health service providers are the personi�cation malnutrition has worsened with staff cutbacks © Médecins Sans Frontières of a system’s core values – they heal and care for people, ease pain during health sector reform. Cutting-edge quality and suffering, prevent disease and mitigate risk – the human link that improvements of health care are best initiated by connects knowledge to health action. workers themselves because they are in the unique xvi The World Health Report 2006 Figure 1 Health workers save lives! High Probability of survival Maternal survival Child survival Infant survival Low Low Density of health workers High position of identifying opportunities for innovation. In health systems, workers func- tion as gatekeepers and navigators for the effective, or wasteful, application of all other resources such as drugs, vaccines and supplies. Picture of the global workforce All of us at some stage work for health – a mother caring for her child, a son escort- ing his parents to a hospital, or a healer drawing on ancient wisdom to offer care and solace. This report considers that “Health workers are all people primarily engaged in actions with the primary intent of enhancing health�. This is consistent with the WHO de�nition of health systems as comprising all activities with the primary goal of improving health – inclusive of family caregivers, patient–provider partners, part- time workers (especially women), health volunteers and community workers. Based on new analyses of national censuses, labour surveys and statistical sources, WHO estimates there to be a total of 59.2 million full-time paid health work- ers worldwide (see Table 1). These workers are in health enterprises whose primary role is to improve health (such as health programmes operated by government or nongovernmental organizations) plus additional health workers in non-health organi- zations (such as nurses staf�ng a company or school clinic). Health service providers constitute about two thirds of the global health workforce, while the remaining third is composed of health management and support workers. Workers are not just individuals but are integral parts of functioning health teams in which each member contributes different skills and performs different functions. Countries demonstrate enormous diversity in the skill mix of health teams. The ratio of nurses to doctors ranges from nearly 8:1 in the African Region to 1.5:1 in the Western Paci�c Region. Among countries, there are approximately four nurses per doctor in Canada and the United States of America, while Chile, Peru, El Salvador and Mexico have fewer than one nurse per doctor. The spectrum of essential worker com- petencies is characterized by imbalances as seen, for example, in the dire shortage of public health specialists and health care managers in many countries. Typically, more than 70% of doctors are male while more than 70% of nurses are female – a marked gender imbalance. About two thirds of the workers are in the public sector and one third in the private sector. overview xvii Table 1 Global health workforce, by density Health management and Total health workforce Health service providers support workers Density Percentage of Percentage of (per 1000 total health total health WHO region Number population) Number workforce Number workforce Africa 1 640 000 2.3 1 360 000 83 280 000 17 Eastern 2 100 000 4.0 1 580 000 75 520 000 25 Mediterranean South-East Asia 7 040 000 4.3 4 730 000 67 2 300 000 33 Western Paci�c 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 avail- able, 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). 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 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 intensi�ed profes- Figure 2 Forces driving the workforce Driving forces Workforce challenges Health needs Numbers Demographics Shortage/excess Disease burden Epidemics Skill mix Health team balance Health systems Financing Distribution Technology Internal (urban/rural) Consumer preferences International migration Context Working conditions Labour and education Compensation Public sector reforms Non-financial incentives Globalization Workplace safety 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 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 identi�ed 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 estimates, there are currently 57 countries with critical shortages equivalent to a global de�cit of 2.4 million doctors, nurses and midwives. The proportional shortfalls are greatest in sub-Saharan Africa, although numerical de�cits are very large in South-East Asia because of its population size. Paradoxically, these insuf�ciencies 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 pro�le of health needs. Critical skills in public health and health policy and management are often in de�cit. Many workers face daunting working environments – poverty-level wages, unsupportive management, insuf�cient social recognition, and weak career development. Almost all countries suffer from maldistribution char- acterized by urban concentration and rural de�cits, but these imbalances are per- haps most disturbing from a regional perspective. The WHO Region of the Americas, 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 �nancing, 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. 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 join an increasingly ageing population, both groups rapidly urbanizing. Many of these countries are dealing with un�nished 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 speci�c health challenges. ■ 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 dif�cul- 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 modi�cation 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 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 speci�c 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 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 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 work- ers in both the public and private sectors. ■ 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 suf�cient 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. ■ 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 overview xxi Figure 4 Working lifespan strategies ENTRY: Preparing the workforce Planning Education Recruitment WORFORCE PERFORMANCE WORKFORCE: Enhancing worker performance Availability Competence Supervision Responsiveness Compensation Productivity EXIT: Systems supports Managing attrition Lifelong learning Migration Career choice Health and safety Retirement nursing schools and 375 schools of public health in aggregate are not producing suf�cient 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, certi�cation or registration). Rapid growth of the private sector in education calls for innovative stewardship to maximize the bene�ts 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 suf�ciently 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, �nan- cial incentives and regulatory enforcement. ■ 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 xxii The World Health Report 2006 and geography. Institutional weaknesses related to recruitment information and effective deployment of health workers merit serious attention, especially where there are expectations in scaling up the health workforce. Workforce: enhancing performance Strategies to improve the performance of the health workforce must initially focus on existing staff because of the time lag in training new health workers. Substantial improvements in the availability, competence, responsiveness and productivity of the workforce can be rapidly achieved through an array of low-cost and practical instruments. ■ Supervision makes a big difference. Supportive yet �rm – and fair – supervision is one of the most effective instruments available to improve the competence of individual health workers, especially when coupled with clear job descriptions and feedback on performance. Moreover, supervision can build a practical integration of new skills acquired through on-the-job training. ■ Fair and reliable compensation. Decent pay that arrives on time is crucial. The way workers are paid, for example salaried or fee-for-service, has effects on productivity and quality of care that require careful monitoring. Financial and non-�nancial incentives such as study leave or child care are more effective when packaged than provided on their own. ■ Critical support systems. No matter how motivated and skilled health workers are, they cannot do their jobs properly in facilities that lack clean water, adequate lighting, heating, vehicles, drugs, working equipment and other supplies. Deci- sions to introduce new technologies – for diagnosis, treatment or communication – should be informed in part by an assessment of their implications for the health workforce. ■ Lifelong learning should be inculcated in the workplace. This may include short- term training, encouraging staff to innovate, and fostering teamwork. Frequently, staff devise simple but effective solutions to improve performance and should be encouraged to share and act on their ideas. Exit: managing migration and attrition Unplanned or excessive exits may cause signi�cant losses of workers and compro- mise the system’s knowledge, memory and culture. In some regions, worker illness, deaths and migration together constitute a haemorrhaging that overwhelms training capacity and threatens workforce stability. Strategies to counteract workforce attri- tion include managing migration, making health a career of choice, and stemming premature sickness and retirement. ■ Managing migration of health workers involves balancing the freedom of in- dividuals to pursue work where they choose with the need to stem excessive losses from both internal migration (urban concentration and rural neglect) and international movements from poorer to richer countries. Some international mi- gration is planned, for example the import of professionals into the Eastern Medi- terranean Region, while other migrations are unplanned with deleterious health consequences. For unplanned migration, tailoring education and recruitment to rural realities, improving working conditions more generally and facilitating the return of migrants represent important retention strategies. Richer countries receiving migrants from poorer countries should adopt responsible recruitment policies, treat migrant health workers fairly, and consider entering into bilateral agreements. overview xxiii ■ Keeping health work as a career of choice for women. The majority of health workers are women and “feminization� trends are well established in the male dominated �eld of medicine. To accommodate female health workers better, more attention must be paid to their safety, including protecting them from violence. Other measures must be put in place. These include more flexible work arrange- ments to accommodate family considerations, and career tracks that promote women towards senior faculty and leadership positions more effectively. ■ Ensuring safe work environments. Outflows from the workforce caused by ill- ness, disability and death are unnecessarily high and demand priority attention especially in areas of high HIV prevalence. Strategies to minimize occupational hazards include the recognition and appropriate management of physical risks and mental stress, as well as full compliance with prevention and protection guidelines. Provision of effective prevention services and access to treatment for all health workers who become HIV-positive are the only reasonable way forward in the pursuit of universal access to HIV prevention, treatment and care. ■ Retirement planning. In an era of ageing workforces and trends towards earlier retirement, unwanted attrition can be stemmed by a range of policies. These policies can reduce incentives for early retirement, decrease the cost of employ- ing older people, recruit retirees back to work and improve conditions for older workers. Succession planning is central to preserving key competencies and skills in the workforce. MOVING FORWARD TOGETHER An imperative for action The unmistakable imperative is to strengthen the workforce so that health systems can tackle crippling diseases and achieve national and global health goals. A strong human infrastructure is fundamental to closing today’s gap between health promise and health reality and anticipating the health challenges of the 21st century. Momentum for action has grown steadily over recent years. Member States of WHO, spearheaded by health leaders from Africa, adopted two resolutions at recent World Health Assemblies calling for global action to build a workforce for national health systems, including stemming the flow of unplanned professional emigration. Europe and Latin America have promoted regional observatories in human resources for health, and the South-East Asia and Eastern Mediterranean Regional Of�ces have launched new public health training initiatives. One hundred global health leaders in the Joint Learning Initiative recommended urgent action to overcome the crisis of human resources for health. Calls for action have come from a series of High-Level Forums for the health-related MDGs in Geneva, Abuja and Paris, and two Oslo Con- sultations have nurtured a participatory stakeholder process to chart a way forward. A clear mandate has emerged for a global plan of action bringing forth national leadership backed by global solidarity. National leadership Strong country strategies require both solid technical content and a credible political process. This involves embracing the breadth of issues inherent in the entry–work- force–exit framework while cultivating trust and brokering agreements through ef- fective engagement of stakeholders in planning and implementation. In addition, national strategies are likely to be more successful if they adopt three priorities: acting now, anticipating the future, and acquiring critical capabilities. xxiv The World Health Report 2006 ■ Acting now for workforce productivity by cutting waste (such as eliminating ghost workers and absenteeism) and improving performance through compen- sation adjustments, work incentives, safer working conditions, and worker mo- bilization efforts. Better intelligence gathering is crucial in order to understand national situations and monitor progress or setbacks. ■ Anticipating the future by engaging stakeholders to craft national strategic plans through evidence-based information and scenarios on likely future trends. Sig- ni�cant growth of private education and services should be anticipated, neces- sitating the targeting of public funds for health equity, promotion and prevention. Public action in information, regulation and delegation are key functions for mixed public and private systems. ■ Acquiring critical capacities by strengthening core institutions for sound work- force development. Leadership and management development in health and other related sectors such as education and �nance is essential for strategic planning and implementation of workforce policies. Standard setting, accrediting and li- censing must be effectively established to improve the work of worker unions, educational institutions, professional associations and civil society. Global solidarity National strategies on their own, however well conceived, are insuf�cient to deal with the realities of health workforce challenges today and in the future. Strategies across countries are similarly constrained by patchy evidence, limited planning tools and a scarcity of technical expertise. Outbreaks of disease and labour market inflections transcend national boundaries, and the depth of the workforce crisis in a signi�cant group of countries requires international assistance. National leadership must there- fore be complemented by global solidarity on at least three fronts: knowledge and learning; cooperative agreements; and responsiveness to workforce crises. ■ Catalysing knowledge and learning. Low-cost but signi�cant investments in the development of better metrics for the workforce, agreement on common technical frameworks, and the identi�cation of and support for priority research will accelerate progress in all countries. Effective pooling of the diverse technical expertise and breadth of experiences can assist countries in accessing the best talent and practices. ■ Striking cooperative agreements. The growing international nature of the health workforce related to the flows of migrants, relief workers and volunteers calls for cooperative agreements to protect the rights and safety of workers and to en- hance the adoption of ethical recruitment practices. The current global situation regarding avian influenza is indicative of a more fundamental need for effective international capacity to marshal the requisite human resources for acute health and humanitarian emergencies. ■ Responding to workforce crises. The magnitude of the health workforce crisis in the world’s poorest countries cannot be overstated and requires an urgent, sustained and coordinated response from the international community. Donors must facilitate the immediate and longer-term �nancing of human resources as a health systems investment. A 50:50 guideline is recommended, whereby 50% of all international assistance funds are devoted to health systems, with half of this funding devoted to national health workforce strengthening strategies. Develop- ment �nancing policies must �nd ways to ensure that hiring ceilings are not the primary constraint to workforce expansion. All partners should critically evaluate their modalities for supporting the workforce with a view to shedding inef�cient practices and aligning more effectively with national leadership. overview xxv National leadership and global solidarity can result in signi�cant structural im- provements of the workforce in all countries, especially those with the most severe crises. Such advances would be characterized by universal access to a motivated, competent and supported health workforce, greater worker, employer and public satisfaction, and more effective stewardship of the workforce by the state, civil society and professional associations. Plan of action National leadership must urgently jump-start country-based actions and sustain them for at least a decade. Table 2 summarizes targets in the plan of action over the decade 2006–2015. ■ Immediate actions over the next few years should consist of lead countries pio- neering national plans for scaling up effective strategies, increasing investments, cutting waste, and strengthening educational institutions. Global support should accelerate progress in countries, with immediate policy attention given to intel- ligence, technical cooperation, policy alignment of �scal space and migration, and harmonization of priority initiatives and donor assistance. ■ At the decade’s mid-point, over half of all countries should have sound national plans with expanded execution of good policies and management practices concerned with workforce incentives, regulation and institutions. Global ad- vances will include shared norms and frameworks, strong technical support, and improved knowledge management. Responsible recruitment and alignment of priority programmes and development instruments to support the health work- force should be in place. ■ The decade goal in all countries is to build high-performing workforces for national health systems to respond to current and emerging challenges. This means that every country should have implemented national strategic plans and should be planning for the future, drawing on robust national capacity. Globally, Table 2 Ten-year plan of action 2006 2010 2015 Immediate Mid-point Decade Country Management Cut waste, improve Use effective managerial Sustain high performing leadership incentives practices workforce Education Revitalize education Strengthen accreditation Prepare workforce for the strategies and licensing future Planning Design national workforce Overcome barriers to Evaluate and redesign strategies implementation strategies, based on robust national capacity Global Knowledge and Develop common technical Assess performance with Share evidence-based good solidarity learning frameworks comparable metrics practices Pool expertise Fund priority research Enabling policies Advocate ethical recruitment Adhere to responsible Manage increased migratory and migrant workers’ rights recruitment guidelines flows for equity and fairness Pursue �scal space Expand �scal space for Support �scal sustainability exceptionality health Crisis response Finance national plans for Expand �nancing to half of Sustain �nancing of national 25% of crisis countries crisis countries plans for all countries in Agree on best donor Adopt 50:50 investment crisis practices for human guideline for priority resources for health programmes xxvi The World Health Report 2006 Figure 5 Global stakeholder alliance Country leadership Support and catalysis Problem-solving Political visibility Global solidarity Knowledge and information Convening Financial resources Alliance of stakeholders National governments Civil society/ nongovernmental organizations Financial institutions/donors Workers United Nations agencies Academia Others a full range of evidence-based guidelines should inform good practice for health workers. Effective cooperative agreements will minimize adverse consequences despite increased international flows of workers. Sustained international �nanc- ing should be in place to support recipient countries for the next 10 years as they scale up their workforce. Moving forward together Moving forward on the plan of action necessitates that stakeholders work together through inclusive alliances and networks – local, national and global – across health problems, professions, disciplines, ministries, sectors and countries. Cooperative structures can pool limited talent and �scal resources and promote mutual learning. Figure 5 proposes how a global workforce alliance can be launched to bring relevant stakeholders to accelerate core country programmes. A premier challenge is advocacy that promotes workforce issues to a high place on the political agenda and keeps them there. The moment is ripe for political support as problem awareness is expanding, effective solutions are emerging, and various countries are already pioneering interventions. Workforce development is a continu- ous process that is always open for improvement. However, immediate acceleration of performance can be attained in virtually all countries if well-documented solutions are applied. Some of the work should be implemented immediately; other aspects will take time. There are no short cuts and there is no time to lose. Now is the time for action, to invest in the future, and to advance health – rapidly and equitably. health workers: health workers: a global profile 1 chapter one a global pro�le 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? 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 Conclusion 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 de�nes 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 de�nition 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 information, 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. 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. Even then, the de�nition of a health action for classifying This report de�nes paid workers is not straightforward. Consider a painter employed by a hospital: the painter’s own actions do not health workers to be all improve health, though the actions of the painter’s employer, the hospital, do. Then take the case of a doctor employed by people engaged a mining company to care for its employees: the actions of the doctor improve health, though the actions of the employer do in actions whose not. A classi�cation 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 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 suf�cient 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 classi�cation system for health workers that should permit the gold standard de�nition 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 �rst 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, classi�cation 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 of�cers 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, of�cial counts of the health workforce often omit people who deliver services outside health organizations, for example doctors employed by mining companies or agricultural �rms, because they classify these employees under the health workers: a global profile 3 Box 1.1 Classifying health workers The third version of the International Standard Classi�cation used to de�ne the different types of economic activity in a of Occupations (ISCO), an international classi�cation 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 ISCO-88 (2). cupational classi�cations are found in the health industry: Many national occupational classi�cations, 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, laundry workers their own classi�cation systems. WHO is now working on a and kitchen staff. Examples of the various types of occu- process to devise a more detailed, standard classi�cation pations included for the health industry classi�cation in system 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 expected to be ready in 2008. than health, such as mining or manufacturing. According- The table below shows the health-speci�c occupation- ly, for this report, health workers include all occupations al classi�cation 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 of�cial occupational classi�cation 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 available. are called “health management and support workers�. At the same time, another internationally agreed clas- This is shown in the �gure, where health workers make si�cation system – the International Standard Industrial up the �rst three of the four occupational boxes. Classi�cation of all Economic Activities (ISIC) – is commonly Occupational classi�cations 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). Health workers in all sectors Sector Health sector All other sectors Health workforce Health service Health management Health service Occupation providers and support workers providers All others • Professionals • Professionals e.g. physician e.g. doctor, nurse e.g. accountant in a hospital employed in mining • Associates • Associates company e.g. laboratory e.g. administrative technician professional in a hospital • Other community • Support staff e.g. traditional e.g. clerical workers, drivers in a hospital practitioner • Craft and trade workers e.g. painter in a hospital 4 The World Health Report 2006 industries that employ them. An accurate count of such workers The global health is dif�cult 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 of�cial 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 different sectors that could inform planning, recruitment, over 59 million 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 �nd 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 estimate of the size of the health workforce globally is just over 59 million workers (see Table 1.1). This �gure 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 ef�ciently 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 Paci�c 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 �ve 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 forgotten in discussions about the health workforce. These present in suf�cient 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. and planning and setting directions for the system as a 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 Percentage of Percentage of (per 1000 total health total health WHO region Number population) Number workforce Number workforce Africa 1 640 000 2.3 1 360 000 83 280 000 17 Eastern 2 100 000 4.0 1 580 000 75 520 000 25 Mediterranean South-East Asia 7 040 000 4.3 4 730 000 67 2 300 000 33 Western Paci�c 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 avail- able, 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 dif�culties 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 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. Insuf�cient infor- mation is available from high income countries to allow similar analysis; it is likely, however, that the proportions of�cially employed by governments are lower, because many providers are of�cially 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 of�cially 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. 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. Insuf�cient 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 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- tion of female doctors in Europe increased steadily during the Europe increased 1990s, as did the proportion of female students in medical schools (12). In the United Kingdom, for example, women now steadily during constitute up to 70% of medical school intakes (13). From the limited information that exists on the ages of the 1990s health workers in different settings, no general patterns can be observed, though some information is available for speci�c 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 of�cial 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. Figure 1.1 Distribution of women in health service professions, by WHO region 100 90 Women (% of health service providers) 80 70 60 50 40 30 20 10 0 Africa Americas South-East Asia Europe Eastern Western Mediterranean Pacific Doctors Nurses Others Data source: (3). 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 percentage of general government health Number of countries WHO region expenditure (GGHE) with available data Africa 29.5 14 South-East Asia 35.5 2 Europe 42.3 18 Western Paci�c 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. 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 bene�ts to health workers are also a signi�cant 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 A typical country health workforce account for just under 50% of total health devotes just over expenditure, suggesting that payments to health workers in the non-government sector make up a higher proportion of total 42% of total general expenditures than in the government sector. However, there is little overlap between the 43 countries described here and those government health included in Table 1.2 because of the way data are reported by different countries, so this information should be interpreted expenditure to paying carefully. It should also be remembered that payments made by households directly to providers, and which are not captured in its health workforce of�cial 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 �gures shows any consistent pattern. The share rose in some countries and fell in others, and the average across all countries is remarkably stable. 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 workforce. This pattern is summarized in Figure 1.2, where the Countries with the vertical axis shows burden of disease, the horizontal axis the number of health workers, and the size of the dots represents 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 world’s �nancial resources for health. In contrast, the workers 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 �nancial 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 �gure 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 �nancial 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). 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 35 30 South-East Asia % of global burden of disease 25 Africa 20 Western Pacific 15 Europe Americas 10 Eastern Mediterranean 5 0 0 5 10 15 20 25 30 35 40 45 % 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 80 75 % in urban localities 70 65 60 Line of spatial equality (% of world population 55 in urban localities) Doctors Nurses Others 50 Data sources: (3, 22). 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 suf�ciency. The following section examines suf�ciency 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, 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 package) across districts. Data on human resources include the and a questionnaire loaded on personal digital assistants, 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, un�lled posts resources, public health risks and programme implementa- and absentee rates. The �gure shows the density of doc- tion, in order to provide updated maps of health services. tors, clinical of�cers, registered and enrolled nurses and For more information, see http://www.who.int/healthinfo/ 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 100 Coverage of births by skilled birth attendants (%) 80 Minimum desired level of coverage 60 40 Threshold estimate (2.28) 20 Lower bound Upper bound (2.02) (2.54) 0 0 1 2 3 4 Doctors, nurses and midwives per 1000 population Data sources: (3, 30, 31). Needs-based suf�ciency 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 identi�cation 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 WHO estimates a Learning Initiative (JLI), a network of global health leaders, launched by the Rockefeller Foundation, suggested that, on shortage of more than average, countries with fewer than 2.5 health care professionals (counting only doctors, nurses and midwives) per 1000 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 desired level of coverage at 80% and partly by the empirical identi�cation of health worker density associated with that level of coverage. Using a similar “threshold� 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 source: (3). 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 de�ned 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 speci�c country assessments of suf�ciency, nor do they detract from the fact that the effect of increasing the number of health 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 Estimated increase WHO region Total With shortages Total stock shortage 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 21 7 312 613 306 031 98 Mediterranean Western Paci�c 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 signi�cant 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 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-speci�c 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 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 dif�cult to determine, partly because salaries in the de�cit 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 �gure 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 �gures 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 identi�ed would have to be increased as well, to ensure that their workers did not migrate to some of the de�cit countries. This type of effect is dif�cult 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. © AFP 2005 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. health workers: a global profile 15 CONCLUSION The global pro�le presented here shows that there are more than 59 million health workers in the world, distributed unequally between and within countries. They are found predominantly in richer areas where health needs are less severe. Their num- bers remain woefully insuf�cient to meet health needs, with the total shortage being in the order of 4.3 million workers. The pro�le also shows how much is not known. Information on skill mix, age pro�les, sources of income, geographical location, and other characteristics that are important for policy development is far from complete. One reason for this is the variation between countries in the de�nitions used to categorize health workers, which makes it dif�cult to ensure that the same people are being included as part of the health workforce in different settings. WHO is confronting this issue by developing a standard classi�cation of health workers in collaboration with countries and other partners. The other reason is simply the lack of data. In some countries, information on the total size of the health workforce is not routinely collected, while little is known about certain categories of health workers even in countries with extensive data reporting systems. The lack of reliable, up-to-date information greatly restricts the ability of policy-makers at national and international levels to develop evidence- based strategies to resolve the health workforce crisis, or to develop health systems to serve the needs of disadvantaged populations. Relatively small investments by the global community in this area could well have substantial returns. Chapter 7 returns to this issue and suggests some possible solutions. Meanwhile, Chapter 2 discusses some of the most important challenges that face the global health workforce today. REFERENCES 1. Dal Poz MR, Kinfu Y, Dräger S, Kunjumen T, Diallo K. Counting health workers: de�nitions, data, methods and global results. Geneva, World Health Organization, 2006 (background paper for The world health report 2006; available at: http://www.who. int/hrh/documents/en/). 2. International Labour Organization. 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Geneva, World Health Organization, 2006 (background paper for The world health report 2006; available at: http://www.who.int/hrh/ documents/en/). responding to ur responding to urgent health needs 19 chapter two gent health needs in this chapter High-priority services: human resources for 19 health and the MDGs This chapter identi�es some of the most Preparing the workforce for the growing 24 burden of chronic diseases and injuries important performance challenges facing Mobilizing for emergency needs: health systems and the global health work- 29 natural disasters and outbreaks force today, examines the ways in which the 34 Working in conflict and post-conflict environments health workforce is meeting them, and sug- 36 Conclusion gests how these responses can be improved. These challenges are, �rst, to scale up interventions to attain the health-related MDGs; second, to shift successfully to community-based and patient-centred para- digms of care for the treatment of chronic diseases; third, to tackle the problems posed by disasters and outbreaks; and fourth, to preserve health services in conflict and post-conflict states. They have been chosen because they provide a reasonable sample of other diseases, such as tuberculosis and malaria the kinds of challenges that exist in many countries and settings. Each (1–6). Chad and the United Republic of Tanzania, of the four sections of this chapter describes the main characteristics of for example, have less than half the workforce they one performance challenge, and how the health workforce is responding require to meet essential health needs adequately or can more adequately respond. (5). It is not only health service providers who are in short supply – shortfalls exist in all categories HIGH-PRIORITY SERVICES: HUMAN of health workers including laboratory technicians, RESOURCES FOR HEALTH AND THE MDGs pharmacists, logisticians and managers. It is now widely accepted that the dire shortage of health workers in The impressive mobilization of donor funds to many places is among the most signi�cant constraints to achieving the achieve the health-related MDGs, and in particular three health-related Millennium Development Goals (MDGs): to reduce to combat HIV/AIDS, has created a new environ- child mortality, improve maternal health, and combat HIV/AIDS and ment in which a shortage of human resources has WHO 20 The World Health Report 2006 replaced �nance issues as the most serious obstacle to implementing national treat- ment plans (7). Achieving the MDGs will depend on �nding effective human resources approaches that can be implemented rapidly (6). But simply training people to deliver disease- specific interventions is unlikely to be sufficient. Such A shortage of approaches should also consider the larger health systems challenges that are related to the pervasive disadvantages as- human resources has sociated with low income. For example, there are huge dis- parities between income groups in access to facility-based replaced �nancial health services (see Figure 2.1). Systematic thinking in several areas is required to formulate issues as the most ways of recruiting and retaining health workers to provide the necessary MDG-related health actions (see Box 2.1). More ef- serious obstacle to fective human resources efforts need to employ critical evalu- ation of current behaviours. implementing national Epidemics of in-service training treatment plans The numerous projects and programmes created in response to the MDGs are replete with budget lines to train staff, but lack comprehensive workforce strategies. As a result, a great deal of effort is directed towards running short training courses, often held in hotels in other countries. The aim of most of these courses is to equip health workers or the trainers of health Figure 2.1 From massive deprivation to marginal exclusion: moving up the coverage ladder 100 Dominican Republic 1996 75 Colombia 1995 % of births in facilities Côte d'Ivoire 1998 50 Côte d'Ivoire 1994 Guatemala 1998 25 Chad 1997 Bangladesh 1993 0 1 2 3 4 5 a Asset quintiles a Asset quintiles provide an index of socioeconomic status at the household level. They divide populations into five groups (in ascending order of wealth from 1 to 5), using a methodology that combines information on household head characteristics as well as household ownership of certain assets, availability of services, and housing characteristics. Source (8). responding to urgent health needs 21 workers with the skills to deliver speci�c interventions. While trainees may welcome an expense-free trip to a major urban centre, these trips pose signi�cant opportunity costs. Staff are rarely replaced when they travel and often the same staff will attend several courses every year. Furthermore, the courses often have few links with local training institutions, and thereby opportunities are missed to involve faculty members or to contribute to the development of locally-based courses. Evaluations of short-term training in Africa in 2000–2001 led to the strong recommendation that training should be on-site as much as possible and delivered through local institutions (9). Overburdened district staff National programmes to achieve disease-speci�c MDGs place many parallel demands on district health managers and service providers, such as reading documents, �lling forms, writing reports, attending meetings and making �eld visits. These demands are often imposed by international donors, and can quickly overwhelm limited, underfunded and insuf�ciently supported district-level staff. Simply keeping up with the reporting requirements of various programmes can occupy between 10% and 20% of a district health manager’s time (10). Two tiers of salaries The onslaught of MDG-related programmes is also exerting severe pressure on salaries. In order to attract workers, well- funded programmes that are implemented through nongov- Two tiers of salaried ernmental mechanisms – notably those focused on HIV/AIDS treatment – often pay salaries that exceed local wages in the workers are emerging, public sector. As a result, two tiers of salaried workers are emerging, often within the same institution. This situation cre- often within the same ates signi�cant problems. The workers who receive less pay often feel aggrieved, resenting the fact that, for example, as an institution. This obstetric nurse they earn less than an HIV nurse. Furthermore, creates signi�cant certain critical services may not be carried out if employers are unable to provide competitive salaries to attract and maintain problems staff. Box 2.1 Health workers and the Millennium Development Goals Several constraints face the health workforce in the deliv- • unsafe conditions in the workplace; ery of interventions aimed at achieving the health-related • poor policies and practices for human resources de- Millennium Development Goals. The main problems can be velopment (poor career structures, working condi- summarized as follows: tions and remuneration); • inappropriate or inadequate training, with curricula that • lack of supportive supervision; are not needs-based; • lack of integration of services with the private • poor access to information and knowledge resources; sector; • inadequate numbers and skills of health workers; • high attrition of health workers, as a consequence of • uneven distribution of workers at different levels of ser- death from the very diseases they work to cure, or vice delivery, from national programme of�cers through because of migration. to health facility personnel; • low morale and motivation; Source: (2). 22 The World Health Report 2006 Strategy 2.1 Scale up workforce planning The enormous shortfall in the human resources needed to provide MDG-related services demands an accelerated expansion of the workforce. Workforce expansion Three factors must be present for this kind of expansion to take place – political leadership, adequate �nancing and a compre- requires political hensive plan. Before necessary reforms can take place, political leaders, leadership, adequate donors and governments alike must view the workforce as an investment to be nurtured, and not as a cost to be minimized. �nancing and a Along with strong leadership must come a commitment to de- vote the necessary funds. This funding must not only cover comprehensive plan health service providers, but also the management and support workers who provide crucial services to the front lines of the health system. The third requirement is a sensible strategy to boost the health workforce, one with short-term as well as longer-term performance goals. The strategy must be based on established human resources needs for priority programmes (2) and it must mobilize the institutions involved in both the production and management of the workforce (see Chapters 3 and 4). These three elements have converged in Malawi, where the Emergency Human Resources Programme has become a top priority for the Ministry of Health (see Box 2.2 An emergency programme for human resources in Malawi Staf�ng in Malawi’s health service is inadequate to maintain in the Ministry of Health and at local level is also being a minimum level of health care, and is particularly low even strengthened. by regional standards. It is also insuf�cient for the delivery The programme, which is supported by the Global of antiretroviral therapy and other HIV/AIDS-related services Fund to Fight AIDS, Tuberculosis and Malaria, the Unit- in response to demand. Of 27 districts, 15 have fewer than ed Kingdom Department for International Development, 1.5 nurses per facility, and �ve districts do not have even the Malawi Government and other donors, is estimated one each, while four districts have no doctor at all. HIV/ to cost about US$ 278 million. Up to US$ 98 million will AIDS-related attrition among the workforce compounds the support salary top-ups, with a further US$ 35 million for shortage. In addition, up to 800 quali�ed nurses living in improved staff housing, and US$ 64 million earmarked for Malawi choose not to work in the health sector. expansion of training capacity. In April 2004, the Ministry of Health called for action to While it is early days, the approach appears to be hav- retain current staff and prevent brain drain as a top priority, ing a positive impact. By the end of 2005, some 5400 highlighting the need to attract back into the system those doctors, nurses and other key staff were receiving the who had left it and remained in Malawi. The 6-year Emer- salary top-up and there has been a reduction in the out- gency Human Resources Programme includes: improving flow of staff from the public sector. Over 700 new health incentives for recruitment and retention of Malawian staff staff have been recruited by the government since July by 52%, gross salary increases for 11 selected professional 2004, with interviews for nearly 200 further posts cur- and technical cadres; external stop-gap recruitment of phy- rently taking place. Plans for infrastructure expansion sicians and nurses; and signi�cant expansion of domestic and additional teaching staff for Malawi training schools training capacity. The programme recognizes the need to will increase training capacity by over 50% on average, address a range of non-�nancial factors affecting reten- triple the number of doctors and nearly double the num- tion, including policies for postings and promotions, perfor- ber of registered nurses in training. While more Malawi- mance management, regrading, opportunities for training ans are being trained, expatriate doctors and nurses will and upgrading of skills, gender issues and quality of hous- continue to be relied on to �ll critical positions. ing. Human resources planning and management capacity Source: (11). responding to urgent health needs 23 Box 2.2). With the support of the international community, countries experiencing similar human resources crises should consider developing similar plans. Strategy 2.2 Capitalize on synergies across priority programmes In responding to the speci�c health challenges of the MDGs, given the urgency and the availability of �nancing, there is a tendency to plan the workforce around speci�c diseases or interventions. As mentioned, this sort of planning risks a number of inef- �ciencies that result mainly from inadequate consideration of the systemic nature of human resources and health services delivery more broadly. Increasingly, this is being recognized and important innovations are emerging. In many cases, channels for delivering these interventions can be combined to use scarce human resources more ef�ciently. The term “piggy-backing� has been coined to identify ways in which services can be added to existing delivery vehicles rather than mobilization of workers for separate, single-purpose, community-di- rected interventions. For example, the WHO Onchocerciasis Control Programme to prevent river blindness in west Africa used community-directed treatment projects to add vitamin A to ivermectin distribution. “Piggy-backing� of other treatment el- ements is also a deliberate strategy of the WHO Global Programme to Eliminate Lymphatic Filariasis (12). Strategy 2.3 Simplify services and delegate appropriately Greater ef�ciencies in workforce performance can be achieved by applying two of the cardinal rules for scaling up interventions effectively: simpli�cation and delega- tion. Simpli�cation often improves staff productivity by allowing more to be done, with greater consistency, and often by less skilled colleagues. Simplifying all basic tasks is the �rst element of the Global Polio Eradication Initiative, is crucial to the scaling up of oral rehydration therapy in Bangladesh (13), and is a core strategy of the WHO/UNAIDS 3 by 5 Initiative (14). Within the Polio Eradication Initiative, for example, all basic tasks were simpli�ed as a result of strategic decisions, technological in- novations and locally appropriate adaptation. All available human resources, from unskilled volunteers to highly skilled workers, both inside and outside the health sector, were considered to be potential “vaccinators� and, if necessary, surveil- lance of�cers (15). The WHO/UNAIDS 3 by 5 Initiative has shown that people living with HIV/AIDS can make important contributions across the spectrum of HIV/AIDS prevention and treatment services (16). In many areas, programmes aimed at integrating skills among providers of pri- mary care for children, adolescents and adults are taking place at the district and primary care level. WHO’s Integrated Management of Adolescent and Adult Illness (IMAI) and the HIV adaptation of Integrated Management of Childhood Illness (IMCI- HIV) provide a novel approach to scaling up HIV prevention, care and treatment, as well as tuberculosis care and co-management of TB/HIV/AIDS patients (see Box 2.3). Despite these promising examples, increased efforts will be required to identify pragmatic ways of working across priority programmes. Simpli�cation facilitates but is not a prerequisite of task delegation. Tasks related to service delivery can often be carried out as or even more ef�ciently by less senior staff. Task delegation is especially important in resource-constrained settings where skilled staff are in very short supply. The delegation of malaria diagnosis to volunteer health workers using village-based microscopy in Myanmar and the Philippines, for 24 The World Health Report 2006 In several southern example, has been shown to be reliable and to improve the treatment of malaria, while at the same time raising the morale and self-esteem African countries, of workers (18, 19). Plans to simplify and to delegate tasks require careful assessment death from HIV/AIDS of the intended impact. In the 1970s and 1980s, for example, tens of thousands of traditional birth attendants were trained throughout the is the largest cause of developing world (20) in the hope of improving the survival of mothers in settings where professional midwives were rare. But, after more than worker exits from the three decades of well-meant attempts, there is no convincing evidence that the training strategy has reduced maternal mortality rates (8). workforce Strategy 2.4 Secure the health and safety of health workers In several southern African countries, death from HIV/AIDS is the larg- est cause of worker exits from the workforce. Those who remain often work in under- staffed health facilities that are overburdened with patients (many with HIV/AIDS) and that have inadequate means to treat them. These working conditions, in turn, fuel low morale, burn-out and absenteeism. In light of this fact, efforts are now under way to address occupational health and safety risks through the prevention of needle-stick injuries, post-exposure prophylaxis, and increasing the supplies of protective equip- ment. More and more countries are making provisions to ensure treatment access to workers who become infected with HIV (21), and in 2005 the International Labour Organization and WHO agreed to joint guidelines designed to help workers involved in the global struggle against HIV/AIDS stay healthy (see Chapter 5). PREPARING THE WORKFORCE FOR THE GROWING BURDEN OF CHRONIC DISEASES AND INJURIES As well as those diseases which form the primary focus of the MDGs, the world is faced with a massive and growing burden of chronic diseases, which are among Box 2.3 Task shifting in the health care workforce More than 25 countries in Africa are now using a set of • placing strong emphasis on patient self-management simpli�ed operational guidelines from WHO’s Integrated and community involvement. Management of Adult and Adolescent Illness (IMAI) to train Based on this approach, tasks in many health care health workers. These guidelines clearly de�ne the tasks settings can be shifted from specialized (and there- required for chronic HIV/AIDS prevention, care, and anti- fore scarce) workers to less specialized ones. The most retroviral therapy (ART), as well as tuberculosis care and important task shift is to the patients themselves (i.e. co-management of TB/HIV/AIDS patients; they allow these self-management). The community can be progressively interventions to be delivered by nurses, clinical of�cers, involved in managing HIV/AIDS care and antiretroviral midwives and various cadres of medical assistants, working therapy for such tasks as treatment support, repeat drug together in a clinical team in the hospital outpatient facility prescriptions and simple monitoring. or in peripheral health centres. IMAI training focuses on the needs of the clinical team. Shifting tasks between health care workers and expand- The training uses adult participatory training methods ing the clinical team can relieve short-term human resource that emphasize the acquisition of skills and case prac- limitations in settings with low resources. Rapid scaling up tice, rather than just knowledge. It also considers people involves: living with HIV/AIDS as experts in their own illness and as a valuable educational resource to support the training • shifting tasks to the lowest relevant cadre; of health workers. • expanding the clinical team by including people living with AIDS; Source: (17). responding to urgent health needs 25 the world’s leading causes of death and disability. Trends indicate that they are likely to become even more important over the next decade (22). The epidemiologic importance of such conditions is matched by their direct and indirect social and economic consequences. New paradigms of care require a workforce response In recent years, the traditional focus on acute, inpatient and sub-specialty care has given way to new paradigms of care emphasizing self-management, and com- munity-based patient-centred pre-hospital care (23) (see Figure 2.2). This evolution has been accompanied by a recognition by experts, professional bodies and health workers themselves of both the inadequacies of traditional training and deployment of the workforce, and the imperative for new approaches (25–29). Strategy 2.5 Deploy towards a continuum of care Five core competencies for long-term patient care have been identi�ed: patient-cen- tred care, partnering, quality improvement, information and communication technol- ogy, and a public health perspective (see Box 2.4). The challenge is to translate these into practice through the institutions that produce and deploy the health workforce. Changes in the curriculum, new teaching methods, and innovative training models are necessary (31–33). Decisions surrounding training and recruitment must also reflect the continuum of care and take into account the distribution and type of workers required to meet the health care needs of the population. Provision of community mental health services for example relies heavily on effective education outreach programmes for police of- �cers, religious healers and social workers. Non-professional workers can help meet some of the demand for care as long as they are competent and supervised, and can draw upon professional staff when necessary to deal with complex cases. Box 2.4 Core competencies for long-term patient care PATIENT-CENTRED CARE INFORMATION AND COMMUNICATION TECHNOLOGY • Learn how to negotiate individualized care plans with • Develop information systems (e.g. patient registries), patients, taking into account their needs, values, and even if paper-based, to ensure continuity of care and preferences. planned follow-up. • Learn how to support patient self-management efforts. • Use available technology and communication systems • Learn how to organize and implement group medical vis- to exchange patient information with other health its for patients who share common health problems. care workers and to consult specialists from primary health care. PARTNERING • Work as a member of a multidisciplinary health care PUBLIC HEALTH PERSPECTIVE team. • Work in a community-based setting and conduct community outreach to promote healthy lifestyles, QUALITY IMPROVEMENT encourage responsible and safe behaviour, and re- • Design and participate in health care quality improve- duce the stigma associated with physical disability ment projects. and mental illness. • Learn to think beyond caring for one patient at a time to a “population� perspective. • Hone skills for clinical prevention. Source: (30). 26 The World Health Report 2006 Village volunteers are another largely untapped but potentially valuable resource. In Ghana in 1999, for example, the WHO Nations for Mental Health Project launched a three-year pilot project that trained volunteers selected by their communities to identify, refer and follow-up people in their villages who had mental disorders. The government has now adopted the project and it is being extended to other districts (24). It is important to recognize that the shift to community-based care should not overlook the other end of the continuum, i.e. specialist and sub-specialist care. In many parts of the world, the critical shortage of such specialists is a major constraint to the integrity of the continuum of care concept. The shortages of specialists, such as psychiatrists, in many parts of the world, means that care is often not available. Psychiatrists have a crucial role to play in managing and treating complex cases of mental disorders, in providing ongoing supervision and support to non-specialists working in the mental health �eld, and in teaching and training other mental health professionals (see Figure 2.3). The shift from hospital-based to community-based care, and the new emphasis on multidisciplinary and intersectoral approaches, means changing roles for staff as well. These changing roles present challenges for managers, health workers and regulatory agencies. Scope-of-practice regulations, designed to establish minimum standards and protect patients, can become impediments to the pursuit of change. Managers need to engage actively with health workers, listen to their requirements and present the case for service reform and new, evidence-based ways of working. The challenge for health workers is to embrace change as an opportunity for further learning and personal and professional development, given their legitimate concerns related to personal status and income. Figure 2.2 Optimal mix of mental health services Low High Long-stay facilities and specialist services Frequency of need Community Psychiatric Costs mental services in health general services hospitals Mental health services through primary health care Informal community care Self-care High Low Quantity of services needed Data source: (24). responding to urgent health needs 27 Figure 2.3 Global distribution of psychiatrists 0–0.05 0.05–0.6 0.6–2 2–9 9–28.5 Per 100 000 population Source: (34). Strategy 2.6 Foster collaboration Inherent in the new paradigm of care is a strong emphasis on collaboration and teamwork between health worker and patient. Creating a relationship that values the patient as a partner in his or her own care has been frequently shown to improve health behaviour and clinical outcomes. Extensive evidence shows that interventions designed to promote patients’ roles in the prevention and management of chronic diseases can lead to improved outcomes (31, 35, 36). What patients and their families do for themselves on a daily basis, such as engaging in physical activity, eating properly, avoiding tobacco use, sleeping regularly, and adhering to treatment plans, signi�cantly influences their health. Health workers are instrumental in helping pa- tients to initiate new behaviours and to self-manage their conditions more effectively, and thus serious attention must be paid to their communication skills (33). A team approach is required not only in the management of individuals with chronic conditions but in addressing these public health challenges more broadly. In general, care for chronic diseases is best delivered with a collaborative effort involv- ing public health specialists, policy and service planners, researchers, information technology designers, and support personnel. The multidisciplinary team in mental health includes psychiatrists, psychologists, nurses, general practitioners, occupa- tional therapists and community/social workers who can share their expertise and collaborate with each other (37). 28 The World Health Report 2006 Studies show that Strategy 2.7 Promote continuous learning for patient safety errors in health care are As health services for chronic conditions have evolved, so too has their complexity. Although much has improved, the volume of information, the not only frequent but number of medications, and the myriad of providers has led to a number of unintended consequences. There may be, for example, errors related also leading causes of to dosages, misidenti�cation of patients, insanitary or unhygienic prac- tices related to hand washing or equipment, or inadequate follow-up of mortality patients. Studies show that errors in health care are not only frequent and morbidity but are also leading causes of mortality and morbidity (33). Although awareness of errors and unsafe practices is an important �rst step in dealing with the complexities of care provision, there is also a need to develop evidence-based approaches to deal with them more effectively, such as risk management programmes, patient-centred approaches, and patient empowerment (38) (see Box 2.5). Box 2.5 Patient safety A growing body of research evidence suggests that unsafe • Identify risks and hazards in the health care environ- patient care is very common in health care systems glob- ment and act to reduce their potential to cause patient ally. No country – rich or poor – can claim to be coping fully harm. At its simplest this requires ways in which staff with the problem. can report hazards and events within the health care Caring for patients involves a complex interplay of peo- organization. Identifying problems should be seen as ple, technology, devices and medicines. Health care work- a source of learning, not blame. Reporting is of little ers must make many decisions and judgements on a daily value, however, if no action is taken. Strategies to basis, and things can and do go wrong. minimize identi�ed risks and hazards are also vital. Experience in both health care and other high-risk in- • Work safely as part of a team. Even where human re- dustries shows that errors and mistakes are often provoked sources are limited, effective teamwork can promote by weak systems. De�ciencies in system design can cre- good communication, willingness to share information ate problems at many levels including the individual clini- and effective interpersonal relationships. Effectively cian, health care team, organization and health care system. transferring information between health care work- Such de�ciencies can include a lack of clear protocols for ers is increasingly recognized as an important part of treating patients, lack of knowledge and experience among improving patient safety. Problems in teamwork can health care workers, poor supervision of junior staff, frag- lead to diagnostic delays and poor management of mented patient information and poor coordination. life-threatening events. A completely risk-free health care environment is prob- ably unattainable. Much can be done, however, to improve It is vital to ensure that patient safety is a key compo- the “error wisdom� of front-line staff. In particular, health nent of educational curricula, training programmes and care workers who are educated and trained to work to- induction schemes. Organizations have a responsibility gether well can reduce risks to patients and themselves. to provide the appropriate systems and support to enable Three core knowledge and performance requirements are their workforce to learn and apply the skills and knowl- suggested below. edge required for patient safety. Strong organizational • Communicate effectively and honestly with patients and leadership for patient safety is important. their families about the risks of health care interventions, The WHO World Alliance for Patient Safety is leading especially when things have gone wrong. Unintended the global work on patient safety. Launched in October harm to patients is often made worse by the defensive 2004, the Alliance provides a vehicle for international way that many health care organizations respond to pa- collaboration and action to coordinate, spread and ac- tients and their families after a serious event. In some celerate improvements in patient safety worldwide. This countries, secretiveness on the part of health care orga- includes international action on patient safety education nizations is associated with increased litigation. and training. More information is available at www.who. int/patientsafety. Sources: (39, 40). responding to urgent health needs 29 To improve the quality of long-term care more generally, continuing education in chronic disease management is necessary. Lifelong learning is a cornerstone of continued �tness to practice, and is closely connected to the quality of care and patient safety (25, 28). MOBILIZING FOR EMERGENCY NEEDS: NATURAL DISASTERS AND OUTBREAKS At least 40 countries worldwide are at risk of being affected by severe natural disas- ters and no country is immune to an outbreak of a highly infectious disease. Sudden catastrophic events can quickly overwhelm local and national health systems, espe- cially those that are already suffering from staff shortages or lack of funds. During disasters, local communities are the �rst to respond, followed by local and national governments. Because no society has the resources to be prepared adequately at all times, no nation can manage a major disaster or outbreak on its own. Quali�ed, experienced, and well-prepared international health personnel are usually needed to help (see Box 2.6) Furthermore, when the immediate priority of humanitarian assistance is to save lives, partnership with, and strengthening of, local institutions is often seen by ex- ternal actors as an obstacle that delays the delivery of relief. Early investment in na- tional staff is rarely considered a necessary component of an emergency response. Sub-Saharan Africa, the area of the world most severely affected by natural and man-made disasters, is particularly vulnerable in this regard (42). An international emergency response workforce has not yet been organized in a systematic way. As a result, human resource shortages remain a serious constraint to achieving better humanitarian and health outcomes. Preparedness plans can help The loss of life, illness and disease caused by outbreaks and other natural disasters can be reduced if preparedness plans are in place and easily and quickly activated. Emergency preparedness requires the availability of an up-to-date database of the Box 2.6 Responding to infectious disease outbreaks – SARS The WHO Regional Of�ce for the Western Paci�c is based Response Network, which was established in 2000. This in Manila, Philippines. In responding promptly to the SARS was very important as it provided operational support threat, it formed an outbreak response and preparedness teams with speci�c tasks, from coordination through to team. This initially drew on the expertise of WHO staff in the resource mobilization, including human resources. WHO region, but was quickly complemented by professionals in support to countries consisted of providing technical the �eld of epidemiology, infection control, laboratory diag- guidelines, on-site expertise and resource mobilization. nosis and public information. It was important that the kind of expertise developed WHO teams of epidemiologists and infection control matched the needs in each country. Among the lessons experts fanned out across the region to China, Hong Kong learnt were the need to have one focal point to coordinate (China), the Philippines, Singapore and Viet Nam. Infection partners who share a commitment and common goals, control equipment, such as masks and gowns, was dis- and the need for transparent policies and political com- patched from Manila to newly affected countries and to mitment at the country level. those considered vulnerable to an attack. The region was fortunate to have a network in place Source: (41). before SARS struck called the Global Outbreak Alert and 30 The World Health Report 2006 The loss of life, illness actual competencies of health personnel, knowledge about how to communicate risk effectively, and a way of prioritizing training needs, and disease caused by policies and actions to ensure the safety of health personnel. Comprehensive preparedness plans should include components outbreaks and other related to the way the health system needs to react, and those related to preparing the overall workforce response. Three general responses natural disasters are critical during a disaster or outbreak situation: a “command and control approach�, collaboration across sectors, and risk communica- can be reduced by tion. In turn, the plans for health workforce response should include training of appropriate staff, adequate deployment and match of skills, preparedness and protection of health workers. Strategy 2.8 Take a “command and control� approach A “command and control� approach to management is critical if resources are to be directed in a timely manner. Coordination and team work are essential but once consensus has been reached, the speed of an intervention can be enhanced if action is triggered in a directive fashion. In such situations, feedback channels must be established so that corrective action can be taken when new situations during an unfolding crisis demand changes in the direction of action. Simple management tools for supportive staff supervision using equally simple indicators facilitate the flow of information in such situations. This approach calls for the integration of existing resources, thus avoiding duplication or unnecessary diversion of human resources. It also requires the mapping of all existing resources including appropriate back-up support and response scenarios in case of loss of resources or sudden increase in demand. Another essential action that is required in order to control the rapid spread of fear and panic during disease outbreaks is risk communication. This includes conveying information about risks of infection to health workers, lay people and the media, in a way that is transparent, honest, credible and compassionate (43). Strategy 2.9 Help remove sector boundaries An “all out� response to a disaster or outbreak requires the removal of boundaries between health workers in different sectors. Preparing the workforce at all levels of the system and coordinating with other sectors greatly reduces the impact of the emergency. Collaboration with other sectors permits the best use of existing resources, prevents the often observed confusion found during initial intervention periods, and allows rapid implementation of life-saving measures. Planning speci�c roles and functions for staff in the military, transport and education sectors mini- mizes confusion and maximizes the input of scarce human resources. Moreover, as the tsunami of December 2004 and the earthquake in South Asia of October 2005 have shown, international support must be mobilized and coordinated. At international level, the Global Outbreak Alert and Response Network (GOARN)1 provides an operational framework that links international networks and institutions and keeps the international community alert to the threat of outbreaks and ready to respond. 1 http://www.who.int/csr/outbreaknetwork/en/. responding to urgent health needs 31 Strategy 2.10 Train appropriate health staff for emergency response Mounting immediate and effective responses to disasters and outbreaks as varied as earthquakes, tsunamis, hurricanes, floods, SARS and avian influenza requires an ag- ile workforce with highly specialized skills. These include the ability to carry out rapid diagnosis, surveillance, organization and logistics, containment, communications and emergency surgery, and to create temporary facilities. But emergency prepared- ness must go beyond identi�cation of skills. Training institutions and programmes must be designated where these skills are generated and updated (see Box 2.7). A weakness found in many countries is a scarcity of planning and management capacity, both to prepare for emergencies and to deal with them when they happen. Many countries simply do not have enough human resource planners and manag- ers, so new ways must be developed to produce them and to activate them when the need arises. One approach is to give supplementary training on the manage- ment of emergencies to managers who already occupy key positions in agencies or organizations likely to be involved in an emergency response. These organizations usually include hospitals, ministries of health, local government, the military, those responsible for transport and communications, civil protection, social welfare and so on. This supplementary training can be conducted by national government or nongovernmental agencies. Priority should also be given to the development of new cadres focused on emergency planning and management within the various agencies and institutions responsible for emergency management. These new cadres could be developed Box 2.7 Thailand’s response to epidemics and disasters Thailand is a middle income country (with a per capita GDP It is also important to strengthen the limited speciality of US$ 2000) that in recent years has been affected by of “�eld epidemiologists�, as they are the �rst group to SARS, the tsunami of December 2004 and avian influenza. move into disaster areas. Thailand’s Field Epidemiology In the avian influenza epidemic, 60 million chickens were Training Programme (FETP) was launched in 1980 to train killed and the government paid US$ 120 million to farmers epidemiologists with an interest in public health and to in compensation. A vertical plan for avian influenza was ap- improve epidemiological capacity within the Ministry of proved by the cabinet in January 2005, for US$ 120 million Public Health. The programme requires three years’ train- for three years, with an intensive human resources compo- ing after graduation from medical school. FETP trainees nent. In the recent epidemic, Thailand called on its 800 000 have responded rapidly to 353 health threats to date, and village health volunteers to assist in bird surveillance. These the government has started to double the intake. volunteers have existed in Thailand’s villages since the era Thailand’s �eld epidemiologists were mobilized when of primary health care. The country also used its network of the tsunami hit in December 2004. They carried out ac- 100 000 health centres, 750 public hospitals, 95 provincial tive disease surveillance in all affected districts. Data hospitals and 1330 teams in every district, who were on call were collected from all medical facilities, two shelters for 24 hours a day. displaced persons, and two forensic identi�cation cen- Balanced distribution of health workers is of the utmost tres. FETP trainees visited each site daily and collected importance in the rapid response to infectious diseases and individual case-report forms that included information on disasters. Inequitable distribution leaning towards urban disease syndrome, age, sex and nationality. These teams centres makes an effective response dif�cult: during the analysed data and identi�ed events requiring further ac- tsunami it was possible to recruit from districts around the tion. Given the threat of pandemics, governments need capital, because health workers were equitably distributed. to invest now in their human resources, before the epi- Incentives are important to facilitate balanced distribution: demics arrive. a newly graduated medical doctor receives US$ 1500 per month to go to the most remote districts, which provides Sources: (44, 45). very strong encouragement to serve in such areas. 32 The World Health Report 2006 through training, capacity assessment exercises, simulations and In responding to major using emergencies as opportunities for learning by doing. All these natural disasters or actions should be part of a national strategy for capacity develop- ment which is attuned to the different risks and levels of prepared- disease outbreaks, ness of individual countries. At the global level, training of interagency and national country skilled disaster teams needs to emphasize the importance of working effectively, ef�ciently and safely, and according to agreed benchmarks and coordination teams are standards. To that end, WHO and other members of the Inter-Agency Standing Committee are developing a Health Emergency Action Re- as essential as a large sponse Network,1 one component of which is a specialized training course aimed at improving the skills of humanitarian personnel number of trained working in the �eld. The training programme includes the necessary volunteers mix of scienti�c knowledge, technical skills, attitudes, behaviours and �eld know-how, and familiarity with standard operating proce- dures and support platforms. Strategy 2.11 Develop an emergency deployment strategy for different kinds of health workers Strategies for the deployment of different types and cadres of health workers with speci�c roles and functions during a crisis period is an essential component of an emergency preparedness plan. The plan should include a distribution of tasks across the health workforce which matches skills and capacities to anticipated health inter- ventions. Table 2.1 lists the various types of health personnel that were redeployed within Turkey’s public health care delivery system during the recent avian influenza outbreak. In addition to ministry of health personnel, those in other sectors must also be mobilized. In responding to major natural disasters or disease outbreaks, skilled disaster coordination teams are essential, particularly to manage the large number of trained volunteers that are deployed in these situations. Given the scarcity of skilled work- ers and overwhelming demand, ef�cient triage is imperative. Transferring simpli�ed tasks and skills to the right members of the workforce and avoiding “de-skilling� of highly quali�ed staff are essential components of an effective deployment of the health workforce during emergencies. Strategy 2.12 Ensure adequate support for front-line workers Staff dealing with emergencies must be supported with suf�cient transport, supplies and communications equipment. These should all be speci�ed in the emergency response plan. In the case of pandemics, providing access to prevention and treat- ment for the health workforce is a priority (46). Information about infection control measures needs to be made available and taught regularly. In accordance with clear guidelines, medicines or vaccines should be made available to front-line workers. Emergencies demand extra working hours beyond the call of duty, often leading to physical and mental exhaustion (21). Incentives and rewards, both �nancial and personal, have to be provided to compensate health workers for their extra efforts. This helps to boost morale and maintain levels of service commitment at the highest level possible. Planning for losses will further enhance preparedness (47). 1 For more information, see http://www.who.int/hac/techguidance/training/hearnet/en. responding to urgent health needs 33 Table 2.1 Deployment of state-employed health personnel in response to avian influenza outbreak in Turkey Type of health professional with respect to work locale Secondary and tertiary MOH District health level health care Primary level health care Competencies (Central) directorate (hospitals) (health centres) required in an PHS/ outbreak of GP/N/ Other Other avian influenza NM PHS GP N/NM IDS S GP N PHS S GP N/ NM HO EHT Operations management Surveillance Identi�cation of cases Veri�cation of cases * Isolation of new cases Treatment of new ** ** cases Quarantine of contacts Management of health personnel information Risk communication Management of media *** and public information Veterinary containment (culling chickens) Intersectoral issues (transport, tourism) * By central national reference laboratories. ** In Turkey only infectious disease specialists have the legal right to prescribe Tamiflu. *** Nobody but high-level MOH of�cials have the authority to speak to the media. EHT: Environmental health technician: 4 years of high school training with special emphasis on environmental health issues. GP: General practitioner: graduate of 6 years of medical school with a licence to practice medicine. HO: Health of�cer: same as nurse but only high school graduates. IDS: Infectious disease specialist: medical school graduate with 4–5 years of training. N: Nurse: 4 years of high school or university training; no difference in employment or job de�nitions though more college graduates employed in hospitals. NM: Nurse/midwife: same as nurse but trained more speci�cally to provide MCH services, including home deliveries. Other S: Other specialist: internal medicine, pediatrics, etc.: medical school graduate with 4–5 years of training. PHS: Public health specialist: medical school graduate with 3–4 years of community medicine and public health training. 34 The World Health Report 2006 WORKING IN CONFLICT AND Conflict often causes POST-CONFLICT ENVIRONMENTS Conflict often causes severe and long-lasting damage to the health severe and long- workforce. Quali�ed personnel may be killed or forced to abandon their jobs. In protracted conflicts, a number of destructive tenden- lasting damage to the cies emerge. Civilian workers flee health centres and hospitals in health workforce dangerous areas, and those in safer areas become overstaffed. Management systems collapse, working environments deteriorate and professional values decline (48). Health workers desperate to make a living may slide into practices such as taking under- the-table fees or embezzling drugs. In long-lasting conflicts, relief agencies, whose main objective is often to recruit personnel to care for refugees, may compete for the few available health workers. In such situations the local public services are almost invariably the losers (49). A severe crisis, especially if it is protracted, can radically distort the composition and diminish the competence of the health workforce. “Crash courses� intended to prepare health workers to cope with epidemics of infectious diseases and sexual violence during the acute phase of a crisis are often inadequate. Improvised training tends to continue through the post-conflict reconstruction period, as the complexities of educating health personnel are ignored and hasty initiatives – involving abbrevi- ated courses of study – are taken to �ll the gaps of key staff, such as doctors and nurses. Such distortions – which hamper the recovery of the health sector after conflicts have ended, and often demand aggressive, sustained and well-resourced strategies to remedy them – can be minimized through effective stewardship. Strategy 2.13 Obtain and maintain strategic information In the ever-changing environment of complex emergencies, those with stewardship responsibilities in the health sector have to invest from a very early stage in obtain- ing and updating strategic information on the health workforce. This means �nding out how many health workers there are, where they are, and what their capacities are. Such assessments, drawing on quantitative and qualitative information, should include all categories of health workers, whatever their status or quali�cations (not just those in the public sector). A frequently made mistake is to launch ambitious and detailed �eld studies or inventories which take too long to be useful and carry heavy opportunity costs. Efforts to obtain strategic information should be pragmatic, and a stimulus to action. Such information, even if incomplete, can help maintain a human resource focus in wider sectoral plans or initiatives. Strategy 2.14 Invest in advanced planning and focused interventions The establishment of a high-level focal point for human resources for health within the ministry of health – as in Afghanistan, where it was placed at General Directorate level – or within the body which is acting as health authority, can be a useful rallying and reference point (50). Such a move makes it more likely that advance plans for the rehabilitation of human resources will be considered when spending priorities and public expenditure management are reviewed. Mozambique, for example, made hu- man resources for health plans before conflict had ended and was able to introduce corrective measures in a timely manner (51). At the same time, action needs to be focused on and geared towards the speci�c context. In phases of acute conflict the responding to urgent health needs 35 protection of human resources will be paramount. Similarly, in times of protracted conflict, repair will be essential, as will be Even in countries rehabilitation during transition phases. in crisis, many Strategy 2.15 Protect what works During acute conflict the focus should be on maintaining and professionals work supporting what works. Box 2.8 highlights the importance of tirelessly and often protecting health systems and services during conflicts. The workforce must be marshalled to support institutional islands without salaries of dependable critical services, particularly medical supply depots and hospitals. Maintaining a number of centres of good clinical and managerial practice is paramount for safe- guarding the concept of what a functioning hospital, health centre or operational district really means. Donor funds should be channelled into structures that are still functioning in order to keep them adequately supplied and maintained. This is better than using them hastily to introduce new modes of intervention, such as mobile clinics, or to launch population-wide immunization campaigns. All this works better if it is done with the full involvement of nongovernmental organiza- tions and humanitarian agencies, and with short-term planning horizons such as the 90-day cycle used in Darfur (Sudan) and Liberia. Even in countries in crisis, there are many professionals working tirelessly at �eld level, often without salaries. To make progress the �rst need is cash to get institu- tions working, to enable those who work in them to feed themselves, and to prevent recourse to levying of user charges or pilfering of supplies. Paying decent wages to local workers is far cheaper than bringing in foreign volunteers. Strategy 2.16 Repair and prepare Protracted conflicts and complex emergencies require the initial focus to be on re- pair, on getting things working, and not on reform. Offering minimum health services in rural areas requires immediate strengthening of the health care system and the workforce. This is a dif�cult process to manage and depends partly on identifying incentives (such as monetary or career incentives) to encourage health workers to take positions in less desirable locations. Keeping a focus on repairing and preparing means: ■ redeploying health workers on an area per area or district per district basis (rather than programme per programme), in a pragmatic and flexible fashion; ■ providing protection and support to health workers; ■ taking early measures to avoid commercialization of the health sector. User charges are inef�cient and have perverse effects; ■ obtaining the commitment of the donor community and all the other major ac- tors to reach a consensus on human resource planning criteria and standards concerning support for existing networks, salary scales, contracts, and essential drug guidelines. Strategy 2.17 Rehabilitate when stability begins Once a crisis situation has begun to stabilize, the �rst need is to adopt measures to correct distortions in the labour market. These include the following: ■ Establish systems to assess the level of competence of health workers emerging from the crisis, in combination with a review of categories, job descriptions and training programmes that have proliferated during the crisis. 36 The World Health Report 2006 ■ Establish retraining to �ll gaps. Health workers who have received mostly class- room training should receive clinical training, while people who received hands- on training should in turn obtain the classroom background necessary to gain more autonomy. ■ Limit further unregulated workforce expansion. If the size of the workforce is too great, freeze recruitment and pre-service training and invest in in-service train- ing. Consideration should be given to whether it is preferable to train additional staff or whether priority should be given to retrain existing staff with limited quali�cations. ■ Emphasize medical and nursing education quite early in post-conflict situations, to re-establish educational standards, and avoid the mass training of poorly quali- �ed doctors and nurses. ■ Continue to redeploy personnel and establish health care networks in the areas that have remained excluded. ■ Extend the supply of health services, offer access to all, regardless of ability to pay, and protect against any �nancial consequences of seeking care. CONCLUSION The challenges highlighted in this chapter illustrate the spectrum of needs to which the health workforce is expected to respond. Viewing these challenges from a work- force perspective helps identify both opportunities and constraints. The speci�c as- sessments reveal a tremendous amount of diversity and at the same time a number of commonalities – working across sectors, simpli�cation of tasks, adequate support to health workers. Importantly, for the theme of this report, the imperative of working together emerges repeatedly. Collaboration across sectors for chronic diseases and emergen- cies, striking synergies across programmes for the MDGs, and bringing stakeholders together to reach consensus on strategies to protect what works in the context of conflicts makes the case for working together abundantly clear. Box 2.8 Protecting health systems and biomedical practice during conflicts Uses and misuses of biomedical and public health knowl- sions that protect the public and biomedical practitioners edge during time of war or armed conflict are commonplace. from harm (and from doing harm) both in peacetime and Public health and medical crimes such as diverting medical in times of conflict. In June 1977, for example, 27 articles, supplies and human resources, abuse and torture, medi- which are known as the “principles of medical neutrality� cal killing in the name of science, and eugenics for social in times of war, were added to the body of International goals, have been perpetrated with the complicity of health Humanitarian Law, the Protocols Additional to the Geneva and medical professionals in countries such as Bosnia and Conventions. The most recent reformulation of aid work- Herzegovina, Cambodia, Nazi Germany and Rwanda. Much ers’ competencies and responsibilities in times of conflict more frequent, though, are cases in which health profes- and man-made disasters appears in the Sphere Hand- sionals are victims themselves. The attack against Vukovar book, a document that aims to improve the quality and Hospital on the eve of the war in the former Yugoslavia, in the accountability of the humanitarian system. 1991, underscores the extreme vulnerability of health facili- The protection of health systems and biomedical ties and medical personnel operating in war zones. practice from harm requires a universal commitment. Since the Nuremberg Code in 1947 concluded the judge- As prerequisites to such a commitment, formal educa- ment of the Doctors Trial – the Medical Case of the subse- tion curricula for health professionals should gradu- quent Nuremberg Proceedings – and founded bioethics as ally incorporate studies in bioethics, human rights and an independent discipline, dozens of binding treaties, dec- humanitarian law. larations and other texts have drawn up very speci�c provi- responding to urgent health needs 37 Examining each from a workforce perspective reveals important insights not only about needs but also exciting innovations. The efforts to integrate clinical manage- ment of adult illness and the shift to competencies arising from the new paradigm of chronic care management represent important innovations in the training and de- ployment of the workforce. Harnessing and nurturing these insights and innovations should be a primary focus of more systematic planning for the health workforce. Planning for the health workforce both within these major challenges and across them is a key message that emerges from this chapter. As suggested, in conflict/ post-conflict situations, a human resources assessment is an important �rst step. When shortfalls in the existing total of health workers related to achieving service delivery targets are known, appropriately scaled (as opposed to incremental) re- sponses can be articulated. The �ndings of such assessments help create a more realistic, broader picture of the needs of the health sector. These speci�c analyses, however, point to the need for more comprehensive planning of the workforce along the lines of the entry, stock and exit model (see Overview). The call for new types of skills, workers, better standardization of skills, new programmes and retraining, places signi�cant demands on the health worker training institutions. These are discussed in more depth in Chapter 3. 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Of coping, poaching and the harm they can do. Health in Emergencies, 2003, 18:3. 50. Smith JH. Issues in post-conflict human resources development. Paper presented at: REACH–Afghanistan, Management Sciences for Health, Geneva, 12 September 2005. Geneva, World Health Organization, 2005. 51. Health service delivery in post-conflict states. High level forum on health MDGs. Paris, 14–15 November 2005 (http://www.hlfhealthmdgs.org/Documents/ HealthServiceDelivery.pdf, accessed 30 January 2006). preparing the 41 chapter three health workforce in this chapter 41 Workforce entry: the right mix Training: the right institutions to produce 43 The previous chapter provided an overview the right workers 54 Rethinking recruitment: gateway to the workforce of the enormous challenges facing the health 59 Conclusion workforce. Chapter 3 and the following two chapters deal with many of these challenges, using the framework of strategies to train, sustain and retain the workforce. This chapter is about preparation: getting it right at the beginning; giving the right train- ing to the right people to create an effective workforce for the delivery of health care. It focuses on the entry of health workers into the workforce and on the health train- ing institutions – schools, universities and training colleges – which provide them with the knowledge and competencies for the jobs they will be required to do. WORKFORCE ENTRY: THE RIGHT MIX Preparing the health workforce to work towards attainment of its (competencies). Maintaining a reasonable balance in health objectives represents one of the most important challenges terms of numbers, diversity and competencies of the and opportunities for health systems. Going beyond the traditional health workforce requires a thorough understanding notion of skill mix, this chapter extends the concept of mix to in- of the driving forces and challenges that shape health clude: how many people are trained (numbers); the degree to which and education systems as well as labour markets, as they reflect the sociocultural and demographic characteristics of depicted in Figure 3.1. This understanding, however the population (diversity); and what tasks the different levels of imperfect, can be used as a guide to policies and pos- health workers are trained to do and are capable of performing sible actions related to training and recruitment. © AFP 2005 42 The World Health Report 2006 Figure 3.1 Getting the mix right: challenges to health workforce production Drivers influencing Challenges Possible actions Desired impact worforce composition on workforce production Limited shortages - Increase class size Health needs - Shorten training time Demographics Numbers Appropriate numbers Disease burden Widespread shortages - Develop new institutions Epidemics - Increase regional cooperation Health systems Maldistribution - Select from underserved areas Financing - Locate training in underserved areas Technology Diversity Enhanced diversity Consumer preferences Homogeneity - Outreach to minorities to apply - Retention efforts during training Context Missing - New institutions, cadres Labour and education - Regional, international networks Competencies Competencies ensured Public sector reforms Globalization Ineffective - Evaluation and certification - Accreditation, licensure Source: (1). The “pipeline� for recruitment The process that leads to health workers’ entry into the workforce can be seen as one by which individuals progress through educational institutions and graduate with speci�c skills or degrees that facilitate their recruitment by employers to the health workforce (see Figure 3.2). This “pipeline� spans primary, secondary and tertiary education institutions and health services facilities that produce a range of work- ers from auxiliaries to technicians and professionals. Along the pipeline, criteria for entry to training institutions, attrition while training, and the markets for recruitment determine how many and what types of individuals move forward to become health workers. A focus on health training institutions and the markets for recruitment yields insights on how to manage entries to the health workforce in line with performance objectives. Figure 3.2 Pipeline to generate and recruit the health workforce Training institutions Potential workers - Primary - Professionals Licensing / certification - Secondary - Technicians Accreditation Pool - Tertiary - Auxiliaries of Selection Graduates Recruitment Health workforce eligibles - Professional - Community workers - Technical Attrition Migration Work in other sectors preparing the health workforce 43 TRAINING: THE RIGHT INSTITUTIONS TO PRODUCE THE RIGHT WORKERS The 20th century produced sweeping changes to the health training institutional landscape. Flexner’s seminal report in 1910 instilled a scienti�c approach to medical education that led to the closure of more than half the medical schools in the United States and strengthened public con�dence that all doctors would meet similar stan- dards of knowledge, skills and competencies (2). Less than a decade later, demand for the training of �eld workers for public health campaigns was part of the rationale for the building of schools of public health in China, the United States, Yugoslavia and many other countries (3). As part of a comprehensive plan for the development of essential health services, the Bhore report’s recommendations led to an overhaul of India’s health training institutions (4). Other major reforms with widespread impact have emphasized new types of workers such as China’s “barefoot doctors� (5, 6) or new ways of training health workers emphasizing problem solving (7). The 21st century is bringing new challenges, with many observers expressing concern that the institutional landscape is neither responding to current problems nor preparing for what lies ahead (see Box 3.1). Worldwide, increasing prevalence of chronic diseases, unanticipated disease outbreaks, and the race to meet the Millen- nium Development Goals (MDGs), place enormous expectations and responsibility on the role of health training institutions, as discussed in Chapter 2. A clearer un- derstanding of the institutional landscape is required, combined with greater support for change, so that health training institutions are more effective in responding to these challenges (9). Health training institutions undertake six key functions: stew- ardship or institutional governance; provision of educational services; selection and Box 3.1 Is the future of academic medicine in jeopardy? “Academic medicine� is often de�ned as a triad of research, education have? Most medical students and trainees clinical service, and medical education. It might also be de- appear to hold strong views on the importance of val- �ned as the capacity to study, discover, evaluate, teach, ues such as altruism, collaboration, and shared learn- and improve health systems. But many commentators and ing, and on the role of academic medical institutions reports worry that academic medicine is in crisis around to provide ethical leadership. the world. The lack of basic infrastructure in lower income • Developing a strategy to reform medical training countries means that it is floundering, if not absent. Even and enhance diversity. Overcoming signi�cant dis- in high income countries, government investments may be incentives for pursuing a career in academic medi- wasted if structural changes, such as creating better and cine, across regions and settings, is a key point for more flexible career paths, are not made. Academic medi- action. Evidence suggests that even though the intel- cine seems to be failing to realize its potential and leader- lectual rewards are appealing, the lack of pay par- ship responsibility, at a time when the disease burden and ity with clinical colleagues and the uncertainty of poverty are increasing. funding for research are major drawbacks. Others In response to these concerns, in 2003 the BMJ, the Lan- include absence of a clear career path, the lack of cet, and 40 other partners launched the International Cam- flexible training opportunities, and insuf�cient men- paign to Revitalize Academic Medicine (ICRAM), a global toring, which further detract from a supportive work initiative to debate the future of academic medicine which environment. These factors are even more salient for focuses on two issues: women. Despite the fact that mentoring is associated • Rede�ning core values of academic medicine. Even with career advancement and satisfaction, publica- though many institutions state that they promote the tion in peer-reviewed journals and success with grant goals of scienti�c excellence, innovation, and patient- applications, it is almost non-existent in academic oriented care, no consensus on a global vision for aca- medical training. demic medicine exists. What impact does introducing commercial activity and corporate models into medical Source: (8). 44 The World Health Report 2006 Table 3.1 Functions of health educational institutions to generate the health workforce Governance Managing the stock and quality of institutions across education and health sectors Educational services Orienting curriculum content and process towards professional competencies Selecting staff Deploying good quality, well supported and motivated teaching staff or trainers Ensuring adequate levels, fair �nancing for student access and ef�cient Financing coordination of sources Developing training sites and learning materials to accommodate diverse student Infrastructure and technology needs Information and knowledge Generating information to inform policy and evaluate health workforce production employment of staff members; �nancing of training; development and maintenance of infrastructure and technology; and generation of information and knowledge. These functions are described in Table 3.1. Together, they make up the system to support the generation of the health workforce and are explored in more detail in the following sections. Governance The speci�c priorities related to the number, range and quality of health train- ing institutions are: the disciplinary mix of institutions, accreditation to maintain standards, management of the applicant pool, and retention of students through to graduation. Getting the right balance of schools and graduates Globally, educational establishments training health workers are heavily tipped to- wards the production of physicians and nurses: 1691 and 5492, respectively, in contrast to 914 schools of pharmacy, 773 schools of dentistry and 375 schools of public health. The WHO Eastern Mediterranean and South-East Asia regions have remarkably fewer schools of public health (not counting departments within other schools) than other regions (see Table 3.2). In too many countries, unfortunately, data on institutions are lacking or, if available, are not part of a comprehensive strategy Table 3.2 Health professional training institutions, by WHO region Nursing and Public WHO region Medical midwifery Dental health Pharmacy Africa 66 288 34 50 57 Americas 441 947 252 112 272 South-East 295 1145 133 12 118 Asia Europe 412 1338 247 81 219 Eastern 137 225 35 8 46 Mediterranean Western Paci�c 340 1549 72 112 202 Total 1691 5492 773 375 914 Source: Mercer H, Dal Poz MR. Global health professional training capacity (background paper for The world health report 2006; http://www.who.int/hrh/documents/en/). preparing the health workforce 45 for the health workforce (10). To be able to respond to shortages or surpluses by implementing such actions as altering class sizes or opening or closing institutions, it is �rst necessary to evaluate the current capacity to train different types of work- ers, the relationship between pre-service and in-service training, and the politics of changing the situation. The costs of inaugurating new training institutions may appear high in the short term, yet will need to be compared with the rate of returning foreign-trained graduates. Strategy 3.1 Encourage training across the health care spectrum Widespread shortages of public health and management cadres need to be tackled urgently through new approaches to leadership and feasible strategies. In South- East Asia, a public health initiative is serving as a catalyst for greater regional insti- tutional capacity: in Bangladesh, the innovative nongovernmental organization BRAC has opened a school of public health to foster leadership in improving the health of Box 3.2 The public health movement in South-East Asia: regional initiatives and new schools Countries in South-East Asia have less than 5% of the • Students and teaching staff bene�t from a close col- world’s schools of public health, but almost a third of the laboration with Bangladesh’s Centre for Health and world’s population. Thus, increasing public health training Population Research (ICDDR,B). Staff members are for the health professions is urgently needed in these coun- drawn from Bangladesh, the region and internation- tries. National, regional and international stakeholders are ally, which adds to a stimulating environment, as do aligning resources and political will to make this happen the prestigious academic partners from around the with new and innovative approaches to creating schools of world. public health. The South-East Asia Public Health Initiative was launched In India, the newly created Public Health Foundation is in 2004 with the aim of strengthening public health planning mobilizing resources to establish �ve schools of public with �ve goals: health spread across the country in Ahmedabad, Chen- • position public health high on regional and national nai, Hyderabad, New Delhi and Kolkata. The founda- agendas; tion reflects a public–private partnership based on the • strengthen public health education; principles of strengthening existing institutions and en- • enhance technical cooperation on the development of abling multiple stakeholders to work together. These new national public health training institutions; schools will offer: • establish a public health education institutions’ network; • structured, multidisciplinary educational programmes • facilitate the de�nition of an appropriate package of es- combining standards of excellence comparable to the sential public health functions in countries. best institutions in the world and course content rel- evant to India’s needs; In Dhaka, Bangladesh, the BRAC University James P Grant • shorter and longer term training of health and allied School of Public Health aims to train a cadre of profession- professionals drawn from people already engaged als who will improve the health outcomes of populations in in occupations relevant to public health – employed disadvantaged areas of the world. in government, academic institutions or nongovern- • Its �rst 25 students are mostly from low income coun- mental organizations – and people not currently em- tries – Afghanistan, Bangladesh, India, Kenya, Nepal, ployed who want to pursue a career in public health, Pakistan, the Philippines and Uganda – but also from the such as potential health policy analysts and health United States, and graduated in January 2006. managers; • Students learn through �eldwork centred around the • research on the prioritized health problems of public health problems of Bangladeshi communities. India, including knowledge generation and knowledge • Graduates are expected to become leading public health translation components. practitioners, managers, researchers, educators and policy-makers, and the school will run an active place- Sources: (11, 12). ment service. 46 The World Health Report 2006 poor and disadvantaged population groups. In India, a new partnership between the Ministry of Health and key players from academia and the private sector, are planning to establish �ve schools of public health to address national public health priorities (see Box 3.2). Accreditation: promoting competence and trust Accreditation is an essential mechanism not only for assessing institutional perfor- mance but, more fundamentally, for securing public trust (see Chapter 6). Conducted primarily by ministries of education or delegated councils, accreditation requires facilities to generate evidence in support of performance objectives related to train- ing. A recent survey of medical schools (13) shows that accreditation pro- grammes are unevenly spread – they exist in three quarters of Eastern Ingenuity is Mediterranean countries, just under half of the countries in South-East Asia, and only about a third of African countries. Furthermore, private required to expand medical schools are less likely than publicly funded ones to undergo ac- creditation procedures, a worrying fact in light of their growing role in training centres’ educating the workforce (see Box 3.3). In relatively poor countries where efforts to scale up the health workforce using workers with less formal capacity training are widespread, ingenuity is required to expand rapidly the ef- fective capacity of training centres, including skills to carry out accredi- tation and the modest �nancial resources to sustain it. Efforts are also needed to extend accreditation and quality improvement beyond schools of medicine or nursing to include other faculties such as schools of public health (19). Managing admissions to enhance diversity Entrance to most training programmes for health professions requires a secondary education. Many countries suffer from inadequate �nancing at this level, however, and struggle with high secondary school drop-out rates and low enrolment, espe- cially among poorer groups. These factors severely limit the pool of people who can enter education programmes for health careers. The pro�les of students entering health professions rarely reflect national pro�les of social, linguistic and ethnic di- versity, as students are disproportionately admitted from the higher social classes and dominant ethnic groups in society (20, 21). Box 3.3 Rapid growth in private education of health professionals Private universities offering training for health professionals • In Karnataka State, India, 15 of 19 medical colleges are rapidly increasing in low and middle income countries, are private. reflecting a wider phenomenon of increasing private provi- • In the Philippines: in 2004, 307 of 332 nursing schools, sion of technical and vocational education. were private institutions. Recent data from around the world are indicative of this • In Côte d’Ivoire, 60% of all technical students are en- trend: rolled in private schools. • In the WHO Eastern Mediterranean Region, between • In the Democratic Republic of the Congo between 1980 and 2005, private training institutions increased 2001 and 2003 the number of medical and nursing from 10% to almost 60% of all training institutions. graduates doubled, largely as a result of a private sec- • In South America, between 1992 and 2000, Argentina, tor-led increase in the training of health workers. Chile and Peru experienced 60–70% increases in the number of medical schools, which is mainly a reflection Sources: (14–18). of the growth in the private sector. preparing the health workforce 47 Strategy 3.2 Develop admissions policies to reflect diversities The growing diversity of patient populations, combined with a growing awareness of the importance of sociocultural and linguistic issues in providing care (22, 23), has brought new attention to imbalances in the admissions processes. Along with admission quotas, other approaches to increase diversity include outreach to those who might not consider health professional training to be an option (24); special- ized programmes for under-represented students in secondary schools (25); and expanded selection criteria to offer admission to students with personal attributes that make them well suited to providing health services (26). Retaining students through to graduation It is not enough to have the right mix of people entering the educational pipeline – institutions must also carry these trainees to the end of their instruction (27). Very little information from low and middle income countries is available about student attrition rates or the factors that contribute to attrition across institutions, types of training programmes and the sociodemographic pro�les of students. The limited evidence available points to as much as 20–30% of the student body not com- pleting courses because of poor academic performance, �nancial constraints and other personal circumstances including health problems and inadequate housing (28, 29). Retention of nursing students in the United Kingdom and the United States is enhanced through a broad range of activities including academic advice, tutoring for non-native speakers, affordable child care, �nancial aid, career counselling and guaranteed placement upon successful completion of studies (30–32). Mechanisms designed to boost student retention through to graduation should consider existing policies related to admissions criteria and selection procedures. Educational services The knowledge and skills of different kinds of health workers are determined by what they learn, so the organization and administration of the curriculum can be an important catalyst for change and innovation in health systems. Including a new course in a curriculum provides legitimacy to a subject or approach that can spawn changes leading to new disciplines, departments, schools and types of health work- ers, with huge impact on the practice of health care. Over the last 40 years, for example, clinical epidemiology has moved from the margins of medicine to lead the evidence-based transformation of health and health care (33). Strategy 3.3 Ensure quality and responsive curricula In preparing the workforce, the curriculum is expected to meet standards that are often de�ned as core competencies. For example, all cardiologists must be able to read an electrocardiogram, while all public health specialists must understand an odds ratio. Beyond guaranteeing this core, the curriculum must also be responsive to the changing state of knowledge in health and the needs and demands emerg- ing from health systems, including consumers’ expectations. For example, growing recognition of powerful social forces that determine health and access to services has given rise to new courses on social status, globalization, public health ethics and cultural competency (34–41). Aligning what is being taught to what is appropriate – given the needs of speci�c constituencies or populations – demands careful attention. A standard curriculum 48 The World Health Report 2006 for nurses reflecting the realities of health care in a tertiary care setting may not develop the requisite competencies to respond to the needs of indigenous popula- tions in remote areas. Likewise, the core competencies for a Masters in Public Health (MPH) in Europe may be expected to differ from what is required of an MPH in Africa. A recent study found that less than half of all training institutions in several African countries covered immunization adequately (42), despite declining national immu- nization coverage rates. Many recommendations for change in curricula emerging from consensus panels and commissions are insuf�ciently sensitive to the challenge of implementation. New courses cannot �nd their way into the programme if faculty skills, key learning materials or institutional supports are not available. Curricular decisions require more than just simple changes on paper, as their implications may challenge professional boundaries, hierarchies, responsibilities, and remunerated services. Changes in content – which constitute one dimension of orienting skills, numbers and diversity more generally – require broad participation not only by faculty members but also by professional orga- nizations, regulatory bodies and patient groups (43, 44). Engagement of The workforce these groups with their different interests may limit the scope and speed refrain in this of decisions (45) but is essential to the legitimacy of curriculum change. The nature of curricular development is usually to acquire new content report – train, without being able to shed the old (46). This one-way movement has led to overloaded curricula, often resulting in dilution of their focus and insuf- sustain and retain – �cient depth in the treatment of the subjects they cover. extends to teachers Acquiring competencies to learn In recognition of the rapid growth and rate of change of knowledge, and the dynamics of the workplace, there is increasing acceptance that train- ing programmes cannot teach people everything they will need to know. The ability to acquire new skills and knowledge that prepare for lifelong learning is itself a core competency that curricula must nurture. In response, educational pro- cesses have been moving away from didactic teaching and towards student-centred and problem-based learning, with greater emphasis on “know how� rather than “know all� (47). Students and their teachers express satisfaction with this shift, and faculty members enjoy teaching using problem-based learning (48, 49). Early exposure to clinical practice or public health service promotes competence by teaching students how to integrate and apply knowledge in practice settings, learn from role models, and experience interdisciplinary and team approaches to the provision of health services (50, 51). Recent evaluations of this method, referred to as practice-based or apprentice learning, have demonstrated an increase in empa- thy towards people with illnesses, greater self-con�dence and professional identity among students, and effective learning from the tacit knowledge of experienced practitioners (52–54). An example of patient-focused practice in a school of phar- macy is given in Box 3.4. Workforce of teachers The workforce refrain of this report – train, sustain and retain – extends to teachers and faculty members in health professional education institutions. A lack of flexible training opportunities, insuf�cient mentoring, and career advancement dif�culties for women when the “feminization� of medicine is increasing are among the key �ndings of the international campaign described in Box 3.1. Although published evidence is preparing the health workforce 49 scarce, the challenges faced by other trainers of health workers are not unlike those in academic medical faculties. Typically, academic training centres have a three-part mission: teaching, research and service delivery. These three aspects should ideally receive equal attention and institutional resources, with staff being encouraged to contribute to each. The real- ity is that incentives are often heavily weighted in favour of research and service delivery, to the detriment of teaching. In parallel, the imperative to generate income to support overhead costs through service delivery or research leaves education and teaching as the poor relations (59). In South-East Asia, the trend towards following money is steering teaching towards more lucrative areas of specialty medicine, potentially decreasing the capacity of the health workforce to respond to basic public health needs (60). Understanding what motivates teachers and supporting them in ways that help increase motivation is important. A study in Australia, for example, found that clini- cal supervisors rated personal satisfaction as the main motivating factor to teach, followed by the opportunity to attract students to their own area of specialty (61). Personal acknowledgment by the school through faculty appointments, subsidized continuing education, and access to information were other incentives to pursue Box 3.4 Practice-based teaching, problem-based learning, and patient-focused practice all go together It is crucial to encourage health professionals to undertake • re-evaluation and application of new knowledge to the lifelong learning and develop relevant workplace competen- problem; cies that can adapt to diverse challenges and populations. • assessment and reflection on learning (57). New trends in education aim to improve the health of the public by implementing this idea in training methods; this Patient-focused practice: involves integrating three approaches and yields greater • integrates teaching and learning with clinical improvements in skills, attitudes and behaviours of health practice; professionals than programmes that do not employ this • shares experiences of illness, disease and recovery integration (55). with patients; • understands varying needs for care; Practice-based teaching aims to: • observes and participates in the ways in which differ- • bridge the gap between academia and practice; ent service providers work together to meet the needs • bene�t students, schools, agencies and communities; of patients. • involve and develop critical thinking and problem- solving skills; Training pharmacy students: the Clinical Partners • be interdisciplinary, multidisciplinary and multidimensional; Programme at the Ohio State University College of • develop learning partnerships among academic staff, Pharmacy provides an active learning environment, of- practitioners and students, to educate teachers, prac- fers a patient-focused model based on pharmaceutical titioners and researchers; care principles, and is an arena for applied research in • incorporate experiential education, including critical re- pharmacy practice. Integration with clinical practice is flection, observation and learning by doing (56). undertaken at an early stage and sustained, with stu- dents attached to speci�c patients – called “longitudinal Problem-based learning complements practice-based patients� – whom they follow through all stages of care. teaching through: The programme offers multiple services and competency • identifying the problem; development, including anticoagulation management, di- • exploring pre-existing knowledge; abetes self-management, cholesterol management, hep- • generating hypotheses and possible mechanisms; atitis C education, herbal product and dietary supplement • identifying learning issues and objectives; consultations, medication management, smoking cessa- • self study and group learning; tion, and wellness (58). 50 The World Health Report 2006 teaching. In contrast, reluctance to teach was based on lack of rewards, perceived emphasis on research for promotions with little value placed on teaching, lack of teaching skills, the competitive agendas of clinical service and research, perceived inappropriateness of curriculum design, and heavy administrative load resulting from large classes. Despite these disincentives, a strong commitment to teaching and mentoring has been observed among health professionals in many countries (62). Twinning arrangements and long-term partnerships between academic medical centres in high income countries with universities and health facilities in low income countries, such as on HIV/AIDS care, have the potential to strengthen faculty development and enrich curricula and teaching materials (63–66). Similarly, the appearance of networks of health training institutions – with virtual links – promises additional opportunities to share teaching resources (67). An international foundation with the speci�c aim of supporting the development of an academic medical faculty is described in Box 3.5. Sharing experience of these and similar innovative arrangements gives the op- portunity of evaluating what does and does not work. Strategy 3.4 Encourage and support teaching excellence The critical role of teaching staff in preparing the health workforce justi�es a much more comprehensive strategy to support teaching excellence. Key components might include: more credible career tracks for teaching; career advancement for women faculty members, particularly in academic medicine; good material and technical support; reasonable remuneration; constructive feedback and evaluation; access to mentoring; training opportunities to improve teaching; and awards for teaching as well as innovation in curriculum content. Financing At present there are no normative guidelines on the amount of money that should be invested in generating the health workforce. Although there are scattered studies on the costs of training speci�c types of health workers (68), in most countries there are no comprehensive data on the amounts countries and development agencies invest in pre-service and in-service training of the health workforce. Despite this evidence gap, it is clear that the level of �nancing and the way in which it is disbursed to health training institutions have important implications for the size, skills and diversity of the health workforce. Box 3.5 Faculty development programmes: training trainers in professional health education One goal of the Foundation for Advancement of Interna- and active engagement in an Internet discussion group. tional Medical Education and Research (FAIMER) is to The programme is designed to teach education methods create a global network of medical educators to develop and and leadership skills, as well as to develop strong pro- exchange information and ideas to improve education. It of- fessional bonds with other medical educators around the fers a two-year, part-time fellowship programme designed world. FAIMER’s educational programmes currently focus for international medical school educators. The �rst year on serving medical educators and institutions in South consists of two residential sessions in the USA, and an in- Asia, sub-Saharan Africa and South America. The goal tersession curriculum innovation project at the participant’s is to establish regional networks of educators who can home institution. The second year, completed from the Fel- develop such programmes locally. For more information, low’s home country, involves mentoring an entering Fellow see http://www.ecfmg.org/faimer. preparing the health workforce 51 Box 3.6 From in-service to pre-service training: Integrated Management of Childhood Illness (IMCI) Integrated Management of Childhood Illness (IMCI) was de- • Given limited trainers – as in-service trainers are veloped in the mid-1990s by WHO and other partners as more expensive yet often have high rates of turnover a prevention and treatment strategy to ensure the health and attrition – pre-service training might lower costs and well-being of children aged under �ve years around and increase returns to investment by leveraging the world. The IMCI strategy consists of improving the case both limited training resources and captive student management skills of health workers, health systems gen- audiences. erally, and family and community health practices (71). It • Even if instituted only for medical students, pre- supports the training of physicians, nurses and other health service training would infuse future doctors with core workers to provide integrated care (72). IMCI principles to integrate eventually into their own In-service training broadens existing health workers’ practices, that of their peers and that of other cadres skill sets primarily via an 11-day clinical training block with of health workers, since doctors are often responsible lectures, active teaching methods and accompanying prac- for training nurses, paramedics, and other auxiliary tical aids all ideally catered to the speci�c type of health health workers. professional and the extent of their previous training. • The IMCI model chapter for textbooks (see �gure), de- Pre-service training is a more recent addition to IMCI, veloped by WHO and UNICEF (77), facilitates the pro- and aims to introduce these same core skills much earlier cess of introducing IMCI content into locally authored to health workers, as a core training module within health and edited health training textbooks. education curricula. Bene�ts of pre-service over in-service training. The bene�ts of diverting more limited funds from in-service to pre-service training programmes are nu- merous, based on the shared experienc- es of health education institutions in all The Integrated Case Management Process six WHO regions: Bolivia, Ecuador, Egypt, Ethiopia, Indonesia, Moldova, Morocco, OUTPATIENT HEALTH FACILITY Nepal, the Philippines, United Republic of Check for DANGER SIGNS Tanzania, Uzbekistan, Viet Nam and many - Convulsions - Lethargy/unconsciousness other countries are involved in this excer- - Inability to drink/breastfeed cise (73–76). Key lessons learnt include the - Vomiting following: Assess MAIN SYMPTOMS • Funding for in-service IMCI training is - Cough/difficulty breathing dif�cult to secure from national and/or - Diarrhoea district health budgets, and the stan- - Fever - Ear problems dard 11-day training presents sub- stantial personnel time diverted from Assess nutrition and IMMUNIZATION STATUS patient care, particularly for resource- and POTENTIAL FEEDING constrained health facilities. PROBLEMS Check for OTHER PROBLEMS CLASSIFY CONDITIONS and IDENTIFY TREATMENT ACTIONS According to colour- coded treatment Urgent referral Treatment at outpatient Home management OUTPATIENT HEALTH FACILITY health facility HOME - Pre-referral treatments OUTPATIENT HEALTH FACILITY Caretaker is counselled on how to: - Advise parents - Treat local infection - Give oral drugs - Refer child - Give oral drugs - Treat local infections at home - Advise and teach caretaker - Continue feeding - Follow-up - When to return immediately - Follow-up REFERRAL FACILITY - Emergency triage and treatment Source: (77). (ETAT) - Diagnosis - Treatment - Monitoring and follow-up 52 The World Health Report 2006 Drawing on the pipeline model of the ways in which health workers are recruited (Figure 3.2), the pool of applicants for health training is contingent more broadly on the level of �nancing of education. In poorer countries, very low enrolment rates for secondary and tertiary school attendance reflect inadequate �nancing of education (69) and may limit the overall size and socioeconomic diversity of the applicant pool, or compromise preparedness. In these contexts, improved �nancing of primary and secondary education is essential to increase the supply of health workers (70). The signi�cant training costs associated with scaling up the health workforce, identi�ed in Chapter 1, suggest that major increases in the funding of health training are critically needed in countries with severe health worker shortages. Higher levels of �nancing are required to increase training capacity (more institutions or expanded enrolment) and to improve quality with better infrastructure and highly motivated teachers. Redirecting some resources currently spent on in-service training to pre- service training would tap an important source of �nancing for resource-strapped establishments. Innovative efforts to integrate training for priority programmes into the curricula of health training institutions are demonstrating that this works (see Box 3.6). Achieving large increases in levels of �nancing and better coordination across sectors requires political commitment, donor support and negotiation with �nance, education and other ministries (see Chapter 7). Attaining the desired diversity of the workforce is linked, in part, to the way health training is �nanced. Private sector health training institutions are increasing in number worldwide (see Box 3.3). The decline in public sector subsidies of health training institutions raises concerns that students who are less well-off may avoid considering health care as an occupation, cluster in programmes where the training is less costly, take on paid work while training (at the expense of the acquisition of skills and knowledge), or �nd their career choices limited by indebtedness. Provision of fee exemptions, scholarships and loans are among the mechanisms to preserve access to training (78). Infrastructure and technology The construction, repair and maintenance of buildings, special laboratories and other �eld sites, along with the acquisition of learning materials, are among the infrastruc- ture requirements of health training institutions. Insuf�ciencies in infrastructure may place a signi�cant constraint on the numbers of students who can be taught effec- tively and limit expansion of training, even for basic services (79). A recent survey of psychiatric training infrastructure in 120 countries found that about 70 countries had grossly inadequate facilities (80). Given the expense involved in building and maintaining health training institutions for very small countries such as small island states, regional training facilities offer a more affordable option to build up national capacities and leadership (see Box 3.7). The physical location of training facilities can influence considerably the diversity pro�le of staff and students. Health training institutions are most often located in urban areas, and recognition of this urban bias has led to increasing efforts to build them in rural areas or create effective virtual links using information communication technologies (81, 82). preparing the health workforce 53 16 C i Box 3.7 Regionalization of training for health professionals: � f i i f i Countries support and bene�t from The University of the West Indies University of the South Paci�c and the University of the West Indies By working together, small island nations provide better Tonga, Tuvalu and Vanuatu. It has campuses in all the 12 access to education and training, build their own capacity member countries and the main campus, Laucala, is in and national leadership, promote values appropriate for the Fiji. Although there is no faculty for health sciences, there region, and become globally competitive. Regional institu- are faculties for arts and law; business and economics; tions spanning large geographical areas need well-devel- islands and oceans; and science and technology. oped distance learning programmes, with flexible schedules University of the West Indies (UWI). Established in to accommodate students needs. Advanced communication 1948 as a College of the University of London, UWI is a re- technologies are also required to reach students. Two suc- gional training institution that gained full university sta- cessful examples of regional collaboration and integration in tus in 1962, with a current student population of 11 000. education offer a potential model for the education of health One of four different faculties, Medical Sciences offers a professionals in other areas of the world. wide range of undergraduate, graduate and postgradu- University of the South Paci�c (USP). Established in ate programmes. Critical to the success of the university 1968, USP spreads across 33 million square kilometres of is the fact that graduates all return to their respective ocean, an area more than three times the size of Europe. countries and work in the health sector as care provid- The university is jointly owned by the governments of 12 ers, managers or policy-makers. One prime minister and island countries: the Cook Islands, Fiji, Kiribati, the Marshall four ministers of health in the region are graduates of the Islands, Nauru, Niue, Samoa, the Solomon Islands, Tokelau, Faculty of Medical Sciences. Sixteen countries support and bene�t from the University of the West Indies Turks and Caicos Islands Grand Turk British Anguilla St Kitts and Nevis Bahamas The Valley Nassau Virgin Islands St John s Antigua 5 Basseterre 10 Tortola 6 Jamaica 4 3 Montserrat 7 Plymouth 8 9 1 2 Dominica 1 - Mona Campus 2 - Morant Bay 3 - Port Antonio Roseau 4 - Brown s Town 5 - Montego Bay 6 - Savanna-La-Mar 7 - Mandeville 8 - Denbigh 9 - Vere 10 - Ocho Rios St Lucia Cave Hill Campus Belize City Q.E. Hospital Tobago The Morne Barbados St Augustine Trinidad and Tobago Georgetown Campus Sangre Grande Belize Grand Cayman Kingstown San Fernando St George s St Vincent Mayaro Grenada 54 The World Health Report 2006 Strategy 3.5 Find innovative ways to access teaching expertise and materials Access to textbooks and other quality teaching materials represents an important challenge and can be tackled in a number of ways. The PALTEX programme in Latin American and Caribbean countries screens for quality and offers volume discounts for a wide range of textbooks and basic diagnostic tools to over 600 institutions (83). Information and communication technologies are being used in remote and resource- poor settings to access expertise in the faculty and diffuse training materials more effectively. The Health InterNetwork Access to Research Initiative (HINARI), set up by WHO with the committed involvement of major publishers, enables academic and research institutions, government of�ces and teaching hospitals, particularly in low income countries, to gain access to one of the world’s largest collections of biomedical and health literature. Over 3200 full-text journals and other resources are now available free to health institutions in 69 countries, and for very low cost in a further 44 countries (84). Information for policy-making Countering the dearth of information about the provision of educational and training services, students, programmes and graduates is a major priority. Analysis of the literature databases over the last 30 years reveals that the overwhelming focus of enquiry has been on education evaluation, teaching methods and the curriculum (see Box 3.8). Few of the countries with the most acute health worker shortages routinely collect and report data on the number of graduates, or even the number of training facilities for health professionals (87). Even fewer countries break this information down subnationally in terms of the reach of different institutions, or by various socioeconomic attributes of students and graduates. Although important for description and comparison with normative standards, from a planning perspective numbers alone are just a start. Strategy 3.6 Evaluate institutional performance, policy options and actions To inform policy and decision-making related to health worker training, information about current and prospective performance is required. For example, an analysis from the Canadian province of Nova Scotia indicates that demand for physician ser- vices will grow faster than supply over the next 15 years if current policies on training remain unchanged (88). To evaluate the performance of health training institutions, a national strategy to strengthen workforce data generation and synthesis is needed. These national data should be coupled with cross-national information on the costs and effectiveness of different ways of training and recruiting health workers, such as through observatories on human resources for health (see Chapters 6 and 7). RETHINKING RECRUITMENT: GATEWAY TO THE WORKFORCE Recruitment represents entry into the formal health workforce. It is thus a critical function whose performance has to be managed at the levels of both the system and individual employers. Five performance outcomes are relevant to assess recruitment: numbers, competencies, background (diversity), location, and time. preparing the health workforce 55 Box 3.8 The evidence base to enhance performance of health educational institutions Figure (a) below shows that roughly 90% of all research arti- schools for the same period, 55% concerned medical cles on topics addressing health workforce training, indexed schools, 17% nursing schools and only 2% public health in PubMed between 1970 and 2004, focused on educational schools. Despite huge shortages in the health workforce measurement, teaching methods or curriculum issues. The across different classes of workers, each year research level of research on other topics that may provide important addressing health educational institutions remains heav- insights on enhancing skills, diversity and numbers – such ily skewed towards medical schools, without signi�cant as fellowships and scholarships, school admissions and stu- increases in the number of articles addressing dental, dent drop-outs – has remained marginal. More research on nursing, veterinarian, public health, pharmacy or other appropriate topics should be conducted in low income coun- health occupation schools. Similar �ndings are noted tries (85) and included within research syntheses. from the analysis of regional databases of scienti�c lit- The range of health educational institutions represented erature (86). in research is too narrow. Figure (b) below shows that of all research articles indexed in PubMed on health professional (a) Research articles on topics addressing health workforce training1 5000 Educational measurement Educational models Teaching Fellowships and scholarships 4000 Curriculum School admission criteria Accreditation Student drop-outs Number of articles 3000 2000 1000 0 1970 1975 1980 1985 1990 1995 2000 2005 Year (b) Research articles on health professional schools1 700 Medical schools Public health schools Dental schools Pharmacy schools 600 Nursing schools Other health occupation schools Veterinary schools 500 Number of articles 400 300 200 100 0 1970 1975 1980 1985 1990 1995 2000 2005 Year 1 As indexed in PubMed, 1970–2004. 56 The World Health Report 2006 ■ Numbers recruited should reflect not only current needs and demands but also the extent of underemployment or low productivity (see Chapter 4) and attrition (see Chapter 5). ■ Competencies, the skills and experience of recruits, should reflect both the prod- ucts of the educational pipeline and non-technical qualities (e.g. compassion and motivation) required for effective health services delivery. ■ The background of health workers recruited and their positioning in the right location must be compatible with the sociocultural and linguistic pro�les of the population being served. ■ Recruitment must be time sensitive as in the case of the rapid mobilization of workers to deal with responses to humanitarian emergencies and disease out- breaks. Imperfect labour markets To a large degree, recruitment performance outcomes reflect the context of the broader labour market. Employers, on the demand side of the market, delineate the types and conditions of employment, while the workers, on the supply side, contribute their skills and their individual preferences about how and where to work. Market equilibrium is reached once labour demand equals supply of workers. Market equilibrium can coexist, however, with urban over-supply and rural scarcity of health workers as well as underserved population subgroups. A more complex picture is illustrated in Figure 3.3: that labour supply reflects the outcome of demand for education, whereas labour demand reflects the out- come of demand for health services mediated through employers and �nancing mechanisms. Figure 3.3 Relationship of education, labour and health services markets with human resources Education market Labour market Health services market Training institutions Health organizations Service units Installed capacity Individual practice Protocols Programme Positions Infrastructure Curriculum Salaries Technology Prices Inputs Prices Transformation Linking process Production process process Labour Labour Demand Education demand supply demand for services Applicants Graduates Unemployed Linked Opportunities Resources Users Students Resources Workers Intellectual capacity Competencies Performance Skills Experience Abilities Capacity Expectations Substitutions Source: (1). preparing the health workforce 57 This more realistic situation reflects values, priorities, constraints and competition across different sectors, institutional actors and individuals. Prospective students often consider how quickly they are able to pay off educational debts and work in a desirable location. Based on a study from Colombia, the minimum working time needed to pay off debt incurred during pre-service training is shown in Figure 3.4 for two different health workers (1). At the same time, many governments pursue numbers-based recruitment strategies reflecting broader reforms, such as overall downsizing of the public sector or structural adjustment, rather than speci�c health priorities (89). Standardized government wage and work conditions, which rarely accommodate health worker needs, also limit the public sector to hire and retain Figure 3.4 Projected time to recuperate student investments in education, Colombia, 2000 a) Non-specialist physicians 30 20 Colombian pesos (millions) 10 0 Years 1 2 3 4 5 6 7 8 9 10 -10 -20 -30 -40 -50 b) Physiotherapists 15 10 Colombian pesos (millions) 5 0 Years -5 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 -10 -15 -20 -25 -30 Training fees Cumulative debt Income Source: (89). 58 The World Health Report 2006 workers in the health labour market. In low income countries where trained health service providers are scarce, the public sector often competes to recruit workers with the private sector, international nongovernmental organizations and other donors, and multilateral entities offering attractive local or international employment packages. Dr Elizabeth Madraa, manager of Uganda’s AIDS Control Programme, laments, “We keep training them and they go to NGOs or abroad, where they can get better money; then we have to train [more people] again.� (90). Recruitment agencies, contracted by large employers, further fuel this exodus. These imperfections necessitate strong leadership and actions that push forward health goals. The magnitude of health workforce migration and the unregulated practices of recruitment agencies have resulted, for example, in a grow- ing number of ethical recruitment guidelines (see Chapter 5). Strategy 3.7 Improve recruitment performance Actions on several fronts can enhance recruitment performance. These relate to increasing information, striving towards greater ef�ciency, managing incentives for self-employed workers and increasing equity in the coverage of health services, and are expanded below. Information. Recruitment needs, demands and performance are often not ar- ticulated well through the existing planning processes or survey instruments. Fur- thermore, poor recruitment capacity impedes efforts to scale up activities, respond rapidly or develop new cadres. Essential data inputs for recruit- Actions on several ment management include vacancy rates and trends, gaps or surpluses in worker supply relative to regional demand, and performance metrics such fronts can enhance as time taken to hire individuals or �ll vacant posts. Gauging workers’ perceptions of employers (see Chapter 4 on magnet institutions) provides recruitment the basis for recruiters to respond more appropriately to prospective em- ployees’ concerns. performance Ef�ciency. The consequences of institutional inef�ciency abound: sluggish bureaucracies encourage prospective recruits to withhold ap- plications, quit prior to starting work or simply succumb to the low mo- rale pervading many public health services; failure to de�ne or establish posts for rural health workers has led new recruits to saturate urban areas (91); and non-transparent, politically motivated appointments supplant the best recruits. To improve recruitment ef�ciency, bureaucracies must hire quali�ed human resources personnel who must be supported to manage recruitment according to best prac- tices. Merit-based recruitment is a good example of best practice that is strongly correlated with the quality and integrity of government institutions. Complex issues such as the appropriate degree of centralization or decentralization of recruitment procedures, as in government-run health services, require context-speci�c analysis of costs, bene�ts and the political realities concerning the overall management of government-run health services across central, district and local levels (92–94). Management of self-recruitment. In many settings, health workers are not for- mally recruited by an employer but set up their own practice, i.e. are self-employed. Licensure, certi�cation and registration of health workers as well as professional associations can help to manage and ensure competence of the self-employed health workforce. If these regulatory capacities are lacking or weak, then public trust may be eroded (see Chapter 6). In Bangladesh, for example, the risk of neonatal mortal- ity was found to be six times higher when mothers consulted self-employed health preparing the health workforce 59 workers with no recognized quali�cations, rather than health workers possessing recognized quali�cations (95). Where government reimburses self-employed health workers it can exercise influence over their numbers and locations as an important mechanism to achieve better balance between types of workers (for example gen- eralists or specialists), where they work, and whom they serve. Recruitment to areas of need. Recruitment represents an ideal opportunity to place workers where they are needed. Around the world, affluent urban areas are magnets for health workers, leaving urban slums and remote rural areas rela- tively underserved. Compulsory service or bonding arrangements following publicly subsidized education are widespread but are rarely evaluated (96). There is grow- ing evidence to suggest that local recruitment is a strong predictor of long-term staff retention (97), thus highlighting the importance of training opportunities for people from rural and remote communities. Identifying respected members of such communities who are suitable for training and acceptable to the population, as in Pakistan (see Box 3.9), meets health service needs, training objectives, and diversity selection. CONCLUSION This chapter has reviewed issues associated with generating and recruiting the health workforce. The policy questions that have been discussed here – related to training, health workers’ competencies, and labour markets – lead naturally to ques- tions about the management of the existing health workers, the subject of Chapter 4. Box 3.9 Pakistan’s Lady Health Workers: selection and development of new cadres Created in 1994 to improve health care access in rural com- between their communities and the formal health sys- munities and urban slums, Pakistan’s National Programme tem, helping coordinate such services as immunization for Family Planning and Primary Health Care has relied heav- and anaemia control, and provide antenatal and postnatal ily on the performance of its 80 000 Lady Health Workers care to mothers. Recent research shows a clear connec- who provide basic health care to nearly 70% of the country’s tion between the presence of Lady Health Workers and population (98). The stringent selection criteria used include improved community health (99–100). Independent eval- the requirement that they come from the community they uations note that after Lady Health Worker cadres were will serve, be at least 18 years old, have successfully com- introduced, substantial increases were documented in pleted a middle school education and be recommended by childhood vaccination rates, child growth monitoring, the residents of their community as a good candidate. Mar- use of contraception and antenatal services, provision of ried women are given preference. They receive 15 months iron tablets to pregnant women and in lowering rates of of training (three months full time, 12 months part time), and childhood diarrhoea (101). study basics of primary health care and hygiene, commu- nity organization, interpersonal communication, data col- Key lessons: lection and health management information systems. 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Oxford, Oxford Policy Management, 2002 (http://www.opml.co.uk/social_policy/health/cn1064_lhw.html, accessed 8 February 2006). preparing the health workforce 65 making the most making the most of existing health workers 67 of existing chapter four health workers in this chapter 67 What is a well-performing health workforce? 70 What determines how health workers perform? 71 What influences health workers’ performance? 86 How are levers linked to the four dimensions of A country’s health workforce is made up of workforce performance? health workers who are at many different 89 Conclusion stages of their working lives; they work in many different organizations and under changing conditions and pressures. Whatever the circumstances, an effective workforce strategy has to focus on three core chal- lenges: improving recruitment, helping the existing workforce to perform better, and slowing the rate at which workers leave the health workforce. This chapter explores the second of these challenges: optimizing the performance of current workers. Strategies to boost worker performance are critical for four tivity, and reviews the levers available to improve these reasons: different dimensions. Many ways of improving performance They will be likely to show results sooner than strategies to exist, some aimed at individual health workers and some increase numbers. directed at the organizations in which they work. The possibilities of increasing the supply of health workers will always be limited. WHAT IS A WELL-PERFORMING A motivated and productive workforce will encourage re- HEALTH WORKFORCE? cruitment and retention. Health workforce performance is critical because it has an Governments have an obligation to society to ensure that immediate impact on health service delivery and ultimately limited human and �nancial resources are used as fairly and on population health. A well-performing workforce is one as ef�ciently as possible. that works in ways that are responsive, fair and ef�cient to This chapter outlines four dimensions of workforce perfor- achieve the best health outcomes possible, given available mance: availability, competence, responsiveness and produc- resources and circumstances. Andrew Smith/UNV 68 The World Health Report 2006 Table 4.1 Dimensions of health workforce performance Dimension Description Availability Availability in terms of space and time: encompasses distribution and attendance of existing workers Competence Encompasses the combination of technical knowledge, skills and behaviours Responsiveness People are treated decently, regardless of whether or not their health improves or who they are Productivity Producing the maximum effective health services and health outcomes possible given the existing stock of health workers; reducing waste of staff time or skills Evaluations of health workforce performance by the extent to which it contributes to the desired improvement in population health leave no doubt that performance can vary widely. Box 4.1 provides one illustration of how health workers use available �nancial resources to very different effect on infant mortality, even after controlling for education and poverty in the population. Examining performance this way reveals areas where a workforce is performing well and areas where improvements should be possible, but this method does not explain why performance varies or what can be done about it. Box 4.1 Infant mortality and health worker density, Viet Nam Infant mortality rates were examined in relation to the den- in terms of health expenditure per capita. An indicator sity of health service providers in 1999. Average results was derived of the ef�ciency with which health workers across the provinces are represented by the black points in in each province use the available �nancial resources to the �gure below. Many provinces, denoted by the red points, reduce mortality, controlling for education and poverty. do better than expected for their health worker densities Ef�ciency ranges from 40% to 99%, raising the question – they lie below the black line – while others do less well. of why health workers in some provinces seem to per- More detailed analysis reveals that this is explained, in part, form better than in others (1, 2). by differences in �nancial resource availability, measured Infant mortality rate and per capita density of health professionals, by province, Viet Nam Infant mortality rate per 1000 live births 80 National average for health professionals 60 40 National average for infant mortality 20 0 0 5 10 15 20 Health professionals per 10 000 population Expected provincial infant mortality rate given available resources (from model). Observed provincial infant mortality rate. making the most of existing health workers 69 Another approach is to look at four dimensions of workforce performance that are believed to contribute to the achievement of better service delivery and health (see Table 4.1). Looking at the problem this way can help in selecting areas for action. This simple outline sets the scope for any health workforce strategy and provides a framework for assessing whether or not it is having its desired effects. This frame- work moves beyond the traditional focus on inputs (having the right number of staff, in the right place, at the right time, with the right skills, and the right support to work (3)) to consider workforce outputs and outcomes. What is known about the various dimensions of health workforce performance shown in Table 4.1? Chapter 1 has already outlined what is known about workforce availability, across and within countries. This chapter describes efforts to capture some of the other dimensions more systematically. For all of them data are scarce, especially in lower income countries. However, if countries are to track whether workforce policies are having their desired effects, some metrics of performance are needed. Studies of productivity in the health sector have been conducted in both rich and poor countries (4). A recent study estimated the potential gains in productivity of existing staff in two African countries could be as much as 35% and 26%, respectively (5). Efforts, ranging from the simple to the sophisticated, are under way to assess the extent to which health workers are competent (6–9), and Figure 4.1 Patients’ perception of respectful treatment at health facilities in 19 countries Uruguay Czech Republic Malaysia Mexico Slovakia United Arab Emirates Ecuador Myanmar Sri Lanka Ghana Tunisia Croatia India Russian Federation South Africa China Côte d’Ivoire Philippines Mauritania 0 10 20 30 40 50 60 70 80 90 100 Patients perceiving that they had been treated with respect on their last visit to a health facility (%) WHO regions: Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific Source: (10). 70 The World Health Report 2006 exhibit aspects of responsiveness such as respect towards the people they see. Figure 4.1 illustrates results from a survey in 19 countries, which found that the proportion of patients who thought they were treated with respect when they visited health facilities varied from 60% to 90%. For each dimension of health workforce performance, important differences be- tween health workers may be seen, and policy responses should bear these in mind. Box 4.2 provides one example. It is dif�cult to measure and monitor performance and all too easy to manipulate data (15). Many human resource and staf�ng indicators are routinely collected only in systems with relatively sophisticated information infrastructure. More work is needed to establish which existing indicators could best capture the four dimensions of work- force performance, but Table 4.2 illustrates some possibilities. These four dimensions are a consequence of factors such as staff turnover and motivation. Indicators of the determinants of performance, such as supervision visits and workplace safety, may also be worth measuring. Many people view feedback on performance not just as a necessity for policy, but also as a powerful tool to influence the behaviour of health workers and organizations if linked to rewards and sanctions. The uses of performance monitoring are discussed later in this chapter. WHAT DETERMINES HOW HEALTH WORKERS PERFORM? To understand why health workers perform differently, it is useful to consider the factors known to influence their work. For many years it was assumed that poor health worker performance was primarily caused by a lack of knowledge and skills. In recent years this perception has changed, and three broad groups of factors are now recognized. Characteristics of the population being served: it is simpler to increase immuniza- tion coverage or adherence to treatment for tuberculosis or HIV infection where the population understands the bene�ts and has the motivation and resources to seek services. Characteristics of health workers themselves, including their own sociocultural background, knowledge, experience and motivation. Box 4.2 Differences in performance of male and female health service providers Male and female health workers sometimes approach their internists and family doctors than with specialist obste- work and interact with patients in different ways. A recent tricians and gynaecologists (12). Female patients, espe- study in Brazil found that women spent longer in consulta- cially those seeking gynaecological and obstetric advice, tion with each child under �ve years of age (an additional reported greater satisfaction with female than male phy- minute, on average) than their male counterparts, even ad- sicians (13, 14). justing for other determinants of time inputs such as patient Taken together, these �ndings suggest that certain loads. The difference was more pronounced for providers aspects of the care rendered by women health workers trained in the Integrated Management of Childhood Illness can, in speci�c circumstances, be more responsive to the protocols, suggesting that the influence of training might needs of patients than the care provided by male physi- also differ according to the sex of the practitioner (11). cians. These differences could be important for the de- In the United States, women were more likely to undergo velopment of the health workforce, but need to be better screening with Pap smears and mammograms if they were understood. seen by female physicians, and this was more evident with making the most of existing health workers 71 Characteristics of the health system, and the wider environment, that determine the condi- Table 4.2 Human resource indicators to assess tions under which health workers work. These health workforce performance include the inputs available to them to do their Dimension Possible indicators jobs, how the health system is organized, how Availability Staff ratios the workers are paid, supervised and managed, Absence rates and factors such as their personal safety. Waiting time Competence Individual: prescribing practices These elements are interconnected. For example, Institutional: readmission rates; live births; motivation (the level of effort and desire to perform cross-infections well) is considered by many to be crucial to perfor- Responsiveness Patient satisfaction; assessment of mance. Motivation is determined both by factors responsiveness internal to health workers and by factors in their Productivity Occupied beds; outpatient visits; interventions delivered per worker or facility work and social environment (17). Source: (16). WHAT INFLUENCES HEALTH WORKERS’ PERFORMANCE? Leverage can be applied to stimulate better performance from both individuals and the health workforce as a whole. The main levers available to support performance include a group that are job related; those related to the support systems that all workers need to do their jobs; and levers that shape and create an enabling work environment. It is rare to �nd a direct relationship between one speci�c lever and a desired change. Collectively, they make up a checklist of options for policy-makers to consider, from which various instruments have to be selected and combined to meet speci�c health workforce challenges. Figure 4.2 summarizes some of the key levers that exist and the Figure 4.2 Levers to influence the four dimensions characteristics of the workforce that they can collectively influence. of health workforce performance Some of these instruments have been found to be relatively easy to implement, others are more complex. Levers Health workforce performance Some offer the prospect of relatively early results, others are much longer Job related term. Some are low cost, others are Job descriptions Availability expensive. Some are not exactly Norms and codes of conduct policy levers but affect productivity Skills matched with tasks – paying a heating bill, for example, Supervision so that a facility is warm enough for staff and patients to use. All of these Competence levers need to be set within a vision Support system related for the workforce over the medium Remuneration to long term. Improvements in work- Information and communication force performance and productivity Infrastructure and supplies usually result from a bundle of linked Responsiveness interventions, rather than uncoordi- nated or single ones (18). Enabling work environment Selecting the right instruments to Lifelong learning use and judging when and where to Team management use them, require not just knowledge Responsibility with accountability Productivity 72 The World Health Report 2006 of the instruments themselves, but also an understanding of other important issues that can influence how well the levers work, such as the structure, culture and insti- tutional capacity of the organization concerned, and wider social values and expecta- tions. Action to encourage better performance and productivity can be directed at the individual, team, organization or overall system level (19). Some of these instruments can be introduced within an existing health system by managers of local facilities or services. Others require decisions by higher level authorities or by other sectors – especially if they involve structural change. While it is pragmatic for managers to focus �rst on one or two things that they can directly influence and that can be changed more easily, there are times when this is inadequate for any substantial improvement in workforce performance and a more comprehensive set of managerial and organizational changes may need to be considered. The next three sections of the chapter summarize current knowledge about the effectiveness of different levers. For each, four issues of concern to decision-makers are considered: the robustness of the knowledge base, what is known about ease of implementation, the cost, and the time frame for effects to take place. Hard evidence of what works is still limited, but this is no excuse for inaction, given the workforce crisis that is facing many countries. At the same time, this lack of evidence makes two things essential: careful monitoring of trends and effects to allow course correc- tions as needed, and a much greater effort to evaluate and share �ndings within and across countries. Job-speci�c levers One set of instruments that influences personnel performance is speci�c to individual jobs or occupations. These levers include clear job descriptions, professional norms and codes of conduct, the proper matching of skills to the tasks in hand, and supervi- sion (20–22). Strategy 4.1 Develop clear job descriptions Job descriptions that clearly set out objectives, responsibilities, authority and lines of accountability are consistently associated with improved achievement of work goals, for all sorts of worker (23). Moreover, moves to develop clear job descriptions can produce quite rapid effects. A programme jointly undertaken by WHO and the Ministry of Health in Indonesia has demonstrated that establishment of clear job descriptions, along with better in-service training and clearer standards, can enhance job satis- faction and compliance with standards among nurses and midwives (see Box 4.3). Health workers in many countries still lack proper job descriptions, so this strategy has widespread potential. Strategy 4.2 Support norms and codes of conduct The performance of health workers, in terms of both competence and responsive- ness, is also influenced by their sense of professional identity, vocation and work ethic. There are many instances of health workers continuing to provide care despite dif�cult and sometimes dangerous working conditions. Some ways of sustaining or, where necessary, creating values, standards and aspirations are outlined below. The notion of “professionalism� and vocation in health has a long history. Almost every doctor and patient has heard of the Hippocratic Oath, which is the longest surviving ethical code of conduct. It is still sworn by many medical graduates. Health workers are expected to conduct themselves with integrity, selflessly to apply techni- making the most of existing health workers 73 cal know-how and to put the interests of the patient above their own (30, 31). Professional codes of conduct are often instilled The performance of through unwritten channels and take time to develop, but can become a signi�cant source of internal motivation. health workers is One of the functions of professional associations is to foster this sense of valued professional identity and hence responsibil- influenced by their ity and higher morale (32). For more “modern� professions, such sense of professional as management, professional associations are relatively new (for example, the European Health Management Association has identity, vocation and existed for only 25 years) and still do not exist in many countries. Creating professional associations may be a desirable long-term work ethic strategy, but they take time to establish. The creation of associa- tions for more informal providers such as drug-sellers has also been tried as a means of bringing their activities more into line with accepted good practice. In very poor countries, coping strategies by health workers to deal with dif�cult living conditions may become so prevalent that maintenance of professional ethos is threatened. Box 4.3 explains how health workers in two countries perceive the problem. Many employers are now introducing explicit written codes of conduct for all their employees, stating, for example, that they should arrive at work on time, treat patients with dignity and respect, and provide them with full information. The effectiveness of such codes has not been documented (and is usually only one aspect of a larger package of managerial interventions) but logic suggests that their effectiveness will depend on the extent to which they are communicated and enforced. More formal instruments are also used to steer the behaviour of health workers in a desired direction. For example, a government might introduce a regulation that no private practice by public sector health workers is allowed during working hours in public facilities. To have the desired effect, such rules and regulations need to be well publicized, and action taken when they are broken. Licensing and accreditation are other tools to promote standards of care of existing workers and the institutions to which they belong. The effectiveness of formal regulations is often limited because the institutional capacity to enforce them is just not there. This problem is discussed further in Chapter 6. Strategy 4.3 Match skills to tasks In rich and poor countries alike and in all types of facilities, numerous examples exist of ways in which the skills of individual health workers or the skill mix within the workforce as a whole are being inef�ciently used. Common reasons for this include the following: Tasks do not match an individual worker’s skills – for example, skilled nurses doing clerical tasks because there are no ward clerks. The opposite also occurs: for example, due to skill shortages, management tasks being carried out by scarce medical personnel, who have no speci�c expertise in these areas; or untrained personnel carrying out skilled tasks such as birth delivery and other interventions (33, 34). Certain tasks consume an excessive amount of time, such as hosting missions and reporting. Workers are not always at work at the times when the workload is highest, i.e. when their skills would be most productive. 74 The World Health Report 2006 Some examples of skill mismatches are given in Box 4.3. Often countries with the scarcest human resources have the greatest demands made on their health workers’ time by external agencies. This problem concerns senior policy-makers, managers and clinical staff. The Paris Declaration on aid ef- fectiveness has a set of principles for harmonization and alignment with partner coun- tries’ systems and procedures that has been endorsed by ministers and development institutions (35). Many health agencies and partnerships are now examining how to put these principles into practice (36). External agencies have a golden opportunity to free up some time for health workers, for example by harmonizing review missions and training courses or by aligning overlapping reporting demands. Shift patterns and time flexibility could provide another way to increase worker productivity. This strategy could potentially achieve a better match between staff- ing levels and workload at limited cost, but there are virtually no evaluations from developing countries (18). Finally, skill delegation or task shifting is another way to increase overall work- force productivity that has received much attention. Most actual experience comes from substitution of physicians by nurses, and from English-speaking countries (37). Chapter 2 provides examples of instances where skill delegation is being adopted. Box 4.3 Job-related challenges to improving health worker performance Develop clear job descriptions: Indonesia improved and tighter management of stock, improved In 2000, a survey of 856 nurses and midwives in �ve prov- working conditions, informing the population about such inces found that 47.4% nurses and midwives did not have practices, and appeals to people’s personal and profes- written job descriptions, 39.8% were engaged in work other sional values (25). than nursing care or midwifery and 70.9% had not received in-service training for the past three years. A Clinical Perfor- Match skills to tasks: examples of mismatches mance Development Management System was developed: it A study in the United Republic of Tanzania estimated that created clear job descriptions that outlined responsibilities 40–50% of a district medical of�cer’s time was being and accountability, provided in-service training consisting spent on report writing and 20% on hosting missions (26). primarily of reflective case discussions, and put in place In Uganda, district managers estimated that they spend a performance monitoring system. Staff bene�ting from 70–80% of their time on planning, reporting and train- the programme reported that the job descriptions, together ing workshops. This left little time for implementation of with standards of operations and procedures, had given activities (27). A survey of hospitals in Washington, DC, them greater con�dence about their roles and responsi- United States, showed that for every hour of patient care bilities. The participating hospitals also reported that the in an emergency care department there was one hour of programme helped to ensure quality and facilitate hospital paperwork (28). accreditation (24). Exercise supportive supervision: Ghana Maintaining professional values: tensions and suggested In quasi-government hospitals, the supervisors’ role was solutions from Cape Verde and Mozambique the linchpin of performance enhancement: keener pres- A study of how health workers perceive the dif�culty of sure and their perceived knowledge of technical processes maintaining professional values found that they experience kept service providers on their toes, with the supervisor a conflict between their self-image of what it means to be themselves feeling more direct pressure to ensure good an honest civil servant who wants to do a decent job, and performance/outputs (for example, to retain their position, the realities of life that make them betray that image. For �nancial incentives and other bene�ts). In the public hospi- example, misuse of access to pharmaceuticals has become tals studied, supervisors seemed to have less authority and a key element in the coping strategies that some health performance emphasis seemed to be placed on behaviours personnel employ to boost their income. The authors con- such as obedience, punctuality and respectfulness rather clude that this ambiguity indicates that the opportunity to than on performance of technical tasks. Systems for re- intervene still exists, and that this should be sooner rather orientation of supervisors and for formal performance ap- than later before practices become too entrenched. Re- praisal of productivity of supervisors rather than directly spondents’ suggestions to change the situation included: on service providers may be useful (29). making the most of existing health workers 75 In some cases, professional resistance and the need for changes in legislation can delay implementation. Strategy 4.4 Exercise supportive supervision Supervision, especially coupled with audit and feedback to staff, Supervision that has been consistently found to improve the performance of many types of health workers, from providers to managers (21, 38). is supportive and While the intent to supervise is almost universal, it often proves dif�cult to put into practice and becomes the �rst casualty in helps to solve speci�c the list of priorities for busy and resource-constrained manag- ers. Supervision often becomes more dif�cult but even more problems can improve important in health systems that are decentralizing. Ministry performance, job central managers, for example, may be perceived as no longer having the authority to supervise districts, or their posts may satisfaction and have been transferred. When it does take place, the nature of the supervision is motivation important. If supervisory visits become sterile administrative events, or are seen as fault-�nding and punitive, they have little positive effect and may have negative effects. In contrast, supervision that is sup- portive, educational and consistent and helps to solve speci�c problems, can improve performance, job satisfaction and motivation. Good supervision made a difference in staff motivation and performance between public hospitals and autonomous quasi- government hospitals in Ghana (see Box 4.3). Strategies to improve supervision tend to neglect three groups, all of whom perform better with supervision. The �rst of these groups consists of supervisors themselves; the second consists of lay health care providers, be they families or community health workers with more formal roles, who often work alone; and last but not least are private providers, who in many low income countries receive virtually no supervision at all. The challenge is to �nd ways to oversee performance that will be accepted by independent, self-employed practitioners. Supervision is one element in various strategies being explored to engage private and informal providers in the delivery of commodities and services. In the example of social franchising projects, franchisees such as drug sellers obtain certain bene�ts, for example subsidized supplies, and in return accept – among other things – to be supervised by the franchiser (39). Basic support systems Every health worker needs some key supports to perform his or her job: remunera- tion, information, and infrastructure, including equipment and supplies. This section does not provide a comprehensive review of the systems that deliver these supports, but focuses on features that have particular relevance to enhancing health workforce performance. Strategy 4.5 Ensure appropriate remuneration Three aspects of remuneration influence the behaviour of health workers: the level and regularity of pay, the way people are paid, and other incentives. Health workers must be paid reasonably for the work they do. They need to receive a living wage; they also need to believe that the wage is commensurate with their responsibilities and that it is fair when compared with others in the same or equivalent jobs. 76 The World Health Report 2006 Box 4.4 Differences in salaries between countries, professions, sectors and sexes (a) Cross-country comparisons of annual salaries of 1 000 000 �gure (a) physicians and nurses (international $, log scale) Average yearly wage rate Doctors and nurses in poor countries earn less than their counterparts 100 000 in most high income countries, even after accounting for differences in the purchasing power of earnings, so substantial �nancial incentives ex- 10 000 ist for them to emigrate. In �gure (a), annual salaries are plotted against Each point on the graph represents a country GDP per capita in international dollars. Available data usually concern General physician doctors and nurses only. 1 000 Professional nurse 100 0 10 000 20 000 30 000 40 000 GDP/capita at international $ (b) Salary differentials between comparable professions (c) Comparisons of salaries between the public and private sectors Differentials in the salaries of health professionals also vary within coun- tries. Salaries can be compared between equivalent professions, public Such comparisons are sparse. Certainly not all private sector workers are and private sectors, and men and women doing the same job. For coun- necessarily highly paid: for example, one study found that around 14% tries with available data, the monthly salary of a teacher is typically 1–1.5 (Latvia) and 50% (Georgia) of private sector health workers were paid at times the salary of a nurse (see �gure (b)) though in Costa Rica, Estonia or below the minimum wage. and the United States nurses reportedly earn more than teachers. Engi- neers are paid more than doctors, sometimes substantially more, in most low income countries, for example Bolivia, Côte d’Ivoire and Honduras. In general, this balance is different in countries with incomes per capita above US$ 10 000 (as in Australia, Slovakia and the United States), so that here doctors are paid more on average. (d) Ratio of wages (PPP US$), men to women 3.5 �gure (b) Likewise, few data are available on differences in earnings between men 3 and women. Figure (c) illustrates salary differentials by sex in four OECD Ratio of average wages countries: in three of them there seems to be parity across the �ve oc- teachers to nurses 2.5 cupations studied. The most rigorous cross-country study available sug- 2 gests that the small differences that exist can be explained by differences 1.5 in the number of hours worked, type of speciality and seniority. This gen- eral �nding could well hide considerable variation across countries. 1 Parity 0.5 0 �gure (c) 0 5000 10 000 15 000 20 000 25 000 30 000 35 000 40 000 45 000 Professional nurse Auxiliary nurse Physiotherapist GDP/capita $ at exchange rate 1.8 1.6 Medical X-ray technician Ambulance driver Ratio of average hourely 4.5 wages men/women 1.4 4 1.2 Parity engineers to physicians 3.5 Ratio of average wages 1.0 3 0.8 2.5 0.6 2 0.4 1.5 0.2 1 Parity 0.0 0.5 Australia Canada Finland Republic of Korea 0 0 10 000 20 000 30 000 40 000 GDP/capita $ at exchange rate Sources: (44–49). Data from most recent year available. making the most of existing health workers 77 Underpayment and a sense of unfair differences stunt productivity and perfor- mance (40). Public sector health workers have developed many coping strategies to deal with salaries that are unrealistically low, or intermittent: dual or multiemploy- ment, absences and ghost workers; informal payments; referring patients to the private sector; and migration to better labour markets (25, 41–43). Raising salaries in the public sector can be dif�cult and costly. In some cases ministries of �nance set public expenditure ceilings; salary levels may be set for all civil servants by public service commissions, who consider it unfair or unwise to raise salaries in one sector alone, or simply lack the ability to do so. Furthermore, for some particularly skilled and scarce health workers, the public sector may simply be unable to match salaries offered by the private sector or that are found overseas. Not all private sector workers are highly paid, however; in some countries, a signi�cant proportion of workers in the private sector are paid at or below the minimum wage (44). Various comparisons of salaries are described in Box 4.4. So what can be done? Despite the dif�culties, a number of low income countries have dramatically increased the pay of public health workers in recent years. In the United Republic of Tanzania, for example, the Selective Accelerated Salary Enhance- ment scheme provided an opportunity for ministries to raise levels of remuneration for high priority groups (15). In Uganda, salaries were increased in 2004 for all health workers following a job evaluation exercise across the whole public service, which used a standard set of criteria (such as length of training, cost of errors, and working hours) to rank jobs and set their associated salary scales. As a consequence, the salaries of the lowest level nurse almost doubled and became equivalent to that of a new university graduate (42). Given the cost of salaries, there has recently been increasing acceptance by external agencies that salary support will be needed in very low income countries for the medium term (see Box 2.2). Some countries have made efforts to remove health workers from the civil ser- vice pay structure, to allow for more freedom in the setting of pay and conditions of service. Zambia tried this approach but it was resisted by professional groups and eventually lost momentum. In Ghana, tax-collectors and bank employees have been successfully de-linked from the civil service, but health workers have not (15). Unpaid salaries present a problem in many countries, from eastern Europe to Af- rica (50), and may provoke absenteeism. Salaries sometimes remain unpaid because human resources management and payroll systems are not working properly. There is no hard evidence on the effects of investing in functioning administrative systems. However, bolstering this essential ingredient for workforce management may be eas- ier to act on than other more politically charged workforce reforms, need not be costly, and could provide relatively quick and signi�cant results. A second cause of unpaid salaries is lack of funds. In Chad, Unpaid salaries donor funds have been successfully used to guarantee timely pay- ment for health workers who were previously experiencing delays of present a problem in 4–7 months (50). The way people are paid makes a major difference to what they many countries, from deliver. Individual health workers, and the facilities in which they work, can be paid in many different ways. For each, pay may be eastern Europe to time-based (salaries or �xed budgets), service-based (fee for ser- Africa vice) or population-based (per capita payments or block contracts) (51). Both facility-based and individual payment mechanisms can 78 The World Health Report 2006 influence how individuals perform. Experience shows that salaries and �xed budgets lead to providers reducing the number of patients seen and services provided, where- as fee-for-service payments encourage incentives for providers to see more cases; offer more services, and deliver more expensive services. Each payment mechanism also has different administrative implications, from simple to more complex (52). Optimal payment systems induce providers to give high-quality, effective treatment while promoting a rational allocation of resources (40). Middle and upper income countries, including Australia, Hungary, the United King- dom, and the United States, have been moving away from input-based budgets and salaries towards performance-related pay based on outputs and outcomes (53–55). Mixed provider payment systems have become more common to balance the different incentives each mechanism creates. Robinson’s study of physician organizations in the United States found that approximately a quarter of physicians were paid on a purely retrospective basis (fee-for-service), another quarter on a purely prospective basis (capitation, non-productivity-based salary) and about half on a mix of the two (48). Some evidence suggests that performance-related pay can lead to improvements in the quality of care provided (56, 57). The idea of introducing performance-related pay in lower income countries has gained popularity recently, for the same reasons that this approach is used in richer countries. However, experience remains very limited. In most lower income countries the majority of public health workers still receive salaries together with allowances unrelated to performance, whereas in the private sector the fee-for-service system is more prevalent. The limited introduction of this mechanism may stem in part from the fact that payment methods with stronger incentives for quality, consumer satisfac- tion, equity or ef�ciency tend to have higher administrative costs and require greater administrative capacity (52). The use of other sources of income, such as allowances, to increase job at- tractiveness – whether in general or only in underserved areas – exists in virtually all countries. Types of supplementary pay and allowances valued by health workers include: contract-signing bonuses; reimbursement of job-related expenses such as uniforms and petrol; education, accommodation, transport or child care subsidies; Box 4.5 Incentives to enhance health workers’ performance Thailand. In the 1990s, payment reforms to improve the part of a public health centre which has no doctor, or availability of health workers in rural areas included: sup- as a private practitioner. The two sectors have different plements to doctors in eight priority specialties and services payment mechanisms but similar non-�nancial bene�ts: who worked in rural areas; non-private practice compensa- public sector doctors receive a salary plus a share of tion for doctors, dentists and pharmacists; monthly salary facility revenue; private doctors are paid on a fee-for- supplements to doctors, pharmacists, dentists and nurses service basis but the fee level is based on local ability in district hospitals and health centres; and overtime and to pay. All participants receive some initial training, plus night shift payments. These supplements were combined accommodation, equipment and transport if needed. In with other non-�nancial incentives. Over time, the availabil- addition, all are expected to join the Medical Association ity of health workers in rural areas has improved (64). and be part of a peer learning network. By 2004, 80 doc- tors (from Mali’s estimated total medical stock of 529) Mali. In 1986, the Ministry of Health introduced a strate- had joined this scheme and were working in rural areas, gy, which continues today, to encourage newly graduated where some had been for over �ve years. An assessment doctors to serve in rural areas. Doctors are contracted to in 2001 found that service coverage in rural facilities with work in underserved areas to deliver the minimum health a doctor was higher than in those without (65). package stipulated in the National Health Policy, either as making the most of existing health workers 79 health insurance; access to loans (e.g. subsidized mortgages); per diem payments while on training courses; allowances for working in remote areas or out of hours (overtime and night shifts); and speci�c service output incentives (e.g. for immuniza- tion) (58). Doctors and nurses are often the main bene�ciaries of income supplements. In the United States, tuition reimbursement or contract-signing bonuses are commonly used to attract nurses. In Jamaica, health insurance, paid vacation and transport are often offered to nurses (59); while bene�ts in Botswana include housing, car loans and medical aid (60). Doctors and nurses How well these measures work depends on how they are de- signed and implemented and what other incentives are in place. are often the main Objectives and target groups need to be de�ned, and in some cases incentives must be negotiated with unions; they must also be viewed bene�ciaries of as fair. Over time they may come to be seen as entitlements rather income supplements than incentives, and their effects may change (61). Well-intentioned incentives can have unintended, perverse effects (58, 62). In Ghana, for example, the additional duty hour allowance introduced for doctors and nurses was resented by nurses, because of the perceived or real disparities in the gains, and is thought to have contributed to the increased migration of nurses (63). Packages of incentives are often required to balance the different effects of individual �nancial (and non-�nancial) incentives. In Thailand, for example, efforts to improve the availability of doctors in rural areas have involved several types of additional payment, as well as educational, infrastructure and social strategies (32) (see Box 4.5 for two examples). Studies of “magnet institutions� – those which are successful in recruiting, retaining and motivating nursing staff – in the United King- dom and the United States, found that critical factors include good human resources management and quality of care (66). These are discussed further later in the chap- ter. All incentives require regular monitoring and adjustment to changing “push and pull� factors: Thailand has employed different tools at different times to improve and maintain the availability of health workers in rural areas. No discussion of remuneration would be complete without acknowledging that in many countries, in all continents, informal payments provide a major source of income for health workers and thus exert major influences on behaviour towards their clients (42, 67). There is no easy way to address the problem of informal payments but there are encouraging examples. In Cameroon, the government introduced a scheme that is now in place in all larger health facilities. It included: having a single point of payment for patients at the facility; clearly displaying the fees and the rules about payment to patients, and telling them where to report any transgressions; using the fees to give bonuses to health workers, but excluding them from the bonus scheme if they break the rules, and publishing names of those receiving bonuses and those removed from the scheme. A key factor in the success of this scheme has been a strong facility manager who enforces the rules fairly (43). The above points concerning remuneration of health workers can be summed up as follows: Secure the minimum: a living wage that arrives on time! When it comes to worker performance, pay matters. External agencies could help to improve worker performance in low income countries by providing salary support for the medium term. 80 The World Health Report 2006 A mix of payment systems and incentives should be used where possible. If insti- tutional capacity is limited, caution should be exercised in adopting approaches with complex administrative requirements. Salary increases alone are not enough to change performance. These must be combined with other strategies to create signi�cant change. Any incentives or remuneration policies must always be monitored and adapted over time to ensure that they produce the desired outcomes. Strategy 4.6 Ensure adequate information and communication A well-known adage states that you manage what you measure. Evidence shows that having information does help health workers to do their jobs better, as long as certain provisos are met: the information must be relevant to the job and available when needed, and workers must have a degree of con�dence in the information’s quality and understand what it is “saying� (21, 68). Health workers at different levels need different sorts of information from many sources: medical records, facility activity re- ports, �nancial accounts, health workforce inventories and payrolls, population-based survey data and scienti�c literature, to name just a few. A well-functioning national information system is a key ingredient to improving workforce performance. Any speci�c efforts to improve overall workforce productivity need to be based on reliable data about workforce level, distribution and skill mix, coupled with informa- tion on the factors thought to be constraining better health worker performance and intelligence on potential policy options. In some instances, individual provider productivity has been improved with com- munication technologies that help health workers to deliver services. There is a grow- ing amount of evidence to suggest that these technologies can lead to productivity gains in the health workforce by improving the way workers provide clinical and public health services. Examples are given in Box 4.6. Many organizational, legal, infrastructural, social and �nancial barriers to the wide- spread use of modern information and communication technology remain, especially Box 4.6 Using modern communication technology to improve data, services and productivity In well-off countries, health workers increasingly use mod- getting appropriate treatment when compared with the ern communication technology to provide care, and stud- existing paging systems (72–74). The need for chronic ies have demonstrated increases in their productivity as a care of HIV/AIDS patients has triggered an exploration result. The use of telephones to remind high-risk individu- of models for resource-poor settings, which are being als about influenza immunization (69) and mammography piloted in a number of low income countries. among managed health care plan members resulted in a Handheld computers are powerful data collection signi�cant increase in uptake of these preventive interven- tools, providing rapid access to information needed to tions, without any other apparent changes in the workforce prevent or respond to disease outbreaks. They can fur- (70). Computer-generated telephone reminders have also nish data at the point of need, even in the absence of been effective in improving medication adherence and blood Internet or telephone connectivity. For example, a Red pressure control in hypertension patients (71). Cross survey team gathering data for measles immuni- There is evidence that computer-based patient records zation in Ghana using such devices processed 10 times can improve patient care, outcomes and costs. Computer- more questionnaires than usual, and returned results ized reminder systems to alert health care staff to repeat to the Ministry of Health with unprecedented ease and tests have reduced the number of patients subjected to un- speed. For more information, see http://www.satellife. necessary repeat testing, while automatic systems com- org/ictinhealth.php. municating critical laboratory results reduced the time for making the most of existing health workers 81 in low income settings (75). In some cases, these technologies may be viewed as magic bullets to solve problems that need quite When looking for different solutions. Nevertheless, it will be important to keep a critical but open mind to their potential: the explosion in the use ways to improve of mobile telephones in low income countries shows how quickly a new technology can be adopted in countries where traditional performance, we have communication infrastructure is weak or unaffordable. Simple found nothing works communication methods such as newsletters and helplines also have a role to play in improving access to information. so well as talking Strategy 4.7 Improve infrastructure and to health workers supplies No matter how motivated and skilled health workers are, they themselves. Their ideas cannot do their jobs properly in facilities that lack clean water, adequate lighting, heating, vehicles, drugs, working equipment are just amazing. They and other supplies (76–78). Two examples illustrate the con- sequences. In Niger, nurses at health centres were reported to will tell you what to do Director of human resources in Africa be reluctant to refer patients to district hospitals because only three of the 33 hospitals provided surgical care, most of them could not give blood transfusions or oxygen, and laboratory and X-ray facilities were rudimentary (79). In Kyrgyzstan, health professionals in primary care providing diabetes care said that their job was hampered by a lack of testing strips, machines to measure blood sugar, weak laboratories and irregular supplies of insulin (77). Drugs being out of stock is a familiar problem to many health workers (see Table 4.3). Hard evidence for the performance bene�ts of improving basic infrastructure and supplies is very thin (81) but it seems highly likely that such improvements – once in place – could create signi�cant, almost immediate gains. For example, paying a utility bill so that the electricity or heating is turned on again may make a quicker differ- ence to productivity than any more speci�c performance management tool. Costs are likely to be variable: some would be unique outlays and some recurring. A simple and obvious, but sometimes overlooked, way to determine the actions that will create the largest and most immediate improvements is to ask the health workers themselves. The physical work environment also needs to be safe, and health workers them- selves need to be provided with health care when sick. Aspects of safety are dis- cussed in Chapter 5. Functioning support systems require consideration of the management and sup- port workers discussed in Chapter 1, such as store managers, accounts clerks, in- formation of�cers, equipment technicians, hospital administrators and personnel and Table 4.3 Pharmaceutical situations in public health facilities in Africa and South-East Asia Indicator Africaa South-East Asiaa Average number of days during which key medicines were out 25 19 of stock in the preceding year Percentage of facilities meeting basic conservation conditions 75% 75% required to maintain medicine quality Percentage of dispensed medicines adequately labelled 71% 87% a Median, seven countries in each region. Source: (80). 82 The World Health Report 2006 procurement managers. These workers are often neglected in workforce discussions, but are critical to scaling up service delivery. An enabling work environment Three general types of levers can be used to promote an enabling work environment. Most involve the managerial culture and organizational arrangements within which health care providers work. They are grouped as follows: lifelong learning, team management and team working, and responsibility with accountability Strategy 4.8 Promote lifelong learning Health workers require up-to-date knowledge to perform well, as has been men- tioned in Chapter 3. Rapid increases in knowledge and changing health systems make this need even more essential today. This is a �eld full of experimentation, but some clear and straightforward messages have emerged. Individual needs vary widely. Basic workers with only weeks of pre-service train- ing have different learning needs from doctors or nurses with a decade or more of education and experience. Nurses in rural Switzerland clearly deal with very different everyday challenges than those in rural Malawi. Nevertheless, some common princi- ples underlie any strong approach to professional development. Table 4.4 summarizes some individual and workplace-wide approaches. Formal one-off, off-site training courses have a poor track record for changing the actual practice of health workers. In-service training is most likely to change worker behaviour when it is interactive, based on real-life problems and coupled with continuing, intermittent support. To illustrate this fact, although the use of oral rehydration salts for childhood diarrhoea greatly increased in the 1980s and 1990s, after more than 2000 train- ing courses on case management and supervision from 1988 to 1993 in over 120 countries, the median percentage of children correctly rehydrated by health workers (from 22 surveys) was only 20% (21). Simple, low-cost approaches that follow the principles of interactive, realistic training with adequate continuing support can be very effective (38). These lessons have been translated into the more encompassing, long-term concept of continuous professional development or lifelong learning. Con- Box 4.7 What sort of training works best? If performance change is the goal, exclusively didactic ap- cation is shown to increase knowledge (94), knowledge- proaches, conferences and activities without any practice seeking behaviour (95), self-con�dence (96) and positive have little or no role to play (83, 84). Evidence suggests that attitudes in three studies, though no effect on behaviour there is more probability of knowledge and skills transfer change was observed. When a videoconference-type into practice when the training course is interactive with training session was compared with in-class face-to- as much hands-on real-life experience as possible. Interac- face training, there was no difference in knowledge ac- tive courses improve prescribing or dispensing behaviour cumulation (97). The most convincing evidence for dis- (85–88), improve speci�c clinical skills (89–90) and posi- tance education is a study which shows that a 10-month tively effect health care utilization while promoting favour- distance education course, supported with 1–2 contacts able patient responses (91). Active learning opportunities, by tutors, caused a signi�cant increase in correct as- sequenced learning, after-training support, reminders and sessment of diarrhoea cases (98). multifaceted activities are effective (92, 93). Distance edu- making the most of existing health workers 83 Table 4.4 Approaches to professional development and performance Training Individual Team or organization-based Intermittent Training courses Retreats Continuous Continuous Wide array of approaches with similar principles but many professional different labels, e.g. total quality management, tools and development techniques Distance learning Web-based training Teleconferencing, collaborating workspaces, other web- and access to based groupware literature tinuous professional development can be simply de�ned as a “systematic, ongoing, cyclical process of self-directed learning� for individuals. Such an approach goes be- yond training to include, for example, career paths, feedback from others, mentoring and secondment (82). Distance education in its various forms also deserves further exploration, given the geographical distribution of the many health professionals in need of continuous professional development. Box 4.7 presents some of the options for educational opportunities. Experience clearly shows that simply disseminating guidelines is ineffective. If guidelines are passively distributed, few people read them, even if they are followed by reminder visits (99–104). When guidelines are distributed during a training course, however, and supported by peer groups to discuss the content and to provide audit and feedback to participants or associated with subsequent supervisory visits, they are signi�cantly more likely to be implemented (105–107 ). In recent years, attention has shifted to multifaceted packages of iterative, on-the- job support, with an emphasis on ways to encourage translation of new knowledge Box 4.8 Quality assurance, supervision and monitoring in Uganda Since 1994 Uganda’s Ministry of Health has engaged in vig- lic service providers and nongovernmental organizations orous quality assurance, supervision and monitoring of dis- are monitored, but not the private sector. tricts and sub-districts through the following approaches: To provide incentives for improvement, Uganda’s Min- • creation of a Quality Assurance Department; istry of Health has put in place an award system called • development and dissemination of standards and the Yellow Star Programme. District health facilities com- guidelines; plying fully with the 35 standards considered the best • initial workshops to assist administrators, political lead- indicators for overall management now receive a plaque ers and clinical staff with identifying and solving com- in the form of a �ve-pointed yellow star, along with of- mon service-related problems; �cial recognition and publicity. Forty-seven districts now • support visits by multidisciplinary teams; participate. • quarterly supervisory visits with routine monitoring (of Uganda’s efforts have resulted in better coordination �nance and planning, for example) and one special focus between health services and local administrators and area such as malaria or child health; political leaders. The 2003/4 health sector review found • supervision that is supportive, non-punitive, and exer- that some districts are performing much better than oth- cised in an atmosphere of trust; ers, and that unexpectedly, poor and rural districts are • verbal feedback and summary reports with key issues not necessarily poor performers. In interviews conducted highlighted and action plans agreed on. across Uganda, the view was widely expressed that good performance stems at least in part from good manage- The programme includes routine monitoring of indicators at ment, especially in a supportive political environment national and district levels, and benchmarking of progress (112). towards the achievement of the national strategic plan. Pub- 84 The World Health Report 2006 into changed practices. Such approaches can be judged in many ways, including the quality of services and productivity. Recently, a wide array of programmes has emerged with different labels, degrees of complexity, tools and techniques, but mostly following a similar set of principles. Some focus on individuals and others on organiza- tion-wide or team-based approaches – where the team may be a work unit of mixed staff or a group of professionals, such as managers, who share the same responsibili- ties in different places. Teamwork and processes such as joint development of guidelines and peer review can be moderately successful in improving health worker performance. The observed bene�ts of teamwork include improved staff well-being (108, 109) and better qual- ity of care (110). Evidence of the effectiveness of organization-wide approaches to achieve sustained improvements in services is limited. For example, in the United Kingdom and the United States, total quality management approaches have shown mixed results (111). Many forms of quality improvement projects have taken place in low income countries with successes reported (see Box 4.8) – but rigorous evaluations are few (21). Ultimately, of course, the most suitable approach depends on the speci�c needs and objectives of the workforce. Strategy 4.9 Establish effective team management Along with the shift in approaches to professional development has come a rising recognition that important gaps exist in the scope of the current response. Over the years most attention has focused on knowledge and skills for clinical services, rather than on more generic skills needed to make health systems work, such as man- agement, accounting, procurement and logistics. Some “softer� managerial skills such as team building and negotiation have also received little attention. As a result, many low income countries receiving large amounts of additional funds to scale up services rapidly are facing some basic skill de�cits in such areas as simple account- ing, drug stock and store management, and basic personnel management. Health system reorganizations may also create a need for new skills. This has been the case in Kyrgyzstan (see Box 4.9), while health reforms in Chile and the United Kingdom increased the need for skilled managers (113, 114). People respond positively to a host of non-�nancial incentives that can be collec- tively captured under the rubric of good management or leadership, terms which are often used interchangeably (116). Whether called management or leadership, these skills bene�t health workers at every level of a health system. Limited but positive evi- dence suggests that the factors listed below may improve individual or organizational Box 4.9 Changing tasks and therefore skill needs In Kyrgyzstan, funds used to be allocated to facilities based providers are paid and that the services provided are on bed and staff numbers. Reforms introduced in 1997 have appropriate and of good quality. A critical new func- changed the system from this passive budgeting approach tion performed by the MHIF is utilization review which to one relying on active or strategic purchasing of personal involves checking claims to protect against fraud while health care services. A new agency, the Mandatory Health contributing to quality improvement. This has led to the Insurance Fund (MHIF), pays inpatient facilities on a per need for a new set of skills: in computer programming, case basis and primary care practices by capitation. The data processing, analysis of clinical data, and the ability hospital payment reforms have involved completely new to discuss and negotiate with providers on the basis of processes of information management, �nancial man- those analyses (113). agement, and quality control to ensure that contracted making the most of existing health workers 85 performance (56, 117–123). Health workers are more motivated to perform well when their organization and managers: These evaluations are provide a clear sense of vision and mission; make people feel recognized and valued whatever their job; a source of motivation listen to staff and increase their participation in decisions – they often have solutions; for us; if we get a good encourage teamwork, mentoring and coaching; grade we make even encourage innovation and appropriate independence; create a culture of benchmarking and comparison; greater efforts to keep provide career structures and opportunities for promotion that are transparent and fair; our rank or to go even give feedback on, and reward, good performance – even with token bene�ts; further use available sanctions for poor performance in ways that are fair and consistent. Public sector manager, Benin Good managers reward their staff. Some examples of non-�nancial rewards that may be used are: tea during night duty, holidays and days off, flexible working hours, ac- cess to and support for training and education, sabbaticals, study leave, and planned career breaks. Some examples of management and leadership are mentioned in Box 4.10. The introduction of performance appraisal systems, such as Zambia’s Perfor- mance Improvement Review system and Malawi’s Performance Contract scheme, are becoming more common. How effective is performance audit and feedback (126)? There are many examples of successful projects, but large-scale evidence that such schemes improve service quality, productivity or health outcomes is still scarce (15). A major review of experience with audit and feedback in high income countries con- cluded that these tools can be effective in improving professional practice but their effect is small to moderate (127 ). Assessment of facility performance is also becoming more common, but experience is still scarce in low income settings. Box 4.10 The importance of management and leadership South Africa. Nurses working in maternal health services them at a country or organizational level to participate were asked about the most important characteristics of the effectively in health policy development and decision- workplace and presented with 16 theoretical workplace making, become effective leaders and managers in nurs- pro�les. The most signi�cant �nding was that good man- ing and health services, prepare future nurse managers agement (e.g. clearly de�ned responsibilities, supportive and leaders for key positions, and influence changes attitude when mistakes are made, rewarding ability and not in nursing curricula so that future nurses are prepared length of service) outranked salary as a preference, unless appropriately. the remuneration was dramatically higher. These results Nurses in more than 50 low and middle income coun- reinforce other research demonstrating the effect of good tries have gained the knowledge, skills and strategies management on employment choices and job satisfaction they need to take leadership roles in nursing and health among health workers (124). systems, build partnerships, and improve health care through participation in this programme. Evaluations in- Leadership for Change programme. The International dicate that graduates are involved in a range of nursing Council of Nurses (ICN) has set up a programme to develop leadership roles, with an increase in nurse leaders’ influ- nurses as effective leaders and managers in a constantly ence, ability to build sustainable partnerships, and ability changing health environment. The Leadership for Change to develop new models of nursing to improve quality of methodology and key strategic goals are designed to assist patient care (125). 86 The World Health Report 2006 As for implementation, introduction of the changes mentioned here is not neces- sarily costly, but neither is it necessarily straightforward. For example, a study on performance management of district health managers in nine Latin American coun- tries found that teamwork was dif�cult to introduce into a health system that promotes hierarchical structure and favours an authoritative management style (128). Strategy 4.10 Combine responsibility with accountability Giving local managers at least some freedom in the allocation of funds can make a big difference to staff and facility performance, as these managers can then quickly deal with local problems unknown to higher level managers (129). Mechanisms to hold health workers accountable for their actions are another way to improve productivity and performance (130). Services can be organized in many different ways, but managers cannot manage them properly if they are not given at least some control over money and staff. Three consistent �ndings have been identi�ed across different health systems. Decentralization is under way in many countries. However, though local managers are often being given more responsibility for service delivery, they are not always being given the greater authority over money and staff required to enable them to ful�l these new responsibilities. There are often few functioning mechanisms to assure accountability in the use of money, recruitment of staff or quality of services provided. Confused lines of reporting are common, especially during periods of reorganiza- tion. This not only reduces accountability and thereby blunts its use as a lever for improving staff performance, but can reduce staff motivation. The general public also has a role to play in holding health workers accountable for their actions (130). Publicizing what patients should expect from their providers is cheap and easy to do and has been done with good results regarding patients’ rights and user fee schedules in both low and high income countries (131). In Uganda, for example, health district performance is ranked and the results are published in the press. Formal mechanisms for handling allegations of provider misconduct can also be effective but have proved dif�cult to use successfully in practice in low income settings (132). HOW ARE LEVERS LINKED TO THE FOUR DIMENSIONS OF HEALTH WORKFORCE PERFORMANCE? The framework at the start of this chapter listed four desired dimensions of health workforce performance: availability, competence, responsiveness and productivity. Rigorous evidence is limited, but Table 4.5 provides an overview of which levers appear to have the greatest effect on each of these dimensions. The results will naturally be influenced by local context. Availability The levers thought to be most effective at increasing the availability of existing staff are those related to salaries and payment mechanisms, together with the materials to “do the job� and a degree of independence allowed to individual health workers to manage their work – whether in the management and deployment of staff for manag- ers, or in clinical decisions for health care providers. Job descriptions and codes of conduct may also help, by providing clarity and the sense of professionalism which often appears to sustain health workers in dif�cult conditions. making the most of existing health workers 87 Table 4.5 An aid to thinking through potential effects of levers on health workforce performance Dimensions of health workforce performance Levers Availability Competence Responsiveness Productivity 1 Job descriptions + + + + Norms and codes of 2 ++ + ++ + / ++ conduct 3 Match skills to tasks + + + +++ Supportive 4 + +++ ++ ++ supervision 5(a) Salary levels +++ + + ++ 5(b) Payment mechanisms ++ / –– +/– +/– +++ / ––– Information and 6 0 ++ + ++ communication Infrastructure and 7 ++ 0 + ++ supplies 8 Lifelong learning + +++ + + Teamwork and 9 + + ++ +++ management Responsibility with 10 ++ + ++ +++ accountability Key: + = positive effect; – = negative effect. + = some effect; ++ = signi�cant effect; +++ = substantial effect. Payment mechanisms: the effects will depend on the mechanism used. Competence The levers that seem to have the greatest influence on health workforce competence (here encompassing technical knowledge, skills and behaviours) are supervision coupled with audit and feedback and lifelong learning. It is important to note, how- ever, that it is the way in which these levers are applied that is crucial: sterile, fault- �nding visits have no effect, whereas supportive supervision (together with audit and feedback) consistently has moderate to large bene�ts. An institutional approach that fosters the culture and practice of lifelong learning is more effective in changing practice than stand-alone, off-site training courses. Responsiveness Responsiveness refers to the goal that people should be treated decently regardless of whether or not their health improves, and irrespective of who they are. As with the other dimensions of performance, no single lever alone is suf�cient but the following appear to have the most signi�cant effect: norms and codes of conduct; supervision; and basic amenities, such as privacy during consultations. Team-based interventions that make health workers feel valued and permitted to innovate can also boost responsiveness. 88 The World Health Report 2006 Productivity Many levers have the potential to improve productivity but three stand out. Strategies to redress skill mismatches could reap huge productivity gains. Adjusting the way that health workers are paid, improved teamwork, and responsibility with account- ability also offer potentially large bene�ts. Table 4.6 Health workforce performance: provisional assessment of implementation and effects of levers Implementation and effects Ease of Relative Potential Evidence base implementation cost effect Timing of impact1 1 = theory 2 = anecdote, example 1 = easy 1 = low 1 = small 1 = near term 3 = some formal studies 2 = moderate 2 = medium 2 = moderate 2 = medium term Levers 4 = strong evidence 3 = dif�cult 3 = high 3 = large 3 = long term Job-speci�c levers Job descriptions 2 1 1 2 1 Norms and codes of 2 2 1 2 2,3 conduct Matching skills to tasks 1 1,2,3* 1,2 3 1 Supportive supervision 3 2 1,2 2,3 1 Basic support systems Remuneration 2 2,3 3 2 1 (salary levels) Remuneration 3 2,3* 2 3 2 (payment mechanisms) Information and 2 2 2 2 1,2,3* communication Infrastructure and 2 2 2,3* 3 1 supplies Enabling work environment Lifelong learning 3 1 1 2 1 Team management 3 1,2,3* 1 2 1 Responsibility with 3 1,2,3* 2 3 1 accountability 1 Once implemented. *Depends on cause of problem, speci�c interventions introduced. making the most of existing health workers 89 CONCLUSION This chapter has described the levers that can influence workforce performance. Table 4.6 summarizes what is known about implementation of the measures proposed here. An inevitable tension exists between the perspectives and goals of individuals and the organizations to which they belong. Organizations have to perform well and deploy their staff to the greatest advantage, while also providing places for individuals to thrive. This tension must be continually monitored and managed. Moreover, manag- ing any change is a subtle and often dif�cult process, for several reasons. Changes may be needed at several levels. Legal and regulatory frameworks may need to be changed, which can be complex and slow. Resources are often needed to support change. Probably most importantly, local stakeholders must be brought “on board� as they can facilitate or equally effectively block a reform that has been carefully ne- gotiated at central level (78). 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Health Policy and Planning, 1996, 11:265–279. managing exits managing exits from the workforce 97 chapter five from the workforce in this chapter 98 Ebbs and flows of migration 105 Occupational risks to health workers Each year, substantial numbers of health 107 Change of occupation or work status workers leave the health workforce, either 109 Retirement temporarily or permanently. These exits can 112 Conclusion provoke shortages if workers who leave are not replaced, and such shortages com- promise the delivery and quality of health services (1, 2). Chapter 3 discussed the routes new workers take into the workforce; this chapter examines the other end of the spectrum – the various ways in which workers depart active service. It also suggests ways of managing exits in times of worker shortage as well as in times of surplus, in order to optimize the performance of the health workforce. Finally, it reviews and analyses the factors that influence exits and proposes strategies for managing them. The main reasons people leave the health workforce are depicted in morbidity and mortality rates (in Africa, mainly Figure 5.1: migration; risk of violence, illness or death; change of occu- attributable to HIV/AIDS and tuberculosis), increas- pation or work status; and retirement. Some workers leave temporarily, ing migration, and ageing (especially in high income because of illness or maternity or in order to attend advanced education countries). These factors pose serious challenges courses, for example. Others are lost permanently, because of death or to the goal of maintaining a suf�cient and effective a change of occupation. In some cases, a health worker migrates from health workforce. one country to another, thus permanently leaving one health workforce High turnover rates in the health workforce may to join another. Partial exits occur when full-time health workers move lead to higher provider costs. They are also a threat to part-time employment: changes in the numbers of full-time and part- to the quality of care, because they may disrupt time workers can alter the health workforce equilibrium. organizational function, reduce team ef�ciency, Over the last few decades, the working lifespan of health workers and cause a loss of institutional knowledge. Stud- Stephenie Hollyman/WHO has altered because of changes in their working patterns, growing ies show that the costs associated with retention 98 The World Health Report 2006 Figure 5.1 Exit routes from the health workforce Migration (within the home country from rural to urban regions or to another country) Risk of violence, illness or death Health workforce Change of occupation or activity (e.g. unemployment, part-time employment or work outside the health sector) Retirement (at statutory age or by early retirement) problems are often substantial (3). Turnover can have potential bene�ts, however, as it may provide an opportunity to match personnel skills better to workplace needs, facilitate the introduction of new ideas into well-established organizations, and in- crease organizational flexibility (4). In this context, it is important for policy-makers to manage exits from the health workforce to ensure the least possible disruption of services. EBBS AND FLOWS OF MIGRATION Concerns about the adverse impact of the flows of skilled professionals from poorer to richer countries have thrust the migration of health workers to the forefront of the policy agenda in recent years (5). However, statistics on global flows of health workers remain far from complete (5–12). For the select number of countries that do track migration, available information is generally limited to registered doctors and nurses. Data on movements of pharmacists, occupational therapists and the many other types of health workers identi�ed in this report are virtually non-existent. Not knowing how many health workers are on the move, where they have come from, or where they are going makes it dif�cult to grasp the scale of the problem. Table 5.1 Doctors and nurses trained abroad working in OECD countries Doctors trained abroad Nurses trained abroad OECD country Number Percentage of total Number Percentage of total Australia 11 122 21 NA NA Canada 13 620 23 19 061 6 Finland 1 003 9 140 0 France 11 269 6 NA NA Germany 17 318 6 26 284 3 Ireland NA NA 8 758 14 New Zealand 2 832 34 10 616 21 Portugal 1 258 4 NA NA United Kingdom 69 813 33 65 000 10 United States 213 331 27 99 456 5 NA, not applicable. managing exits from the workforce 99 Data from OECD countries indicate that doctors and nurses trained abroad comprise a signi�cant percentage of the total workforce in most of them, but especially in English-speaking countries (see A better life and Table 5.1). It appears that doctors trained in sub-Saharan Africa and work- livelihood are at the ing in OECD countries represent close to one quarter (23%) of the current doctor workforce in those source countries, ranging from as root of decisions to low as 3% in Cameroon to as high as 37% in South Africa. Nurses and midwives trained in sub-Saharan Africa and working in OECD migrate countries represent one twentieth (5%) of the current workforce but with an extremely wide range from as low as 0.1% in Uganda to as high as 34% in Zimbabwe (see Tables 5.2 and 5.3 overleaf). Why are health workers moving? These OECD data on migrant flows hide the complex patterns and reasons for health workers moving. Migration takes place within countries from rural to urban areas; within regions from poorer to better-off countries and across continents. A better life and livelihood are at the root of decisions to migrate. Classically this is provoked by a (growing) discontent or dissatisfaction with existing working/living conditions – so-called push factors, as well as by awareness of the existence of (and desire to �nd) better jobs elsewhere – so-called pull factors. A recent study from sub- Saharan Africa points to both push and pull factors being signi�cant (10). Workers’ concerns about lack of promotion prospects, poor management, heavy workload, lack of facilities, a declining health service, inadequate living conditions and high levels of violence and crime are among the push factors for migration (see Figure 5.2). Prospects for better remuneration, upgrading quali�cations, gaining experi- ence, a safer environment and family-related matters are among the pull factors Figure 5.2 Health workers’ reasons to migrate in four African countries (Cameroon, South Africa, Uganda and Zimbabwe) Better remuneration Safer environment Living conditions Lack of facilities Lack of promotion No future Heavy workload To save money Work tempo Declining health service Economic decline Poor management Upgrade qualifications 0 50 100 150 200 250 Number of respondents Source: (10). 100 The World Health Report 2006 Table 5.2 Doctors trained in sub-Saharan Africa working in OECD countries Doctors working in eight OECD recipient countriesa Total doctors in Percentage of home Source country home country Number country workforce Angola 881 168 19 Cameroon 3 124 109 3 Ethiopia 1 936 335 17 Ghana 3 240 926 29 Mozambique 514 22 4 Nigeria 34 923 4 261 12 South Africa 32 973 12 136 37 Uganda 1 918 316 16 United Republic of 822 46 6 Tanzania Zimbabwe 2 086 237 11 Total 82 417 18 556 Average 23 a Recipient countries: Australia, Canada, Finland, France, Germany, Portugal, United Kingdom, United States of America. Source: (11). Table 5.3 Nurses and midwives trained in sub-Saharan Africa working in OECD countries Nurses and midwives working in seven OECD recipient countriesa Total nurses and midwives Percentage of home Source country working in home country Number country workforce Angola 13 627 105 0 Botswana 7 747 572 7 Cameroon 26 032 84 0 Ethiopia 20 763 195 0 Ghana 17 322 2 267 13 Guinea-Bissau 3 203 30 0 Kenya 37 113 1 213 3 Lesotho 1 123 200 18 Malawi 11 022 453 4 Mauritius 4 438 781 18 Mozambique 6 183 34 0 Namibia 6 145 54 0 Nigeria 210 306 5 375 3 South Africa 184 459 13 496 7 Swaziland 4 590 299 7 Uganda 17 472 21 0 United Republic of 13 292 37 0 Tanzania Zambia 22 010 1 198 5 Zimbabwe 9 357 3 183 34 Total 616 204 29 597 Average 5 a Recipient countries: Canada, Denmark, Finland, Ireland, Portugal, United Kingdom, United States of America. Note: Data compiled by WHO from various sources. managing exits from the workforce 101 (see Figure 5.2). In Zimbabwe, for example, a startling 77% of �nal university students were being encouraged to migrate by their families (13). Losing its workforce Beyond the individual and the family, accelerated globaliza- tion of the service sector in the last two decades has helped can bring a fragile drive migration in the health �eld (14–18). In addition, there is a growing unmet demand for health workers in high income coun- health system close to tries due in part to rapidly ageing populations. Two important responses in the global market are occurring. First, a growing collapse number of middle income countries are training health workers for international export (see Box 5.1) and second, professional agencies are more actively sourcing workers internationally, raising questions about the ethics of recruitment (see Box 5.2). Impacts of migration The movement of health workers abroad has redeeming features. Each year, mi- gration generates billions of dollars in remittances (the money sent back home by migrants) and has therefore been associated with a decline in poverty in low income countries (22). If health workers return, they bring signi�cant skills and expertise back to their home countries. Nonetheless, when large numbers of doctors and nurses leave, the countries that �nanced their education lose a return on their invest- ment and end up unwillingly providing the wealthy countries to which their health personnel have migrated with a kind of “perverse subsidy� (23). Financial loss is not the most damaging outcome, however. When a country has a fragile health system, the loss of its workforce can bring the whole system close to collapse and the consequences can be measured in lives lost. In these circumstances, the calculus of international migration shifts from brain drain or gain to “fatal flows� (24). Strategies to manage migration The complex combination of individual worker, workplace and market forces that generate flows of health workers defy any simple or single action related to migration. The following sections deal with managing migration in order to protect health work- ers and minimize inequities. Action at three levels – in source countries, in receiving countries and internationally – can diminish the negative aspects of migration. Box 5.1 Turning brain drain into brain gain — the Philippines The Commission on Filipinos Overseas estimates that The Philippine Overseas Employment Administration was more than 7.3 million Filipinos – approximately 8% of the founded in 1995 to promote the return and reintegration country’s population – reside abroad. The government of of migrants. Many privileges are granted to returnees, in- the Philippines has encouraged temporary migration by its cluding tax-free shopping for one year, loans for business professionals in recent years and taken measures to turn capital at preferential rates and eligibility for subsidized remittances into an effective tool for national development scholarships. (including health care) by encouraging migrants to send re- The Philippines experiment has had encouraging re- mittances via of�cial channels. In 2004, the Central Bank of the sults and is seen by some developing countries as a role Philippines reported total remittances of US$ 8.5 billion, repre- model. senting 10% of the country’s gross domestic product (GDP). At the same time the government is taking measures to draw its migrants home after a period of service abroad. Source: (19) 102 The World Health Report 2006 Source country strategies Source countries can consider a wide range of options for managing migration, including two main strategies: providing health workers with appropriate training for their place of employment, and making it easy for them to return home after working abroad. Strategy 5.1 Adjust training to need and demands Training that is focused on local conditions can help to limit workforce attrition. Lessons from longstanding efforts to improve workforce coverage in rural areas suggest that training local workers – in local languages and in skills relevant to local conditions – helps to stem exits of health workers (25, 26). Such approaches to train- ing often lead to credentials that do not have international recognition, which further limits migration. Success, however, is contingent on a wide range of on-the-job incentives and support and on the involvement of key institutions such as universities and professional associations (25, 27) Even in the face of continued migration, expansion of training may help to reduce workforce shortfalls. Preserving the quality of training requires effective accreditation capacity, especially if expansion of training institutions is rapid. The Philippines has In low income countries with tight �scal constraints, such an expansion would entail either signi�cant private sector �nancial been training nurses for involvement or foreign aid. It is essential that job opportunities for graduates also grow, either through the public sector (�scal export for many years constraints permitting) or through the private sector. Training can also be speci�cally tailored to meet export requirements. The Philippines, as part of a larger policy to encourage worker migration (see Box 5.1), has been training health workers, especially nurses, for export for many years – they constitute 76% of foreign nurse graduates in the United States, for example (28). Likewise, Cuba has exported thousands of health workers as part of its bilateral relations with other countries. Some countries, including China, India, Indonesia and Viet Nam, are ei- ther actively involved or contemplating export strategies (29). These strategies have not been systematically evaluated, but experience indicates that they are resource intensive and require the establishment of institutional capacity for training and accreditation, and careful management of interactions with the internal or domestic health worker market. Box 5.2 Recruitment agencies and migration Medical recruitment agencies are thriving, and there is where dozens of agencies have sprung up in an attempt widespread concern that they are stimulating the migration to attract Polish doctors to work in the United Kingdom. of health workers from low income countries. A 2004 study Many people question the ethical practices of recruit- found that such agencies spurred the majority of recruit- ment agencies. Health workers contracted by private ment from Cameroon (10), and a recent analysis of nearly recruitment agencies are sometimes subjected to un- 400 émigré nurses in London found that as many as two foreseen charges such as placement fees that put them thirds of them were recruited by agencies to work in Brit- at an immediate �nancial disadvantage. Studies have ain (9). The president of the largest nursing union in Mauri- also shown that migrant health workers often begin jobs tius recently noted that British employers send recruitment before their registration is completed and are paid sub- agents to contact nurses directly and then discreetly nego- standard wages during the waiting period (20–21). tiate contracts with them. Another example is in Warsaw, managing exits from the workforce 103 Strategy 5.2 Improve local conditions As pointed out in Chapter 4, the actions related to improving employment conditions of workers help to remove the “push� factors that induce workers to migrate. Despite the absence of any systematic assessment of the effects of these interventions on migration rates, experience shows that pay, �nancial incentives and safety, good management and career development are all important. Efforts to improve living conditions related to transport, housing and education of family members are also used to help attract, and retain, health workers (30). In situations where the education of health workers is paid for by a prospective employer, in either the public or the private sector, contractual obligations or “bonds� are arranged whereby graduates agree to work for the employer for a speci�ed pe- riod of time. The practice of bonding is widespread yet its effectiveness is poorly un- derstood. Experience of bonding is mixed: it does ensure coverage, but it is strongly associated with low performance among workers and high turnover rates (31). Surveys of migrant workers indicate that in general they have a strong interest in returning to work in their home country (32). As the “brain gain� strategy of the Philippines exempli�es (Box 5.1), active institutional management of migration can facilitate migrants’ welfare not only abroad but also on their return home. Special migration services for health workers may also help to retain productive links with local health institutions while workers are away (33). Receiving country strategies Receiving countries should be concerned for the rights and welfare of migrant health workers and responsive to the adverse consequences in source countries associated with their absence. Strategy 5.3 Ensure fair treatment of migrant workers The scant but increasing evidence on the experience of migrant health workers raises concerns related to their unmet expectations on remittances, personal secu- rity, racial and cultural isolation and unequal work conditions, with limited knowledge of their rights and the ability to exercise them (21, 34–37). Migrant workers should be recruited on terms and conditions equal to those of locally recruited staff and given opportunities for cultural orientation. It is vital to have policies in place that identify and deal with racism among staff and clients (38). Strategy 5.4 Adopt responsible recruitment policies Receiving countries have a responsibility to ensure that recruitment of workers from countries with severe workforce shortages is sensitive to the adverse consequences. The signi�cant investments made in training health care professionals and the im- mediate impact of their absence through migration must �gure more prominently as considerations among prospective employers and recruitment agencies. Discussions and negotiations with ministries of health, workforce planning units and training institutions, similar to bilateral agreements, will help to avoid claims of “poaching� and other disreputable recruitment behaviour. The development of instruments for normative practices in international recruitment is discussed below. 104 The World Health Report 2006 Strategy 5.5 Provide support to human resources in source countries Many recipient countries are also providers of overseas development assistance for health. Through this structure, support could be more directly targeted to expanding the health workforce, not only to stem the impact of outgoing migration but also to overcome the human resources constraints to achieving the health-related Millen- nium Development Goals (MDGs) (see Chapter 2). Apart from help to strengthen the health workforce in source countries, important external sources of direct human resources support are provided in humanitarian dis- asters and disease eradication efforts and through the proliferation of international nongovernmental organizations. Cuba’s “medical brigades�, for example, provide 450 health professionals to shortfall areas in South Africa and over 500 to rural areas of Haiti. The American Association of Physicians of Indian Origin, with its 35 000 practitioners, is an important pool of volunteer service (39). Direct twinning of health institutions between rich and poor countries, a popular form of development assistance (40), also involves substantial flows of health workers in both directions. With greater awareness of the human resources shortfalls in poor countries and expectations to meet the targets of the health-related MDGs, ambitious policies are being considered to increase these flows (41). More systematic efforts to understand the collective experience of these programmes could enhance the bene�ts for source and receiving countries in both the short and long term. International instruments From an international perspective, the demand to balance the rights of migrant health workers with equity concerns related to an adequate health workforce in source countries has led to the development of ethical international recruitment policies, codes of practice and various guidelines (42). In the last �ve years about a dozen of these instruments have emerged from national authorities, professional associations Box 5.3 Bilateral agreement between South Africa and the United Kingdom An agreement between South Africa and the United King- • revitalization of hospitals, including governance; dom was signed in 2003 aiming to create partnerships on • twinning of hospitals to share best practices and health education and workforce issues and facilitate time- strengthen management; limited placements and the exchange of information, advice • training in health care management. and expertise. Within the framework of a Memorandum of Understanding, opportunities have been provided for health The facilitation of mutual access for health profession- professionals from one country to spend time-limited edu- als to universities and other training institutes for spe- cation and practice periods in the other country, to the ben- ci�c training or study visits is part of the agreement. It is e�t of both. planned that the professionals will return home after the Exchange of information and expertise covers the fol- exchange period, and for this purpose their posts will be lowing areas: kept open. They will use the new skills to support health • professional regulation; system development in their own country. At the Com- • public health and primary care; monwealth Ministers’ meeting in May 2005, the South • workforce planning; African Minister of Health reported on the success of • strategic planning; the bilateral agreement in managing migration of health • public–private partnership, including private �nance workers. initiatives; Source: (41). managing exits from the workforce 105 and international bodies. Although not legally binding, they set important norms for behaviour among the key actors involved in the international recruitment of health workers. Whether these norms have suf�cient influence to change behaviour re- mains to be seen. Mode 4 of the General Agreement on Trade in Services (GATS) of the World Trade Organization (WTO) deals with the temporary movement of people who sup- ply services in the territory of another WTO member. To date, this framework has not been used to assess the fairness of a trade agreement between two countries related to health service providers. As with other GATS processes, the ability of poorer countries effectively to represent and defend their interests cannot be taken for granted (43). Bilateral agreements on health service providers can provide an explicit and negotiated framework to manage migration. Cuba has had longstanding bilateral agreements regarding health workers with many countries but for many other countries this instrument is more recent (see Box 5.3). Given the complexities of migration patterns – countries may receive health workers from many countries as well as sending health workers elsewhere – there are important questions about the feasibility of managing multiple bilateral agreements for any given country. In addition, the extent to which a bilateral agreement between two governments can cover nongovernmental flows of health workers is not clear. OCCUPATIONAL RISKS TO HEALTH WORKERS In many countries, health workers face the risk of violence, accidents, illness and death, and these risks may prompt them to leave their workplaces. Violence Violence can strike workers in any occupation, but statistics show that health work- ers are at particularly high risk (44, 45). In Sweden, for example, health care is the sector with the highest risk of violence, as shown in Figure 5.3 (46). Figure 5.3 Occupations at risk of violence, Sweden Health care 24 Social services 23 Other occupations 10 Education 7 Transport 7 Banking 7 Postal services 7 Police 5 Child care 4 Retail 4 Security 2 0 5 10 15 20 25 Risk % Source: (46). 106 The World Health Report 2006 In many countries, Violence against women health workers, in particular, has be- come a signi�cant problem (47). The most frequent violent acts health workers face include physical violence, assaults and bullying (48). Some �nd- ings suggest a direct link between aggression and increases in the risk of violence, sick leave, burnout and staff turnover (49, 50). accidents, illness and Strategy 5.6 Develop and implement tactics against violence death Through their joint programme on workplace violence in the health sector, the International Labour Organization, the International Council of Nurses, WHO and Public Services International have issued guidelines on prevention, care and support for victims, and management of workplace violence (51). Measures to prevent workplace violence can require substantial investment, as illustrated by the Zero Tolerance campaign in the United Kingdom (see Box 5.4). Other risks Occupational hazards and stress are also important deterrents to retention among health workers. In Canada, for example, nurses have one of the highest sick leave rates of all workers, which is mainly attributed to work-induced stress, burnout and musculoskeletal injury (56). Without basic health and safety guidelines and the ability to implement them, health workers are vulnerable to accidents and exposure to infectious diseases, One of the major risks of infection – not only to health service providers but also to health management and support workers such as cleaners and waste collectors Box 5.4 Strategies in action: examples of exit management The following examples show how countries are applying positive health workers and their families, while in Zam- some of the strategies examined in the main text to retain bia, nurses and other health care workers are the focus workers in the health sector and to minimize the effects of of a special programme to provide access to antiretro- exits. viral treatment to prevent mother-to-child transmission of HIV (53). Strategy 5.6 Develop and implement tactics against violence: United Kingdom Strategy 5.9 Target health workers outside the health The Zero Tolerance campaign against violence began in sector: Ireland 1998 and was mainly advertised through a series of high- The Irish Nurses Organisation commissioned a survey of pro�le launches. Following its introduction, a survey of 45 non-practising nurses in Ireland to assess potential “re- NHS trusts revealed that the most common measures imple- turnees� and to evaluate the likely effectiveness of vari- mented were: closed circuit television surveillance (77%), ous strategies to encourage them to return to the health controlled access to certain areas (73%), security guards workforce. The results suggest that flexible working (73%), better lighting (68%), improved signposting, (68%), hours and increased pay could help bring these nurses improvements in space and layout (62%) and in decoration back to work (54). of public areas (47%), provision of smoking areas (42%) and private rooms (33%), improved cleanliness (31%), and regu- Strategy 5.11 Develop the capacity and policy tools to lation of noise (28%) and temperature (15%). Some of the manage retirement: Guyana changes have not been made speci�cally in relation to re- The government decided to recruit retired nurses to �ll duction of workplace violence, but as overall improvements shortages in Guyana’s HIV/AIDS Reduction and Preven- in the institutions (52). tion Projects (GHARP), so that nurses employed else- where in the health service would not be hired away from Strategy 5.7 Initiate and reinforce a safe work environ- their current jobs. GHARP received 495 applications for ment: Swaziland and Zambia 61 positions. When they were recruited, the “new� work- The national nursing association in Swaziland has estab- ers were given training to supplement and update their lished an HIV and TB Wellness Centre of Excellence for HIV knowledge (55). managing exits from the workforce 107 – is injury during unsafe disposal of needles and other biomedical waste. Each year, 3 million health workers worldwide are exposed through the percutaneous route to bloodborne pathogens: 2 million are exposed to hepatitis B, 900 000 to hepatitis C and 170 000 to HIV. These injuries result in 15 000, 70 000 and 1000 infections, respectively. More than 90% of these infections occur in developing countries (57). Strategy 5.7 Initiate and reinforce a safe work environment Infections caused by accidental blood exposure are gener- Each year, 3 million ally preventable if health workers use appropriate protective health workers world- wear such as gloves and eye protection, spills of body fluids are cleaned up promptly, and biomedical waste is disposed of wide are exposed to correctly. WHO also recommends routine immunization against hepatitis B and prompt management of exposure to blood and bloodborne HIV and body fluids (57). hepatitis viruses Illness and death from HIV/AIDS In areas where rates of HIV/AIDS are high, attrition rates of health workers due to illness and death are alarming. In Zambia, deaths among female nurses in two hospitals increased from 2 per 1000 in 1980 to 26.7 per 1000 in 1991. Estimates show that Botswana lost 17% of its health workforce to AIDS between 1999 and 2005. If health workers infected with HIV are not treated, the proportion of those dying as a result of AIDS may reach 40% by 2010 (58, 59). In Lesotho and Malawi, death is the largest cause of attrition (60, 61). Absenteeism in the HIV/AIDS workforce can represent up to 50% of staff time in a health worker’s �nal year of life (62). HIV/AIDS has rendered the health workplace a dangerous place in sub-Saha- ran Africa. Only a few African countries, notably Swaziland and Zambia, have pro- grammes to counsel, support and treat health workers exposed to HIV (see Box 5.4). Rapid expansion of such programmes is imperative (63). In 2005 WHO, the International Labour Organization and a panel of experts (64) established guidelines on HIV/AIDS and health services that provide speci�c recom- mendations on prevention, training, screening, treatment and con�dentiality (see Box 5.5). CHANGE OF OCCUPATION OR WORK STATUS Health workers who leave the health labour market or limit the time they spend working can leave gaps in the workforce. Choosing a reduced work week There is an emerging trend in OECD countries for people to seek a more comfort- able balance between work, leisure and family time; and health workers are no exception. Evidence suggests that many doctors – especially young doctors, who tend to place greater emphasis on personal time – are working fewer hours (65, 66). In addi- tion workers, especially women, are increasingly seeking part-time work (67–71). Strategy 5.8 Accommodate workers’ needs and expectations Offering part-time jobs and facilitating the return of workers who have taken ma- ternity leave can prevent departures from the workforce and encourage the return 108 The World Health Report 2006 of workers who have left. Incentives such as affordable child care, �nancial support for children, and provision of leave adapted to family needs can encourage entry into the workforce, especially nursing (72, 73). Health workers not employed in their �eld There is little reliable information on how many workers below retirement age have left the health sector, but it is certain that their reasons vary. Some workers may �nd available jobs unacceptable or in the wrong location; others may lack job opportuni- ties. The example of nursing is illustrative. In the United States, of the approximately 500 000 registered nurses who are not in the nursing labour market, 36 000 are seeking employment in nursing and 136 000 are working in non-nursing occupa- tions, despite the fact that the estimated number of vacancies exceeds 100 000 (74). In contrast, some 5000 nurses in Kenya are not currently working in their �eld due in part to ceilings or caps placed on public sector recruitment of health workers (75). South Africa has about 35 000 registered nurses who are inactive or unemployed, despite 32 000 vacancies (76). Strategy 5.9 Target health workers outside the health sector Evidence is scarce on the effectiveness of policies to recruit workers from outside the health sector, but there are some indications that they could make a difference. Research could reveal the sort of conditions that would encourage health workers to return to the jobs for which they were trained (see Box 5.4 for an example from Ireland). Absentees and ghost workers Although anecdotal evidence of absenteeism among health workers abounds (es- pecially in South-East Asia), researchers have begun only recently to measure the problem systematically. A recent study involving unannounced visits to primary health facilities in six countries – Bangladesh, Ecuador, India, Indonesia, Peru and Uganda – found medical personnel absenteeism rates from 23% to 40%, with gener- ally higher numbers in lower income countries and in lower income regions within countries (77). One study in Bangladesh revealed, unsurprisingly, that remoteness and dif�culty of access were major correlates of absenteeism. Personnel in facilities in villages or towns that had roads and electricity were far less likely to be absent. Absentee rates Box 5.5 Measures for a safe work environment: HIV/AIDS Key principles of the joint ILO/WHO guidelines on health ser- to HIV/AIDS and the rights and needs of patients as vices and HIV/AIDS: well as workers. Mandatory HIV screening, for the • Prevention and containment of transmission risks: mea- purpose of exclusion from employment, should not be sures should be taken for hazard identi�cation, risk as- required, and employment of workers living with HIV/ sessment and risk control and provisions made for post- AIDS should continue while they are medically �t. exposure management. • Gender focus: as the health services sector is a • Ongoing national dialogue, including all types of nego- major employer of women, special emphasis should tiation, consultation and information-sharing among be placed on the particular challenges faced by them governments, employers and workers, should be a key in the health care working environment. Programmes, mechanism for the introduction of HIV/AIDS policies and education, and training initiatives should ensure that programmes that build a safer and healthier working both men and women understand their rights within environment. the workplace and outside it. • Information, education and training should be offered to sensitize the health care workplace to issues related Source: (64). managing exits from the workforce 109 among doctors tended to correlate positively with conditions such as poor latrine facilities, lack of access to piped and potable water, and the absence of visual privacy at the health centre (78). Ghost workers are individuals who are listed on the payroll but who do not exist, or who work only part time (78). Eliminating ghost workers is a complex task and can be costly. Moreover, in some cases authorities may condone dual employment as a coping strategy that allows health workers to earn a satisfactory income and as a means to attract health workers to otherwise unattractive locations. This com- placency about ghost work may explain why legislation forbidding dual employment has failed in many countries. Another drain on health workforce �nancing in some countries is the continued presence on the books of workers who have left the health sector or died. For example, in Ghana, of the 131 000 civil servants on the payroll at the end of August 1987, 1500 had actually left the service (79). Strategy 5.10 Keep track of the workforce Regular audits, physical head counts, questionnaires, and reconciliation of different data sources could help to identify ghost workers and reduce the number of unau- thorized absences. Such information should be made available to the public, and affected institutions should be empowered to take corrective actions. RETIREMENT The average statutory pensionable age varies by as much as 8.2 years across WHO regions. Europe and the Americas have the highest retirement ages, while South- East Asia has the lowest (see Table 5.4) The statutory pensionable age is younger for women than for men across all regions. The statutory pensionable age often differs from the actual age of retirement (82). Evidence suggests that some independent health workers continue working after they have reached pensionable age (83, 89). At the same time, workers in many countries are choosing to retire before they reach the statutory pensionable age (85). The trend towards earlier retirement seems to be taking hold among health workers as well (84) and is likely to be reinforced by the increasing presence of women, who retire earlier than their male counterparts (86–88). In the United Kingdom, about 10 000 Retirement rates and the risk of shortages Information about the retirement rate of health workers is very nurses retire every year scarce. An expected working life of 30 years for doctors and 23 for nurses (89), as well as a uniform age distribution, would result in a retirement rate of 3% for doctors and 4% for nurses. However, these �gures do not account for other attrition factors such as death, different working patterns such as part-time employment, and the actual age dis- tribution. As a result, the retirement rate in reality is lower. In the United Kingdom, estimates show that about 10 000 nurses (2% of the nursing workforce) retire each year (87). In countries with the greatest needs-based shortages, little information is available about exits from the health workforce. In sub-Saharan Africa, the number of health service providers who retire annually is estimated to be between 8780 and 13 070 (90), representing 0.6–1% of the health workforce. Although these retire- ment �gures for Africa might seem low, they become signi�cant when other attrition factors are taken into account and when they are compared with the �gures related to the inflow of health workers. 110 The World Health Report 2006 Table 5.4 Statutory pensionable age Number of Member States Pensionable age (years) Average for men Average for women WHO region In region Reporting (range) (range) 58 57 Africa 46 37 (50– 65) (50–65) 62 61 Americas 35 34 (55–65) (55–65) 55 55 South-East Asia 11 6 (55–57) (50–57) 64 61 Europe 52 49 (60–67) (55–67) 60 57 Eastern Mediterranean 21 15 (50–65) (50–64) 58 58 Western Paci�c 27 20 (50–65) (50–65) Sources: (80, 81). Health workforce ageing In many countries, a trend towards earlier retirement dovetails with a rise in the average age of health workers, and these dual shifts could lead to mass exits from the health workforce (88, 91, 92). Middle-aged nurses, who are part of the “baby boom� generation born after the Second World War, dominate the workforce in many countries and will reach retirement age within the next 10 to 15 years. In the United States, for example, progressive ageing of the registered nurse population since Figure 5.4 Ageing nurses in the United States of America 600 1980 1984 1988 500 1992 Number of registered nurses (000) 1996 2000 400 2004 300 200 100 0 Less than 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65 25 and over Years of age Source: (91). managing exits from the workforce 111 1980 indicates that there will be accelerated attrition of experienced nurses from the workforce at a time of growing demand (93, 94), as shown in Figure 5.4. The ageing trend is not systematic across countries, however. Some develop- ing countries, like Lesotho, have a younger physician workforce, for example, than industrialized countries such as Switzerland (see Figure 5.5). Unlike illness and migration, retirement is relatively predictable. Proactive retire- ment policies could prevent any shortages connected to early retirement and an ageing workforce. Strategy 5.11 Develop the capacity and policy tools to manage retirement Information systems can capture details of age patterns, yearly outflows caused by retirement and patterns of retirement, which lay the groundwork for effective management policies that reduce or increase retirement outflows. Once those poli- cies are in place, employers may provide incentives to workers to retire earlier or later, and governments may offer subsidies or taxes to change the costs of em- ploying older people or consider making changes to the statutory pensionable age. Retirees represent a pool of health workers who could be recruited back into the health workforce to provide a much needed increase in numbers and experience in resource-constrained environments around the world. Box 5.4 describes one such scheme in Guyana. The need for knowledge transfer Retirement removes from the health care delivery system not just workers them- selves, but also their hands-on experience and institutional knowledge. Failure to transfer the experience and knowledge of exiting workers to those who remain, through succession planning, can deprive the workforce of key competencies and skills. Poor succession planning has been identi�ed as a key challenge associated with nursing in rural and remote areas (96). Strategy 5.12 Develop succession planning Succession planning – which entails such strategies as having prospective retirees mentor younger staff and participate in knowledge sharing mechanisms such as communities of practice – can transmit knowledge from experienced health workers to their successors and minimize the impact of retirement on the workforce. Figure 5.5 Age distribution of doctors Switzerland Lesotho 25 35 30 20 25 Percentage Percentage 15 20 15 10 10 5 5 0 0 25–29 30–34 35–39 40–44 45–49 50–54 55+ 25–29 30–34 35–39 40–44 45–49 50–54 55+ Years Data source: (95). Years Data source: (60). 112 The World Health Report 2006 CONCLUSION Although this chapter is not an exhaustive treatment of the factors leading to tempo- rary or permanent exit from the workforce, it has nonetheless dealt with four major dimensions: migration; risk of violence, illness and death; occupational change; and retirement. Each requires careful analysis in its own right with its respective respons- es, yet when examined as a group, the bigger picture of workforce exits or attrition emerges. This picture reveals the rate of worker outflow, and along with information on inflows, permits an assessment of the relative balance in terms of entry and exits. In a steady state, or workforce equilibrium, the flows into the workforce – primarily from training and recruitment – should equal the outflows. However, if at the baseline there is a major shortfall of workers, as in the case of the 57 countries with critical shortages identi�ed in Chapter 1, then inflows should greatly exceed outflows. The case of sub-Saharan Africa is instructive in this regard. This chapter has revealed major exits of health professionals from the workforce due to migration, ill- health and absenteeism and to a much lesser degree from retirement. Redressing the critical shortages in Africa requires not only expanding inflows through training more workers but signi�cantly diminishing the rate of outflow through better retention, improved worker health, and reducing the wastage that is inherent in absenteeism and ghost workers. The set of factors linked to taking workers out of the workforce draws attention to the importance of looking forward and being aware of trends. The age distribution of the workforce in many richer countries discloses a “greying� trend that will result in accelerated attrition through retirement in the medium term. Likewise, the sex distribution reveals patterns of “feminization�, especially in the medical profession, with patterns of work and retirement among women that differ signi�cantly from those of men. Such trends cannot afford to be ignored. Rather, they call for forward planning to avoid signi�cant imbalances. In the case of women, greater efforts must be made to retain health work as a career of choice by providing greater protection at the workplace from abuse and insecurity, more flexibility in work patterns that ac- commodate family considerations, and promotion ladders that allow them to advance to senior management and leadership positions in the health sector. Finally, as exempli�ed by the case of international migration, the health workforce is strongly linked to global labour markets. Shortages in richer countries send strong market signals to poorer countries with an inevitable response through increased flows of migrant workers. In articulating their plans for the workforce, countries must recognize this and other linkages beyond their borders. The next two chapters focus on the challenges of formulating national strategies in the current global context. managing exits from the workforce 113 REFERENCES 1. Zurn P, Dal Poz MR, Stilwell B, Adams O. Imbalance in the health workforce. 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Deakin, Association for Australian Rural Nurses Inc., 2002 (Position paper; http://www.aarn.asn.au/pdf/papers/ position_paper.pdf, accessed 2 February 2006). formulating 119 chapter six national health workforce strategies in this chapter 120 Building trust and managing expectations The ultimate goal of health workforce strate- 121 Fair and cooperative governing gies is a delivery system that can guarantee 125 Strong leadership universal access to health care and social 126 Strengthening strategic intelligence protection to all citizens in every country. 127 Investing in workforce institutions There is no global blueprint that describes 129 Conclusion how to get there – each nation must devise its own plan. Effective workforce strategies must be matched to a country’s unique situation and based on a social consensus. The workforce presents a set of interrelated problems that cannot be sector reform, occasionally even bring down a quickly tidied up or solved by a “magic bullet�. Workforce problems are government. Yet, successful strategies have been deeply embedded in changing contexts, fraught with uncertainty and demonstrated that can energize the workforce and exacerbated by a lack of information. Most signi�cantly, the problems win public support. The political challenge is to ap- can be emotionally charged because of status issues and politically ply known solutions, to craft new approaches, to sensitive because of divergent interests. That is why workforce solu- monitor progress, and to make mid-course cor- tions require all stakeholders to be engaged together, both in diagnosing rections. problems and in solving them. Previous chapters have focused on dealing The key is to mobilize political commitment to tackle workforce chal- with workforce problems through the manage- lenges. But this is dif�cult because achieving a health impact from an ment of entry, workforce and exit. These aspects investment in the workforce takes time, extending well beyond election determine the performance of a health system and Stephenie Hollyman/WHO cycles. Disgruntled workers can paralyse a health system, stall health- its ability to meet present and future challenges. 120 The World Health Report 2006 However, such problems cannot only be discussed in managerial and technical terms. The perspective of people who use the health care system must also be considered. Their expectations are not about the ef�cient delivery of cost-effective interventions to target populations; they are about getting help and care when faced with a health problem that they cannot cope with by themselves. In the relationship between indi- vidual health workers and individual clients, trust is of paramount importance, and it requires fair governing and effective regulations to build and sustain – which in turn involves leadership, strategic intelligence and capacity building in institutions, tools and training. These essential elements of national workforce strategies are the focus of this chapter. BUILDING TRUST AND MANAGING EXPECTATIONS To the general public, the term “health workers� evokes doctors and nurses. While this does not do justice to the multitude of people who make a health care system work, it does reflect the public’s expectations: encounters with knowledgeable, skilled – and trustworthy – doctors and nurses who will help them to get better and who will act in their best interests. Trust is not automatic: it has to be actively produced and negotiated. It is “slowly gained but easily lost in the face of confounded expectations� (1). In many countries the medical establishment has lost its aura of infallibility, even-handedness and dedication to the patient’s interests. Fuelled by press reports of dysfunctional health care provision, public trust in health workers is eroding in the industrialized world (2) as well as in many developing countries (3–5). Poor people in particular may be sceptical or cynical when talking about their doctors, nurses or midwives: “We would rather treat ourselves than go to the hospital where an angry nurse might inject us with the wrong drug� (6). Trust is jeopardized each time patients do not get the care they need, or get care they do not need, or pay too much for the care they do receive. When patients experience violence, abuse or racketeering in health facilities their fragile trust is shattered. The consequences of loss of trust go beyond the individual relationship between user and provider. A society that mistrusts its health workers discourages them from pursuing this career. The erosion of trust in health workers also affects those who manage and steer the health system (7). The administrations in charge of the health care system – governments, health-insurance institutions and professional organiza- tions – have to make dif�cult trade-offs. They have to decide between competing demands: each citizen’s entitlement of access to health care goods and services; the need to govern the cost of the uptake of these goods and services; and the needs of the professionals and other human resources who deliver these goods and services. The characteristics of the health sector with its large number of actors, asymmetry of information and conflicting interests make it particularly vulnerable to the abuse of entrusted power for private gain (8). The public no longer takes for granted that these trade-offs are always made fairly and effectively, nor do the front-line health workers. Strategy 6.1 Design and implement a workforce strategy that fosters trust The design of a strategy for a national health workforce might include measures actively to produce and negotiate trust in providers and managers of the health system (9, 10). This requires explicit measures that: formulating national health workforce strategies 121 ■ address personal behaviour in the interaction between care providers and pa- tients, between employers and employees, and between managers and insti- tutions (this requires training as well as political leadership, and civil society organizations play a key role); ■ set up managerial and organizational practices that give space for responsive- ness, caring, interpersonal interaction and dialogue, and support the building of trust; ■ take visible steps to eliminate exclusion and protect patients against mismanage- ment and �nancial exploitation; ■ establish decision-making processes that are seen as fair and inclusive. FAIR AND COOPERATIVE GOVERNING Building and sustaining trust and protecting the public from harm require good gov- ernance and effective oversight, as well as fair regulation of the operations of health care facilities and the behaviour of health workers. The problem is that, in many countries, the regulatory environment is opaque and dysfunctional. All too often, weak professional and civil society organizations with few resources or little political clout exist alongside an equally weak state bureaucracy that lacks the structures, the people and the political will for the effective regulation of the health care sector. Self-regulation In many countries, professional organizations decide who can provide care and how providers should behave. Self-regulation can indeed be effective and positive: professional associations can promote professional ethics and positive role models, sanction inappropriate behaviour, and maintain the technical competence of their members. The way health workers balance their own interests and those of their patients depends to a large extent on what is considered “good professional behav- iour� by their teachers and peers. Professional associations can play an active role in shaping that image (see Box 6.1). Self-regulation by professional associations is not always effective, for a number of reasons. First, unlike doctors and nurses, some categories of health workers are not organized in this way. Second, each professional category tends to have its own organization, which results in energy being wasted in battles over boundaries and in defence of professional privileges. Third, in contrast to Europe and the Americas, where the majority of professional organizations are well established and date back at least 100 years, four out of 10 associations in low income countries are less than 25 years old (11). These younger organizations tend to be under-resourced and less well connected politically, and, crucially, to have less authority over their members. The professional self-regulation model is also showing signs of strain because employers increasingly override it. This has long been the case where the state is the traditional employer of health workers, but in countries where large numbers of health workers were self-employed and autonomous, most of them now work in an employer–employee relationship. As a result of this “proletarianization� of health workers (12), it is employers and not professional organizations who exert the most influence on professional behaviour. This is the case whether the employer is the state, a not-for-pro�t nongovernmental organization, a �nancial corporation or an international organization. This shift to employer-power is so pronounced that, in some countries, health professionals have started to form unions in reaction to employer challenges to their autonomy and income (13). As a result, professional 122 The World Health Report 2006 associations by themselves can no longer claim to provide coherent governance, in the public interest, of the health workforce as a whole. “Muddling through� and command-and-control Driven by political pressure for universal access and �nancial protection, govern- ments have taken an increasingly prominent role in �nancing and regulating the collective consumption of health care (14). This has overriden the autonomous gover- nance of professional organizations, and self-regulation has been gradually replaced by a more elaborate institutional control by public administration (15). The way this control operated varied from place to place. In much of Europe and the Americas, where a large part of the workforce was self-employed or employed by private institutions, much of the state’s regulatory efforts focused on payment mechanisms and on training and accreditation mechanisms to de�ne the territory of the various health professions. Given the resistance of professional associations to state encroachment on their autonomy, the process of governing health workers was very much a process of “muddling through� a low-intensity conflict (16, 17). There is a tradition, however, of negotiated regulation that has effectively built up the regulatory capacities of state and social security organizations. In many socialist and developing countries, where a large proportion of health workers are in the employ of government, a more elaborate kind of institutional control has effectively replaced self-regulation. In these countries the public admin- istration tends to rely on a command-and-control approach: the use of hierarchy and administrative rules to govern the health workforce. It is true that a well-function- ing command-and-control structure is advantageous in controlling epidemics and responding to environmental catastrophes. As a strategy to regulate and orient the health care market, however, the approach has its limitations. At worst, when a health system is structurally underfunded or near collapse or the legitimacy of the state is questioned, the command-and-control approach simply does not work. At best, it is ill-adapted to what is expected of health systems today. First of all, administrative rules are a rather blunt instrument to steer the interaction between individual patients and caregivers – particularly when the expectations of the former are rising. Second, such an approach to policy-making and regulation generally focuses on government employees, leaving health workers and institutions Box 6.1 Self-regulation opportunities In 2001, a group of national nursing associations, govern- schools that were closed, and some of the students who ment nurses and regulators from east, central and south- were affected, had powerful connections in political and ern Africa developed and published a prototype regulatory senior civil service circles. framework and guidance on the accreditation of nursing and In Angola, the national nurses associations and the midwifery education programmes. As a result, those coun- Order of Nurses of Portugal are equipping districts with tries in the region that already had registers have begun nursing textbooks. moving away from lifetime registrations to ones that require In Thailand, the Rural Doctors Association has played periodic licensure. an important role in ensuring the commitment – and the In Uganda, the registrar of the Nurses and Midwives presence – of doctors in rural and underserved areas. Council recently closed down a number of health training The “evidence-based medicine� movement is an- schools that did not meet the required standards. These other way of self-regulating the behaviour of health-care measures were taken despite the fact that some of the providers in a manner that serves the public interest. formulating national health workforce strategies 123 outside the public sector to take care of themselves. The regulations that do exist (e.g. prohibiting moonlighting in private practice) are not or cannot be enforced. The failure of the traditional command-and-control approach to stem the unregulated commercialization of the health sector (18) has contributed greatly to the erosion of trust in health care providers and in health systems. Watchdogs and advocates Civil society organizations that act on behalf of citizens (consumer groups, HIV/AIDS activists, etc.) have gained a large amount of influence in the health sector. These organizations have often had an important role for a long time in resource mobiliza- tion and improving health care delivery. In more recent years they have also found many ways to put pressure on providers, professional associations and health care bureaucracies and institutions (3). Some provide citizens with information that puts them in a stronger position when they have to deal with a health care provider. In France, for example, the lay press publishes a ranking of hospitals in the perfor- mance of different procedures Other civil society groups function as watchdog organizations to sound the alarm when citizens are denied their health entitlements or are discriminated against. In Sierra Leone, for example, women’s groups demonstrated in the streets of Freetown demanding that the military government guarantee emergency care for all pregnant women, following newspaper reports that women had died after being denied treat- ment they could not afford. In many countries, civil society groups contribute to priority setting by participating in the planning process, as in Bangladesh (19), or by providing checks and balances on government budgeting, as in Mexico (20). Consumer defence movements are gaining strength because they can push for mechanisms to be put in place to protect people against exclusion, poor-quality care, over-medicalization and catastrophic expenditures. They can also ensure that procedures are adopted that give people the possibility to redress harm. It is clear that a great many people currently lack such protection. For example, in contrast to industrialized countries, regulation of fees charged by private institutions or self- employed care providers is almost non-existent in most developing countries. Even where regulations exist, governments may have major problems enforcing them (21). There are three results: �rst, each year approximately 44 million households worldwide are faced with catastrophic health expenditures (22); second, many more people are excluded from access to care; and third, this situation favours supply- induced over-medicalization (23). One example is the high incidence of caesarean sections around the world (24). Within a single country, mothers with the �nancial means may be subject to an unnecessary and potentially dangerous intervention, while the same procedure is denied to another who needs it to save her life or that of her baby but who cannot mobilize the funds. A model for effective governance None of the models described above – self-regulating professional associations, the command-and-control approach of institutional regulators, and the advocacy of civil society – is suf�cient on its own to regulate the behaviour of health workers and institutions. Rather than relying on one single regulatory monopoly, national health workforce strategies should insist on cooperative governing. Regulations resulting from the participation of all three bodies, as well as health care institutions and the workforce, are more likely to generate trust and cooperation. 124 The World Health Report 2006 Strategy 6.2 Ensure cooperative governance of national workforce policies In order to ensure public safety and good governance of health care providers, ca- pacity building requires investment in the overall regulatory architecture outlined in Figure 6.1. Simultaneous efforts are needed to reinforce the potential contributions of the state and social insurance institutions, as well as those of professional and civil society organizations. This means that, along with the creation of the speci�c technical bodies for licensing, accreditation and so on, forums must be established that allow for interaction among these various groups, which in turn implies the recognition and support, including �nancial, of their contributions (19). Ministries of health may be reluctant to strengthen the very institutions that act as checks and balances on their own work, but in the long run it is in their own interest to have a strong system of dialogue and cooperation. Figure 6.1 Organizations influencing the behaviour of health workers and the health institutions Professional organizations: Institutional regulators: Self regulation of entry Administrative measures, and market rules through funding mechanisms, codes of ethics, sanctions, employment and contracts training, role models managed by state, social health insurance or similar institutions The behaviour of health care institutions and health workers Civil society organizations: Protection of the interest of citizens by: empowering users, functioning as watchdogs, setting policy agenda formulating national health workforce strategies 125 STRONG LEADERSHIP Because the health workforce is a domain of many conflicting interests, policy-mak- ing cannot be exclusively consensual and sometimes there has to be the possibility of arbitrage. Without strong leadership, national policies tend to flounder in a combina- tion of ad hoc solutions, many of which focus on defending the interests of particular professional categories and create problems of their own. National leadership is necessary to initiate the process, push for breakthroughs, engage key stakeholders (workers, government and civil society), promote the synergistic roles of each, and encourage them to adopt a partnership approach. The responsibility for that leadership lies with public authorities: the policy-mak- ers and managers of the public and parapublic sectors. In recent years, however, little or no investment has been made in leadership in the public sector. In an environment of widespread scepticism about public sector and state involvement, stewardship functions have suffered from the stranglehold of macroeconomic constraints on pub- lic sector development, along with, if not more than, other public health functions. The need for administrative and stewardship capacities is perhaps most obvious in extreme situations, such as post-conflict reconstruction in Afghanistan or the Democratic Republic of the Congo. It is also evident in many stable countries, where sector-wide approaches or poverty reduction strategies fail to perform as expected for want of leadership capacity, or where the unregulated commercialization of the health sector is undermining both workforce and health system performance. Leadership is also crucial to deal with competing vested interests and to obtain high-level political endorsement of health workforce strategies. The work of the “change team� that brought about the health reforms in Colombia in the early 1990s exempli�es some of the tactical capacities that are crucial to successful reform (25). At an early stage the team strictly controlled access to the decision-making process, and drew attention away from the health reforms by including proposals in a wider social security reform, the main spotlight of which was on pensions. Nevertheless, the team understood the need to allow certain voices, such as those of senators, to be heard. In working with groups that championed change, they focused their atten- tion on the development of new institutions, such as new insurance agencies, that would take part in the new system. The reform of the old institutions, which would clearly be dif�cult, was tackled in a later phase. Developing leadership skills depends on leadership structures and tactical ca- pacities. The lack of both is recognized. The problem is that most people are inclined to believe that political know-how is an innate quality and therefore ill-suited to capacity building. Those who have attempted to develop training courses for lead- ership have often come to the disenchanting conclusion that they did not make a great deal of headway. There is little empirical evidence on what, if anything, can be done. Interviews with policy-makers, however, show that individual tactical capacities are built through coaching and mentoring, particularly within structured projects, whereas the strongest influence on the creation of the leadership struc- tures comes from the organized sharing of knowledge and experiences with other countries. Coaching, mentoring and intercountry exchange are less straightforward capacity-building tools than training, but they can be organized. If this could be done effectively and on a large scale, it would help remove one of the key constraints to health worker development – the lack of people and structures to provide policy leadership, even in resource-poor or fragile countries. 126 The World Health Report 2006 STRENGTHENING STRATEGIC INTELLIGENCE In all too many cases, the health workforce information that is available to national decision-makers is extremely poor. Many, if not most, ministries of health, for ex- ample, do not know how many health professionals there are in the country, let alone how they are distributed. That major stakeholders have such poor knowledge of their own situation underscores the lack of connection between the acuteness of human resources problems and a coherent policy response. Strategy 6.3 Obtain better intelligence on the health workforce in national situations For a thorough understanding of health workforce problems, systematic work is required in four areas: the extent and nature of the problem in the speci�c national context; what is being done and what can be done; the national politics around the issue; and the potential reactions of health workers and the institutions that employ them. Extent and nature of the national workforce problem In most countries, this information is patchy at best. Among others, Malawi has recently demonstrated that a proper understanding of the nature of local health worker problems can help it to make a quantum leap in the formulation of more coherent policies and strategies (26). Accurate information on medical demography, shortages and oversupply is essential, but there is also a need to cover the range of problems that relate to entry, workforce and exit as well as to performance and trust; there is a need to cover the entire range of health workers, not merely doctors and nurses, and not merely the public sector; and there is a need to look at what there is in the �eld as well as at the expectations of the staff and the public, in the light of the present crisis and the future challenges. Action taken and further options This is an area where even less is being done than in documenting the magnitude and determinants of health workforce problems. Much can be learnt from innovation and problem-solving which takes place at the grass-roots level and escapes the notice of policy-makers. Making assessments of actions and options requires speci�c skills as well as a systematic and institutional approach that involves inventory keeping, monitoring, evaluation, documentation and exchange. Much can also be learnt from experiences in other countries; that assessment, too, has to be carried out in a systematic way, with methodical evaluation, sharing and exchange. National politics around the health workforce To build a workable strategy by changing a dysfunctional situation, it is often use- ful to understand the forces that have created such a situation in the �rst place: otherwise there is a real risk of making a bad situation worse. Much of the rigidity that characterizes the public sector workforce, for example, comes from attempts to protect the workforce from political interference: ill-thought-out policies to create more flexibility may then introduce opportunities for discrimination and favouritism, which would add to the malfunction. To take another example, if the reason for excessively centralized human resource management is insuf�cient management expertise or a lack of accountability mechanisms at more decentralized levels, then rapid administrative decentralization may not be a wise choice. formulating national health workforce strategies 127 Reactions of health workers and their employers The good intentions of policy-makers when designing health system structures, processes and reform programmes are often undermined by a failure to consider how health workers are likely to respond. It is of particular importance to understand the reasons for their resistance to change. For example, one would expect staff in a centralized system to welcome the increased autonomy that comes with decen- tralization. In Uganda and Zimbabwe, however, decentralization was perceived as a threat to job security and raised concerns that the politics of ethnicity would govern both recruitment and personnel (27, 28). Where public services are downsized or shifted to the private sector, health workers can experience the triple stress of fear of job loss, fear of failure to secure alternative employment, and growing workload (29). In other situations, health workers may resist change because they are uncomfort- able with the increased responsibility associated with reform proposals. It is possible to prevent many of these problems through a better understanding of the reactions of the different stakeholders. Informal dialogue goes a long way towards achieving such understanding, but it is also possible to organize more systematic exercises in order to appreciate potential reactions (30). INVESTING IN WORKFORCE INSTITUTIONS When governments have little capacity for policy design, regulatory measures are easily appropriated by interest groups. Policy-making then becomes ineffective at best and counter-productive at worst. Some countries have done well: Malawi’s human resource plan is one example (see Box 2.2). In recent years, however, most countries have not made adequate investments in developing policy-making and regulatory capacities. Indeed, during the 1990s a considerable number of health departments in ministries of health around the world fell victim to public sector downsizing and rationalization. Building or rebuilding country capacities for policy-making in health care delivery requires much more than just tools and training: there is a hierarchy of tools, people and structures (31). Without the policy-makers and managers who can interpret and contextualize the output of costing and budgeting tools, making such tools avail- able and training staff to implement them will be of little bene�t. At the same time, without the institutions, structures and committees that have the authority to make decisions, managers and policy-makers have no way of transforming intellectual exercises into political facts. National-level health workforce institutions are needed to build public trust, fa- cilitate fair and cooperative governing, produce strong leaders, and gather strategic intelligence. These reasons alone should be enough to justify their �nancing, but in reality it is not easy for policy-makers to sell the idea that such institutions need to be built and strengthened – if only because of the long time perspective and the lack of visibility of issues such as return on investment. Since investment in training or tools is more readily accepted and since signi�- cant amounts of funding are now being directed towards training, the way forward is probably to link these directly to institution building. The key is to identify speci�c areas where insuf�ciencies are greatest and where distinct institutional efforts can yield concrete results. Some of these efforts have already been discussed in previous sections of this chapter: building capacity for regulation; leadership structures and tactical ca- pacities; and strategic information on core indicators. Two other areas that warrant 128 The World Health Report 2006 highlighting are learning from microlevel innovations and scenario building and plan- ning. Both are explored below; they can best be organized through the creation of national health workforce observatories (see Box 6.2) or by linking ministry of health departments, academic institutions and nongovernmental organizations in learning networks and communities of practice. Learning from microinnovations Perhaps nowhere has there been as much creative problem-solving and innovation at the microlevel as in the health workforce. Many examples have been mentioned throughout this report. The idea is to learn from these innovations, encouraging what works and discouraging what does not. Making these assessments requires speci�c skills as well as a systematic and institutional approach that involves inventory keep- ing, monitoring, evaluation, documentation and exchange. An accurate assessment is necessary in order to decide which actions merit inclusion in a national health worker strategy: they must be cost-effective, provide quick results, correct present distortions and prevent further deterioration of health care services (34). One such innovation was a stop-gap solution for a lack of doctors in one area of Mozambique, where tecnicos de cirurjia, or assistant medical of�cers, were trained in surgical skills. Their excellent results led policy-makers to generalize the experiment and today tecnicos de cirurjia are a characteristic feature of district hospitals across the country (35). Box 6.2 Human resources for health observatories in Latin America National observatories for human resources for health were considerably. It has built on existing informal networks set up in 22 countries in 1998 as part of an initiative by the where managers and academics were motivated by pro- Pan American Health Organization (PAHO), WHO’s Regional fessional interest in investigating the relevance of plan- Of�ce for the Americas, to counteract the neglect of health ning, management and training in human resources for workforce issues in Latin America during the 1980s and the health sector. Much of the network’s success and early 1990s. PAHO established an Observatory of Human Re- resilience can be attributed to the initial focus on con- sources in Health to link these national observatories, which tent as well as to its working style. The focus on content have helped raise the pro�le of the health workforce agen- allowed network members to build their technical and da, improve the information base, and strengthen health professional capabilities in a spirit of intellectual inde- sector stewardship (32). The observatories provide continu- pendence and autonomy that continues to characterize ity in settings where there may be a signi�cant turnover of interactions today. The style of working is character- decision-makers and policies. Their common characteristic ized by flexibility, creativity, pragmatism, inventiveness is multiple stakeholder participation involving universities, and entrepreneurial spirit . The combination of pursuing ministries of health, professional associations, corporate technical excellence and informal collaboration resulted providers, unions and user representatives. in group learning, and consolidated shared ideas. The institutional arrangements, however, are speci�c On this basis the networks were formalized and in- to each country. The Brazilian Observatory (33) provides stitutionalized in the late 1990s. This move further en- a number of important lessons about state–non-state hanced productivity, largely by intensifying exchanges interactive capacity building. It consists of a network of nationally and internationally with the help of a number university institutes, research centres and one federal of- of personalities in Brazil and in other countries. �ce dealing with human resources for health. There are 13 The Brazilian Observatory shows that informal net- network “nodes� or “workstations� coordinated by a secre- working can develop into more formal structures that tariat staffed by the Ministry of Health and the Brasilia of�ce produce concrete outputs and outcomes. Within the of PAHO. The Observatory’s remit since 1999 has been to network there are demands for an intensi�cation of ex- contribute to, and inform the development, regulation and changes in terms of content and policy relevance, and management of, human resources in the health sector and for the introduction of monitoring and evaluation mecha- related policy areas. nisms to ensure quality and relevance of the network’s The Observatory has produced much valuable informa- outputs. tion and analytical work and its capacities have developed formulating national health workforce strategies 129 Scenario building and planning Scenario building and planning, which are essential to determine long-term orientations, also require speci�c capacities that lend themselves to an institutional approach. National strategists have to make fundamental choices that de�ne what the future workforce will look like and how it will relate to the value systems of the society in which it operates. The demands on health workers are changing fast, and one can only guess what they will be in the future, but the time of omniscient profes- sionals working on their own is de�nitely past. The provision of health care in the future lies in teamwork, with overlapping and complementary skills that constantly adapt to rapid changes in society and technology. At the same time, the health care team will be asked to be much closer to their clients, with a family doctor type of contact point who acts as the hub for the team and as the interface between clients and the health system. The model of separate and independent health care profes- sions will soon be overtaken. More than a planning problem, preparing for these changes is a matter of organiz- ing a broad discussion around entitlements and scenarios for the future. Such dis- cussions may emerge from the civil society movement as in Thailand (36), from local authorities as in Oregon, United States (37), or from the public health establishment as in New Zealand or the Netherlands (38, 39). Debates on scenarios for the future have to take into account the spectrum of drivers shaping the workforce, including changing health needs, demographic trends such as ageing, consumer expectations, growth in private health services, and the global labour market for health workers (see Figure 2 in the Overview to this report). In terms of content, future scenarios are likely to focus on the tensions between commercialization on the one hand and universal access and social protection on the other, and between a technocratic disease orientation and social demands for a more patient-centred approach. It is the process that is of prime importance. Just as fair governance requires cooperation, so too does planning for the future. Experience from priority-setting debates shows that the legitimacy of the choices that are made is less a function of what is actually decided than the perception of procedural fairness (40). If the way decisions are made is inclusive and transparent, societal support follows. There is a clear association between the intensity of dialogue with multiple stakeholders and the strength and sustainability of the policy choices (30, 41). A failure to be inclusive means that opportunities are missed and resistance and resentment build up. CONCLUSION National health workforce strategies must move beyond salary and training in the public sector to strategies for the entire work cycle of entry–workforce–exit in both the public and private sectors. Workforce development is both a technical and politi- cal exercise, requiring the building of trust among stakeholders and linking people’s expectations with health worker performance. Whether in fragile states focusing on short-term and medium-term perspectives, or in more stable countries that focus on longer-term strategies that command more resources, the quality and the success of policy-making and regulation depend �rstly on the inclusion of key stakeholders. Also crucial are the availability of people and resources to carry out the policy formulation work, and the capacity to base the policy on a proper understanding of the nature of the problems. 130 The World Health Report 2006 All country strategies should prioritize the following actions. ■ Build national strategies out of concrete action points that cover management of entry, workforce and exit as well as: building or rebuilding trust; multi-stakeholder management of the regulatory environment; and leadership capacities. ■ Pay attention to the process. The choices to be made may be dif�cult and con- troversial: it is essential to ensure procedural fairness by being inclusive and transparent, but with the courage to arbitrate when vested interests are taking over. ■ Strengthen strategic intelligence, focusing on: (i) understanding the extent and nature of health workforce problems; (ii) evaluating what is being done and de- termining what can be done; (iii) identifying the political drivers that led to the current situation; and (iv) understanding workers’ viewpoints and anticipating their possible reactions to change. ■ Build the country’s health workforce institutional capacity, with a focus on regula- tion, leadership and strategic information, including: (i) analysis and evaluation of microinnovations; and (ii) scenario building and planning for the future. formulating national health workforce strategies 131 REFERENCES 1. Davies H. Falling public trust in health services: implications for accountability. 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University of Canberra, Centre for Research in Public Sector Management, 2003 (http://www.dmt.canberra.edu.au/crpsm/research/pdf/ stewartkringas.pdf, accessed 21 February 2006). formulating national health workforce strategies 133 working together, chapter seven working together, within and across countries 135 within and across countries in this chapter 135 Catalysing knowledge and learning 143 Striking cooperative agreements 143 Responding to the health workforce crisis 147 Moving forward together There are �ve broad areas of concern that 151 Joint steps to the future impel countries to look beyond their borders and work together with others in order to address issues of human resources for health more effectively: The profound lack of information, tools and measures, the resource capacity to be able always to mount an effec- limited amount of evidence on what works, and the absence tive response entirely on its own. of shared standards, technical frameworks and research The enormous workforce crisis that constrains health methodologies are all imperatives for regional and interna- development so profoundly in the world’s poorest coun- tional collaboration. tries requires an international response. The scarcity of technical expertise available to develop bet- This chapter focuses on the rationale for working together ter metrics, monitor performance, set standards, identify and concludes with a plan of action that is based on na- research priorities, and validate methodologies means that a tional leadership and global solidarity. collective global effort is the only way to accelerate progress in these areas. CATALYSING KNOWLEDGE AND The changes in demographics, demand for care, and tech- LEARNING nological advances cut across borders and are manifested As has been pointed out in this report, basic information in increasingly global labour markets. Cooperative arrange- on the workforce that is required in order to inform, plan ments and agreements between countries are essential to and evaluate resources is in very short supply in virtually all manage these flows and minimize adverse effects. countries. The scant information that does exist is dif�cult The reality that a violent conflict, an outbreak of an infec- to aggregate and compare over time and across sources and tious disease, or an unexpected catastrophic event can lay countries (1–4). This limitation is reflected not only in the waste even to the most well-prepared national health sys- challenges inherent in coordinating information flows across tem demonstrates that no country will ever have the human sectors – education, health, labour/employment – but more Jim Holmes/WHO 136 The World Health Report 2006 fundamentally in the absence of agreed frameworks and standards for health work- force assessment. Investment should be made in developing these frameworks and standards so that better tools to understand and respond to health workforce chal- lenges can be made widely available more quickly and at lower cost. A �rm foundation for information An important �rst step towards strengthening the foundations of information about health workers is to develop a clear conceptual framework that describes the bound- aries and make-up of the workforce. Encouragingly, there is a global effort under way to develop a common technical framework (see Box 7.1). Even with such a framework, however, there remain a number of fundamental challenges related to health workforce information that must be taken up. One problem area is the classi�cation of the health workforce. Until 2006, WHO reported only on health professionals – doctors, nurses, midwives, pharmacists and dentists – thus rendering invisible other important service providers as well as all health management and support workers (who account for around one third of the workforce). This oversight reflects the shortcomings of using instruments whose primary purpose is not the collection of information on the health workforce. It un- derlines the need to develop special health workforce classi�cation tools that can be more effectively integrated into existing census, survey and occupational reporting instruments. Another important information need is for metrics to assess performance. Policy- makers and donors are increasingly demanding evidence showing that their deci- sions and investments are indeed strengthening the health workforce. In the area of health information systems, a performance assessment instrument has been developed that permits cross-country comparisons (see Figure 7.1). A similar instru- ment for human resources could lead to more and wiser investments in the health workforce. Among the indicators that can be used in the development of health workforce performance metrics are suf�cient numbers, equitable distribution, good competencies, appropriate sociocultural and linguistic background, responsiveness to clients, and productivity. Human resource information is also needed to understand global labour markets, migratory flows of health workers, and the activities of multinational companies that Figure 7.1 Health information system (HIS) performance HIS results (selected indicators): HIS results (selected indicators): Thailand 2005 Ghana 2005 Total scores Total scores Health status Health status Mortality Mortality Morbidity Morbidity Health service Health service Health system Health system Risk factors Risk factors Not adequate at all Present but not adequate Partly adequate Adequate More than adequate Source: (5). working together, within and across countries 137 Box 7.1 Seeking a common technical framework for human resources for health: a public good useful to all countries? Could a common technical framework help governments and thinking through the issues. Many focused on just one aspect of national planners understand the myriad and complex problems the health workforce, for example human resources planning. of human resources for health – and �nd feasible solutions? The participants agreed that the desired common frame- Could such a framework address all sides of the issue in a com- work needed to be scienti�cally-based, operationally useful prehensive manner, be collaboratively developed, and be univer- (�eld-tested), and useful in a multisectoral and multi-stakeholder sally used – a public good of bene�t to all countries? context. It had to capture the content and processes involved in A common framework would have several bene�ts. First, it developing and implementing a national strategy for human re- would de�ne the key dimensions of technical competence needed sources for health, be simple but comprehensive, and show the to develop and implement a strategy for human resources. This interdependencies among the various players, institutions and is particularly important given the limited pool of expertise avail- labour markets involved in the health workforce. able globally. Second, it would help inform the growing number The �gure below shows the framework that was produced of groups interested in this area of the complexities of the health at the meeting. All seven interlinking thematic areas – human workforce and prevent the spread of simplistic and limited views resource management systems, policy, �nance, education, part- on what is involved (e.g. that developing human resources for nership and leadership – must be taken into account in dealing health is simply about training and increasing salaries). Third, with health workforce development, and this calls for multisector it would be a common reference point for all health workforce involvement. However, the diagram shows only the upper layer of stakeholders and save policy-makers, implementers, donors, a conceptual orientation that also has underlying secondary and academics and others the effort of “re-inventing the wheel�. tertiary levels. An attempt to develop a common technical framework began Work continues to develop and complete the framework. The in December 2005, when WHO and USAID invited 35 representa- goal is to produce an interactive CD-ROM that will convey the tives from multilateral and bilateral agencies, donor countries, detailed content and processes underlying each thematic area. nongovernmental organizations and the academic community to In the meantime, more information on the elements in each the- meet at the Pan American Health Organization in Washington, DC. matic area, on action that can be taken, and on the overall pro- They drew on 11 technical frameworks that had been developed cess for using the framework to develop a national strategy can over the years by researchers and human resources profession- be found in the WHO publication Tools for planning and developing als in various parts of the world. Some of these applied to very human resources for HIV/AIDS and other health services (available speci�c contexts; others offered broad conceptual roadmaps for at: http://www.who.int/hrh/tools/en/). Human resources for health technical framework: achieving a sustainable health workforce SITUATIONAL ANALYSIS PRIORITY SETTING POLICY LEADERSHIP HUMAN RESOURCES FINANCE MANAGEMENT MONITORING SYSTEMS AND EVALUATION PLANNING PARTNERSHIP EDUCATION IMPLEMENTATION HEALTH SYSTEM OTHER HEALTH Equity COUNTRY SYSTEMS Effectiveness SPECIFIC COMPONENTS Efficiency CONTEXTS Quality BETTER HEALTH OUTCOMES 138 The World Health Report 2006 Table 7.1 Short description of results of three Cochrane systematic reviews on human resources for health Total Title of Cochrane Number of studies number of systematic review Research question (initial/�nal) subjects Results Substitution of To investigate the 4253 articles initially Not No difference in quality of care doctors by nurses impact of nurses applicable and health outcomes between in primary care working as substitutes appropriately trained nurses and for primary care doctors doctors on: health outcomes Nurses tend to provide more health advice and achieve higher levels of patient satisfaction, compared with doctors process of care 25 articles, relating Even though using nurses may save to 16 studies, met salary costs, nurses may order more inclusion criteria tests and use other services, which may decrease the cost savings of using nurses instead of doctors resource use costs Lay health workers To assess the effects 8637 abstracts 210 110 LHWs show promising bene�ts in (LHWs) in primary of LHWs’ interventions initially consumers promoting immunization uptake and community in primary and and improving outcomes for acute health care community health respiratory infections and malaria, care on health care when compared to usual care. behaviours, patients’ For other health issues, health and well- evidence is insuf�cient to justify being, and patients’ recommendations for policy and satisfaction with care practice. 400 potentially There is also insuf�cient evidence eligible to assess which LHW training or intervention strategies are likely to be most effective. 43 eventually included Audit and Are audit and feedback 85 randomized > 3500 Audit and feedback can improve feedback: effects effective in improving controlled trials health professional practice, but the effects on professional professional practice professionals are variable. practice and health and health care Only 10 of the 85 When it is effective, the effects are care outcomes outcomes? included studies generally small to moderate. to be of high methodological quality The results of this review do not provide support for mandatory or unevaluated use of audit and feedback. Source: (10). working together, within and across countries 139 employ signi�cant numbers of health workers. In addition to good country data, an accurate, consistent and coherent view of the big picture also requires effective regional and global aggregation and analytical capacities. Reaching agreement on what information will be collected, how data will be aggregated and the neces- sary institutional arrangements is an important priority for concerned international partners. Generation and management of knowledge Strongly linked to building a foundation for health workforce information are chal- lenges related to both the generation and management of knowledge. Given that close to half of health expenditure is spent on the health workforce, it seems in- credible that there is so little research investment or solid evidence in this area. The evidence base within and across countries related to the health workforce is perilously weak, especially when compared with the strength of evidence in other domains of the health sector (6). The absence of a formal designation of the health workforce as a research priority has resulted in a patchy knowledge base. There is considerable research on curricula and teaching methods (see Box 3.8), rural reten- tion schemes and various aspects of health worker management, but large subject areas related to health training institutions, recruitment, management of incentives and attrition lack a critical research mass. Moreover, the existing knowledge base is largely skewed towards high income countries, medical doctors, and descriptive reports as opposed to intervention studies or best practice assessments (7–9). The paucity of research in general is reflected in the fact that there are only 12 systematic reviews on human resource issues available through the Cochrane Collaboration (10). Table 7.1 presents details of three of the most recent systematic reviews on human resources for health. Figure 7.2 Immunization coverage and density of health workers 100 90 80 70 Coverage (%) 60 50 40 30 20 Human resources for health Doctors 10 Nurses 0 1 10 100 1000 Density (per 100 000) Source: (5). 140 The World Health Report 2006 Although the knowledge generation agenda is most important at the country level and in speci�c workplaces, the return from well-designed and rigorous re- search cross-nationally should not be discounted. For example, simply assessing the relationship of the health workforce to key health outcomes across countries has helped to identify very important relationships such as that between nurse density and immunization coverage (11). Figure 7.2 shows that to achieve wider immunization coverage, the density of nurses and other health workforce staff is more important than the density of doctors – simply because in many countries it is nurses, and not doctors, who administer vaccinations. Scaling up and effectively deploying com- munity health workers as a common response to critical shortages in the health workforce would bene�t from insights into a number of important questions (see Box 7.2). In an attempt to draw attention to this neglected area of investigation, the Mexico Summit on Health Research, in 2004, identi�ed health systems research into sub- jects such as the health workforce as one of three priorities for global action (12), echoing the recommendations emerging from an international gathering in Cape Town (13) and the work of a WHO-convened task force (14). In general, preference for research activities should be given to the following: a better balance between primarily descriptive studies and more conceptual or fundamental policy and operations research; more international comparative research, drawing on multiple contexts such as the African migration study (15) and the European nursing exit study (16); the integration of research into speci�c health workforce interventions and more general health sector reforms, so as to document experiences across countries more systematically. This last point underlines the importance of developing more systematic mechanisms to disseminate and share knowledge once it is generated. As stressed in Chapters 2 and 6, in the context of tackling urgent health needs or pursuing ambitious national programmes, there is signi�cant “micro-innovation� that, if critically assessed, could help to accelerate the identi�cation of more effective strategies for human resources. Regional and national observatories are potential mechanisms for harvesting and disseminating new knowledge, provided they effectively engage the full range of stakeholders and their institutions (see Box 6.2). Box 7.2 Research priorities related to community health workers • Recruitment and retention – what factors and policies • Referral linkages – how can referral linkages be enhance recruitment of community health workers and operationalized, especially if communications and reduce attrition? transport systems are weak? • Roles – if community health workers do better with • Communications – can mobile technologies be used speci�c roles, how many roles can they undertake with to improve communications with community health a given level of training and support? How can these be workers and to help improve health outcomes in integrated with other community level work and with isolated communities? other levels in the health system? • Routine supplies – how can basic supplies be made • Improving performance, incentive systems and regularly available, and what is the best mix of remuneration – what level and method of remuneration social marketing, community-based distribution and types of non-�nancial incentives maximize cost– and strengthened health system logistics to ensure effectiveness but are sustainable? What are the other equitable access? effective approaches to improving performance? working together, within and across countries 141 Pooling of expertise Effective technical cooperation relies on being able to draw on appropriate expertise and on having a set of tools that corresponds to the diverse challenges of the health workforce. Global collaboration can improve access to quality tools and expertise. There is a general lack of awareness of the range of tools available as well as un- certainty about which ones work best in speci�c situations. Consequently, a working group of international specialists is developing a compendium of tools to facilitate their greater and more appropriate use (see Box 7.3). Much can also be done to improve the way expertise is managed and used. Countries rely on technical cooperation for three distinct purposes, depending on their particular needs. First, there are quite a number of countries that can bene�t from outside opinion to re�ne their diagnostic overview, ranking and determina- tion of the nature of the country’s human resources for health problems, with their entry, workforce and exit dimensions. Second, countries may have a need for expert collaboration in developing and planning the implementation of human resource policies, especially where the task of scaling up health systems is substantial. There may be a need, for example, to design and monitor �nancial solutions to increase coverage, as well as to build scenarios based on production and retention projec- tions. Third, there may be speci�c sub-areas where highly specialized technical skills are needed (see Box 7.4). Box 7.3 Tools for health workforce assessment and development Reliable tools have been developed to strengthen techni- www.who.int/hrh/tools/en/), where users can see the cal inputs in the planning, management and development range of tools with a brief description; a detailed review of human resources in health. However, a Joint Learning is also available, with a link to access the tool (mostly as Initiative report (7) pointed out that many practitioners are documents in pdf format). All those reviewed so far are unaware of the large number of such aids available, or have free, and all but one are available on the Internet. dif�culty in choosing those appropriate to their need. A In preparing the compendium, researchers have found working group of international human resources specialists some areas with several tools to choose from, but no was therefore established in June 2005 to put together a tools in other areas such as recruitment/retention and compendium of tools consisting of guidelines, models and employee relations/change management. If indeed none analytical methodologies. exist THE Connection will request funding bodies to sup- Known as “THE Connection�, the group identi�es new port the development of new ones to �ll these gaps. The tools which are then reviewed by at least two people using group is well aware that many management tools never a simple protocol developed by the group. If accepted for get used or even distributed to the appropriate users, inclusion in the compendium, a short review is written up and is trying to establish what works in the process of in standard format for each tool, with a section called “Will developing and disseminating tools. It will pass on this it work?� (information on testing and users’ experiences). information to developers. Reviews are organized in a colour-coded system around two One of the key aims of THE Connection has been to general topics: tools for a comprehensive analysis of the establish a network of human resources practitioners. human resources situation, and those that are speci�c to The interaction between members of the working group particular workforce functions. – some of whom have never met personally – and the By December 2005, 15 reviews had been completed and inclusion of other individuals in the process has already at least a further 10 are expected to be available by mid- expanded that network. Including a feedback mechanism 2006. The compendium is constantly evolving as new tools on the reviews, the tools themselves and the identi�ca- are developed, new reviews added and existing reviews up- tion of important gaps should stimulate an even wider dated. To facilitate this process, the compendium is available dialogue among practitioners, facilitating greater techni- as a CD-ROM and also on the Internet (available at: http:// cal cooperation in this challenging area of work. 142 The World Health Report 2006 Whatever the speci�c needs that technical cooperation is responding to, it has to be organized in such a way that it becomes an instrument for institutional and individual capacity building: this implies that technical cooperation has to shift from assistance and gap-�lling to exchange and joint learning. Countries can adopt a num- ber of measures to facilitate this shift. The �rst relates to how expertise and technical cooperation are sourced: for example, pooling funds with transparent sourcing rules; avoiding sourcing from tied funds; sourcing through technical partners that can act as honest brokers; and going through global mechanisms and networks that help to identify quality expertise. Second, countries can keep track of expertise that is provided and set up mechanisms to evaluate systematically its cost and effective- ness, including capacity building. Third, they can accelerate the shift from passive use of expertise towards exchange of experience on a regional and subregional basis, engaging their own experts and institutions in technical networks. As an illustration, in a Memorandum of Understanding between Uganda and its development partners in 2005, the Government of Uganda said it would request technical assistance on a demand-driven basis according to the needs and priorities of the Government in consultation with development partners. Use of Ugandan regional consultants would be encouraged where expertise is available (17). Lastly, countries can rationalize the way they negotiate technical cooperation, for example by establishing codes of conduct. In countries with severely constrained capacities of their own, the most promising avenue for a structural improvement is to federate and expand regional and national observatories and networks of resources (see Box 6.2). Open collaborative structures will make it possible to pool existing knowledge and skills, to set standards and to assess effectiveness in collaboration with countries: a virtuous circle of improved access to possibilities for collaboration, exchange and joint learning that will also lead to an expansion of the global expertise base. Box 7.4 Technical skills for human resource policy-making The development of policy for human resources for health • Health workforce economics: labour economics, in national health workforce planning requires a diversity of labour market analysis, workforce �nancing. expertise in the following areas: • Education: scope of education: public health, medical, nursing, pharmacy, dentistry, community; educational • Policy and planning: policy development and/or process: curricula, pedagogy, technology; educational analysis, workforce planning, medical demographics and stages: pre-service/prior to work, continuous/in-service; modelling, public health priorities, policy implementation, governance: accreditation, �nancing, administration. scenario building. • Workforce management systems and tools: data • Institutional and management development: change collection and analysis; information systems design; management; change processes analysis and monitoring; monitoring and evaluation of workforce development; partnership and consensus building; leadership and team guidelines development; operational research; technology building; sociology of organization and professions. development; performance of workforce; costing tool • Legal frameworks and policies: laws/regulation/ development. conditions of work, strategy development, regulation of • Professionally focused workforce development: professions. medicine, nursing, midwifery, pharmacy, dentistry. working together, within and across countries 143 STRIKING COOPERATIVE AGREEMENTS In planning their health workforce strategies, countries cannot overlook the dynamics of the global labour markets affecting health workers. Pushed by population trends towards ageing, Demand for service changes in consumer expectations and technological innova- tions, the health sector globally continues to defy expectations providers will escalate in terms of its rate of growth. Demand for service providers will escalate markedly in all countries – rich and poor (18, 19). The markedly in all countries workforce shortfalls identi�ed in this report would pale in com- parison with total shortages if all health workforce demands for – rich and poor all countries were projected into the future (20). Demographic changes in Europe and Japan are such that, were the health workforce to remain at its present share of the total workforce, the ratio of health workers to citizens over 65 years of age would drop by 38–40% by 2030. In contrast, were the health workforce to continue to grow at its present rate, its share of the total workforce would more than double (21). These trends are likely to accelerate the international flow of health workers, thus raising the importance of global cooperative mechanisms to minimize the adverse affects of migration. As discussed in Chapter 5, managing migration entails rules that protect the rights and safety of individual workers as well as multilateral principles and bilateral agreements related to recruitment. The emergence of an export and import industry in health workers, the growth of medical tourism, and the volume of workers moving back and forth between countries will increase the need for interna- tional arrangements related to accreditation, quality assurance and social security. As in other areas related to the health workforce, the capacity of interested institu- tions and the ability of processes to be suf�ciently inclusive of key stakeholders will be important determinants of the ability to reach cooperative agreements. Beyond the increasing demands emerging from the market, human conflicts, epidemics and natural disasters (such as avian influenza, SARS and the tsunami of December 2004) raise further demands for effective health workforce cooperation across countries (see Chapter 2). Global training centres for speci�c categories of workers, standardized curricula and codes of practice for volunteers are among the types of agreement that will facilitate more effective international responses. RESPONDING TO THE HEALTH WORKFORCE CRISIS The severity of the health workforce crisis in some of the world’s poorest countries is illustrated by WHO estimates that 57 of them (36 of which are in Africa) have a de�cit of 2.4 million doctors, nurses and midwives. The exodus of skilled professionals from rural areas to urban centres or other nations is one of the factors that have led to severe shortages, inappropriate skill mix and gaps in service coverage in poorer countries. Other factors include the HIV/AIDS epidemic and the policies of resource- poor governments that have capped public sector employment and limited invest- ment in education. Paradoxically, insuf�ciencies in workforce requirements often coexist with large numbers of unemployed health professionals. Poverty, flawed private labour markets, lack of public funds, bureaucratic red tape and political interference are partly responsible for the underutilization of skilled workers. Given the projections for high attrition rates attributable to illness, death and accelerated migration, it seems likely that the crisis of health care providers in many poorer countries will worsen before it gets better. In the WHO African Region, where 144 The World Health Report 2006 The crisis the shortage of health workers stands at about 1.5 million, there are many countries where the annual outflows caused by worker deaths, migration and requires nothing retirement exceed the inflows of newly trained doctors and nurses (22). short of an An extraordinary global response is needed The dire situation provoked by the global health workforce crisis requires outstanding nothing short of an outstanding global response. International action neces- sitates: coalitions around emergency national plans for health care provid- global response ers; health worker-friendly practices among global partners; and suf�cient and sustained �nancing of the health workforce. Coalitions around emergency plans The �rst imperative – emergency national plans for the health workforce – must combine credible technical input across the spectrum of human resource issues with intrepid and innovative strategies to make signi�cant changes in the short term as well as in the medium and longer terms. As explained in Chapter 6, engaging diverse stakeholders across sectors in a clear process at the outset of strategy development will help to forge shared ownership of the coalition. The conditions for developing these strategies in the crisis countries are suboptimal because of the scarcity of expertise, inadequate public sector capacity to lead a complex process, and the dif�culties of convening stakeholders in the midst of multiple competing priorities. High-level political support both nationally and internationally is necessary to ensure priority attention to the development of these plans. Malawi’s Emergency Human Resources Plan bene�ted from close involvement of the ministers of health and �nance as well as from visits from heads of international bilateral and multilateral agencies (23). Towards more worker-friendly practices There is no longer any question that the massive international efforts under way to treat people living with HIV/AIDS and to achieve the Millennium Development Goals (MDGs) must start dealing with workforce constraints more directly. If not, the bil- lions of dollars that are being poured into these programmes are at risk of being wasted. For their part, countries have identi�ed human resources as the area of the health system most in need of investment (5) (see Figure 7.3). Current practices among international stakeholders for supporting the health workforce tend to be antiquated in terms of content, ad hoc with respect to process and unintentionally adverse as regards impact. All multilateral, bilateral and civil society actors involved in health development in countries with a health workforce crisis could bene�t enormously from a thorough review and impact assessment of their activities in this direction. They should ensure that their practices embrace the working lifespan approach of entry, workforce and exit, in order to decrease the risk of focusing too narrowly on single issues such as on-the-job training. Any direct investments by partners in workforce-related issues should be based on a clear rationale of comparative advantage relative to pooling support to national emergency plans for health care providers. Directing support to countries in crisis de�es a single approach, and no such process should be seen as exempt from incorporating a dimension to strengthen the health workforce. This includes – but is not limited to – sector-wide approaches, pov- erty reduction strategies, medium-term expenditure frameworks, and instruments working together, within and across countries 145 such as the country coordinating mechanisms of the Global Fund to Fight AIDS, Tuberculosis and Malaria and the national control programmes for HIV/AIDS. All of these processes should be brought into line with national emergency plans for human resources, and mechanisms should be identi�ed to put the cooperation into place. The decision by the Global Alliance for Vaccines and Immunization (GAVI) to support a health systems strengthening strategy inclusive of the health workforce is now being translated through country applications with principles, requirements and minimal criteria summarized in clear guidelines. Importantly, the strategy seeks to ensure that GAVI’s prospective assistance to the health workforce (and other elements of health systems) in a country is aligned with existing strategies for strengthening the workforce. As the experience of sector-wide approaches and poverty reduction strat- egies has shown, the promise of more effectively integrating policies for the health workforce is constrained by insuf�cient numbers of adequately supported national staff (24). This underlines the need to develop national capacities for strategic intel- ligence (see Chapter 6) and to facilitate access to technical cooperation. The imperative of suf�cient, sustained �nancing Overcoming the workforce shortage will require substantial �nancial commitments to train and pay the additional health workers. The cost of very rapid scaling up of training aimed at eliminating the shortfall by 2015 – the target date for achieving the goals of the Millennium Declaration – was shown in Chapter 1 to be about US$ 136 million per year for the average country. The additional cost of paying health workers once the shortage has been met is just over US$ 311 million per country at current salary levels (25). Assuming that scaling up takes place over a 20-year period – which many ob- servers might argue is more realistic – the required annual investment in training is US$ 88 million per country. Additional salary costs when the workforce is fully Figure 7.3 Country priorities for health systems strengthening Human resources Information systems development Facility, lab and equipment upgrade Management strengthening Institutional strengthening Procurement and supply systems Improved access (non-financial) Private sector involvement Improved access (financial) Community capacity for care Transport/communications Behaviour change 0 5 10 15 20 25 Number of proposals to the Global Fund for Tuberculosis, HIV/AIDS and Malaria, round 5 Source: (5). 146 The World Health Report 2006 staffed would be higher under this scenario (because the population will increase substantially between 2015 and 2025 and so will the need for health workers), reaching in excess of US$ 400 million per country. Translating the �gures into per capita expenditure in health for the average coun- try gives further perspective on the costs of scaling up the health workforce. To meet the investment costs for training over a 20-year period, the average country would need to increase its overall level of health expenditure per capita by about US$ 1.60 each year. By 2025, a minimum increase of US$ 8.30 per capita would be required to pay the salaries of the appropriate workforce. While such costing models are indicative rather than precise, they do reveal important issues. Firstly, scaling up the health workforce on either a 10-year or 20- year trajectory will require very signi�cant dedicated funding. Next, these estimates of the training and salary costs of scaling up are based on doctors, nurses and midwives. Although there are no data, strategies that depend on lower paid cadres with less formal training may be more affordable and therefore merit serious consid- eration. Finally, the results are sensitive to the age of retirement of health workers, their mortality rates, and the extent to which they remain in the country and choose to be employed in the health sector after training. Policies to improve workers’ health, extend retirement age and increase retention may reduce the numbers that need to be trained and may result in cost savings. It is clear from the above that a major expansion of the health workforce has both immediate and long-term cost implications. Understandably, governments with few �nancial resources may be reluctant to commit to such long-term costs without clear signals of support from the international donor community. As the nature and mag- nitude of the health worker crisis comes into greater focus and national strategies to scale up the workforce emerge, now is the time to clarify the role of international �nancial assistance. A global guideline for �nancing The �nancing challenge has two distinct aspects: generating suf�cient volume to cope realistically with the crisis, and sustaining adequate levels of funding over time. Mobilizing the sizeable funds required for the �nancing of the health workforce must be carried out through a combination of improved government budgets and interna- tional development assistance. There are some promising signs. For example, the recent dedication of funds for strengthening health systems amounting to US$ 500 million, budgeted by GAVI over �ve years, indicates how the health workforce is be- coming one of the priority areas for systems support. Similarly, the Emergency Health Workforce Plan in Malawi has dedicated US$ 278 million over six years through a coalition of country and global partners. While bottom-up budgeting around emergency plans is the optimal way to pro- ceed, there is nonetheless a need for a �nancing guideline that can ensure that the response is commensurate with need and around which the international community can mobilize. With respect to the total flows of international development assistance for health, approximately US$ 12 billion per annum in 2004 (26), this report recom- mends a 50:50 principle – that 50% of this �nancing be directed to health systems strengthening, of which at least half is dedicated to supporting emergency health workforce plans. The rationale for this proportional investment relates to the reliance of health workers on functioning health systems and the need for dedicated �nancing of workforce strategies above and beyond the human resources activities that may be inherent in speci�c priority programmes of global health organizations. working together, within and across countries 147 In so far as the proposed expansion is publicly �nanced – through taxes, social health insurance or international solidarity – it is subject to the rules of public �nanc- ing. In an effort to preserve macroeconomic stability and �scal sustainability, inter- national �nance institutions and ministers of �nance use criteria such as the public expenditure:GDP ratio to set ceilings. The most visible consequences for the health sector are the ceilings on recruitment and the stagnant salaries of health workers in public employment. Hiring moratoriums are limiting the expansion of health services and creating unemployment of health workers, particularly in sub-Saharan Africa. Poverty reduction strategies, for example, often refer explicitly to such restrictions. Authorities in Kenya, Mozambique, Zambia and many other countries are thus refraining from hiring health workers because they cannot �nd a way around these stipulations (27). Greater attention to this issue has produced a menu of options to manage better within current public sector �nancing rules. Examples include effective outsourcing as a means of lowering costs and eliminating ghost workers (28, 29). Although such ef�ciency measures would be helpful, they are unlikely to be suf�cient on their own. Recognition of the need to expand �scal space (i.e. make more budget room for health) calls for a status of exception to be accorded to public �nancing of health and its workforce. Negotiating �scal space safeguards for the health workforce will require the health development world to engage productively with ministries of �nance, international �nance institutions and major international stakeholders. Strengthened evidence on the health and economic returns on investment in the health workforce may assist in these negotiations. At the same time, the moral and political rationales related to placing the people’s health �rst and pursuing universal access can help to achieve a health workforce exception. Part of the concern in public �nancing of workforce expansion relates to the ability of governments to pay for staff throughout the length of their careers. Be- cause countries are reluctant to expose themselves to a potentially unsustainable public debt, they need predictability of donor back-up over the long term (30). Donor funds, however, are expressions of current government priorities, and mechanisms for long-term reassurance or guarantees of support are generally not forthcoming. The challenges of funding the scaling up of the health workforce in the longer term, therefore, cannot be separated from the broader dilemma of resource mobilization for health. Bold commitments and new mechanisms may help to provide greater predictability of global aid flows (31). These must be complemented by national strategies that build towards sustainable �nancing of the health sector. MOVING FORWARD TOGETHER Over the last decade much has been done to raise the awareness that, unless prob- lems of the health workforce are dealt with squarely, health systems are going to founder. There are still huge gaps in knowledge about the extent of the fundamental drivers that shape the human resources predicament, and the range of solutions that can be suggested. There is, however, a way out of the crisis. By working together through inclusive stakeholder alliances – global as well as national – problems that cross sectors, interest groups and national boundaries can be tackled: limited expertise can be pooled, and opportunities for mutual learning, sharing and problem-solving can be seized. Global solidarity will make it possible to exploit synergies between the speci�c inputs of bodies such as WHO, interna- tional �nance institutions, academia and professional associations. It is particularly 148 The World Health Report 2006 important to monitor carefully the effects of these inputs so as to build up gradually a critical mass of evidence – and to share this knowledge with all who might bene�t from it. There is not a country in the world that is not facing major health workforce challenges – challenges that affect its health system, its economy and its obliga- tions towards its citizens. All countries need to build or strengthen their institutional capacities to deal with their own predicaments and problems of human resources for health. Some countries need a signi�cant amount of external assistance to succeed in doing so; if such support is not forthcoming, they will fall even further behind because the global forces that drive health workforce development will accelerate distortions. From a global perspective, this would mean an exacerbation of inequali- ties as health workers move to countries where policy-makers are more responsive to their concerns. From a national perspective, it would mean rising political tensions as citizens’ rightful expectations fail to materialize. Momentum for action has grown steadily over recent years. Member States of WHO, spearheaded by health leaders from Africa, adopted two resolutions at recent World Health Assemblies calling for global action to build a workforce for national health systems, including stemming the flow of unplanned professional emigration. Europe and Latin America have promoted regional observatories in human resources for health, and the WHO South-East Asia and Eastern Mediterranean Regional Of�ces have launched new public health training initiatives. One hundred global health lead- ers in the Joint Learning Initiative recommended urgent action to overcome the crisis of human resources for health. Calls for action have come from a series of High- Level Forums for the health-related MDGs in Geneva, Abuja and Paris, and two Oslo Consultations have nurtured a participatory stakeholder process to chart a way forward. A clear mandate has emerged for a global plan of action bringing forth national leadership backed by global solidarity. National leadership Strong country strategies require both solid technical content and a credible politi- cal process. This involves embracing the breadth of issues inherent in the entry– workforce–exit framework while cultivating trust and brokering agreements through effective engagement of stakeholders in planning and implementation. In addition, national strategies are likely to be more successful if they adopt three priorities: acting now, anticipating the future and acquiring critical capabilities. Acting now for workforce productivity by cutting waste (such as eliminating ghost workers and absenteeism) and improving performance through compensation adjustments, work incentives, safer working conditions, and worker mobilization efforts. Better intelligence gathering is crucial, in order to understand national situations and monitor progress or setbacks. Anticipating the future by engaging stakeholders to craft national strategic plans through evidence-based information and scenarios on likely future trends. Sig- ni�cant growth of private education and services should be anticipated, neces- sitating the targeting of public funds for health equity, promotion and prevention. Public action in information, regulation and delegation are key functions for mixed public and private systems. Acquiring critical capacities by strengthening core institutions for sound work- force development. Leadership and management development in health and other related sectors such as education and �nance are essential for strategic working together, within and across countries 149 planning and implementation of workforce policies. Standard setting, accrediting and licensing must be effectively established to improve the work of worker unions, educational institutions, professional associations and civil society. National leadership Global solidarity and global solidarity National strategies on their own, however well conceived, are insuf�cient to deal with the realities of health workforce chal- can result in signi�cant lenges today and in the future. Strategies across countries are similarly constrained by patchy evidence, limited planning tools improvements in all and a scarcity of technical expertise. Outbreaks of disease and labour market inflections transcend national boundaries, and countries the depth of the workforce crisis in a signi�cant group of countries requires inter- national assistance. National leadership must therefore be complemented by global solidarity on at least three fronts: knowledge and learning; cooperative agreements; and responsiveness to health workforce crises. Catalysing knowledge and learning. Low-cost but signi�cant investments in the development of better metrics for the workforce, agreement on common techni- cal frameworks, and the identi�cation of and support for priority research will accelerate progress in all countries. Effective pooling of the diverse technical expertise and breadth of experiences can assist countries in accessing the best talent and practices. Striking cooperative agreements. The growing international nature of the health workforce related to the flows of migrants, relief workers and volunteers calls for cooperative agreements to protect the rights and safety of workers and to en- hance the adoption of ethical recruitment practices. The current global situation regarding avian influenza is indicative of a more fundamental need for effective international capacity to marshal the requisite human resources for acute health and humanitarian emergencies. Responding to health workforce crises. The magnitude of the crisis in the world’s poorest countries cannot be overstated and requires an urgent, sustained and coordinated response from the international community. Donors must facilitate the immediate and longer-term �nancing of human resources as a health systems investment. The costs of scaling up the workforce over a 20-year period cor- responds to an annual increase of about US$ 1.60 in per capita expenditure on health. A 50:50 guideline is recommended, whereby 50% of all priority initiative funds are devoted to health systems, with half of this funding devoted to national health workforce strengthening strategies. Development �nancing policies must �nd ways to ensure that hiring ceilings are not the primary constraint to workforce expansion. All partners should critically evaluate their modalities for supporting the workforce with a view to shedding inef�cient practices and aligning more effectively with national leadership. National leadership and global solidarity can result in signi�cant structural improve- ments of the workforce in all countries, especially those with the most severe crises. Such advances would be characterized by universal access to a motivated, compe- tent and supported health workforce, greater worker, employer and public satisfac- tion, and more effective stewardship of the workforce by the state, civil society and professional associations. 150 The World Health Report 2006 Plan of action National leadership must urgently jump-start country-based actions and sustain them for at least a decade. Table 7.2 summarizes targets in the plan of action over the decade 2006–2015. Immediate actions over the next few years should consist of lead countries pio- neering national plans for scaling up effective strategies, increasing investments, cutting waste, and strengthening educational institutions. Global support should accelerate progress in countries, with immediate policy attention given to intel- ligence, technical cooperation, policy alignment of �scal space and migration, and harmonization of priority initiatives and donor assistance. At the decade’s mid-point, over half of all countries should have sound national plans with expanded execution of good policies and management practices con- cerned with workforce incentives, regulation and institutions. Global advances will include shared norms and frameworks, strong technical support, and im- proved knowledge management. Responsible recruitment and alignment of prior- ity programmes and development instruments to support the health workforce should be in place. The decade goal in all countries is to build high-performing workforces for national health systems to respond to current and emerging challenges. This means that every country should have implemented national strategic plans and should be planning for the future, drawing on robust national capacity. Globally, a full range of evidence-based guidelines should inform good practice for health workers. Effective cooperative agreements will minimize adverse consequences despite increased international flows of workers. Sustained international �nanc- ing should be in place to support recipient countries for the next 10 years as they scale up their workforce. Table 7.2 Ten-year plan of action 2006 2010 2015 Immediate Mid-point Decade Country Management Cut waste, improve Use effective managerial Sustain high performing leadership incentives practices workforce Education Revitalize education Strengthen accreditation Prepare workforce for the strategies and licensing future Planning Design national workforce Overcome barriers to Evaluate and redesign strategies implementation strategies, based on robust national capacity Global Knowledge and Develop common technical Assess performance with Share evidence-based good solidarity learning frameworks comparable metrics practices Pool expertise Fund priority research Enabling policies Advocate ethical recruitment Adhere to responsible Manage increased migratory and migrant workers’ rights recruitment guidelines flows for equity and fairness Pursue �scal space Expand �scal space for Support �scal sustainability exceptionality health Crisis response Finance national plans for Expand �nancing to half of Sustain �nancing of national 25% of crisis countries crisis countries plans for all countries in Agree on best donor Adopt 50:50 investment crisis practices for human guideline for priority resources for health programmes working together, within and across countries 151 Figure 7.4 Global stakeholder alliance Country leadership Support and catalysis Problem-solving Political visibility Global solidarity Knowledge and information Convening Financial resources Alliance of stakeholders National governments Civil society/ nongovernmental organizations Financial institutions/donors Workers United Nations agencies Academia Others JOINT STEPS TO THE FUTURE Moving forward on the plan of action necessitates that stakeholders work together through inclusive alliances and networks – local, national and global – across health problems, professions, disciplines, ministries, sectors and countries. Cooperative structures can pool limited talent and �scal resources and promote mutual learn- ing. Figure 7.4 proposes how a global workforce alliance can be launched to bring relevant stakeholders to accelerate core country programmes. A premier challenge is advocacy that promotes workforce issues to a high place on the political agenda and keeps them there. The moment is ripe for political support as problem awareness is expanding, effective solutions are emerging, and various countries are already pioneering interventions. Workforce development is a continu- ous process that is always open for improvement. However, immediate acceleration of performance can be attained in virtually all countries if well-documented solutions are applied. Some of the work should be implemented immediately; other aspects will take time. There are no short cuts and there is no time to lose. 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To assess overall levels of health achievement, it is crucial to develop the best possible assessment of the life table for each country. Life tables have been de- veloped for all 192 Member States for 2004 starting with a systematic review of all available evidence on levels and trends in under-�ve and adult mortality rates. It is worth noting the efforts of WHO regional of�ces in collecting vital registration data from Member States (2). International agencies such as the United Nations Children’s Fund (UNICEF) also maintain historical databases on under-�ve mortality rates, which have been generously shared and incorporated in these analyses. Other sources of information include data from national censuses or household surveys such as the Demographic and Health Survey (DHS) undertaken by ORC Macro, the World Bank Living Standards Measurement Study, and the Multiple Indicator Cluster Survey (MICS) conducted by UNICEF. Finally, national statistical documents such as statistical yearbooks, reports from specialized agencies and periodical paper �ndings were also incorporated into the database. This review of data sources bene�ted greatly from a collaborative assessment of under-�ve mortality levels for 2004 by UNICEF, WHO, the World Bank and the United Nations Population Division responsible for monitoring child mortality trends. 156 The World Health Report 2006 The four agencies have established the Child Mortality Coordination Group includ- ing an independent group of academics which aims to conduct a critical review of current procedures used in each institution for compiling data and arriving at point estimates (3). WHO uses a standard method to estimate and project life tables for all Member States using comparable data. This may lead to minor differences compared with of�cial life tables prepared by Member States. Life expectancy at birth, the probability of dying before �ve years of age (under- �ve mortality rate) and the probability of dying between 15 and 60 years of age (adult mortality rate) derive from life tables that WHO has estimated for each Member State. Procedures used to estimate the 2004 life table differed for Member States depending on the data available to assess child and adult mortality. Because of increasing heterogeneity of patterns of adult and child mortality, WHO has developed a model life table system of two-parameter logit life tables, and with additional age-speci�c parameters to correct for systematic biases in the application of a two- parameter system (4). This system of model life tables has been used extensively in the development of life tables for those Member States without adequate vital regis- tration and in projecting life tables to 2004 when the most recent data available are from earlier years. Estimates for 2004 have been revised to take into account new data received since publication of The world health report 2005 for many Member States and may not be entirely comparable with those published in previous reports. The methods used to construct life tables are summarized below and a full detailed overview has been published (4, 5). For Member States with vital registration and sample vital registration systems, demographic techniques (Preston–Coale method, Brass Growth–Balance method, Generalized Growth–Balance method and Bennett–Horiuchi method) were �rst ap- plied to assess the level of completeness of recorded mortality data in the population above �ve years of age and then those mortality rates were adjusted accordingly (6). Where vital registration data for 2004 were available, these were used directly to construct the life table. For other countries where the system provided a time series of annual life tables, the parameters (I5 , I60 ) were projected using a weighted regression model giving more weight to recent years (using an exponential weighting scheme such that the weight for each year t was 25% less than that for year t+1). For countries with a total population of less than 750 000 or where the root mean square error from the regression was greater than or equal to 0.011, a shorter-term trend was estimated by applying a weighting factor with 50% annual exponential decay. Projected values of the two life table parameters were then applied to a modi�ed logit life table model, using the most recent national data as the standard, which allows the capture of the most recent age pattern, to predict the full life table for 2004. For all Member States, other data available for child mortality, such as surveys and censuses, were assessed and adjusted to estimate the probable trend over the past few decades in order to predict the child mortality in 2004. A standard approach to predicting child mortality was employed to obtain the estimates for 2004 (7). Those estimates are, on the one hand, used to replace the under-�ve mortality rate in life tables of the countries that have a vital registration or sample vital regis- tration system, but with incomplete registration of numbers of deaths under the age of �ve years; on the other hand, for countries without exploitable vital registration systems, which are mainly those with high mortality, the predicted under-�ve mortality statistical annex explanatory notes 157 rates are used as one of the inputs to the modi�ed logit system. Adult mortality rates were derived from either surveys or censuses where available; otherwise the most likely corresponding level of adult mortality was estimated based on regression models of child versus adult mortality as observed in the set of approximately 1800 life tables. These estimated child and adult mortality rates were then applied to a global standard, de�ned as the average of all the life tables, using the modi�ed logit model to derive the estimates for 2004. It should be noted that the logit model life table system using the global standard does not capture high HIV/AIDS epidemic patterns, because the observed underlying life tables do not come from countries with the epidemic. Similarly, war deaths are not captured because vital registration systems often break down in periods of war (8). For these reasons, for affected countries, mortality without deaths attributable to HIV/AIDS and war was estimated and separate estimates of deaths caused by HIV/AIDS and war in 2004 were added. The main results in Annex Table 1 are reported with uncertainty intervals in order to communicate to the user the plausible range of estimates for each country on each measure. For the countries with vital registration data projected using time series regression models on the parameters of the logit life table system, uncertainty around the regression coef�cients has been accounted for by taking 1000 draws of the parameters using the regression estimates and variance covariance matrix of the estimators. For each of the draws, a new life table was calculated. In cases where additional sources of information provided plausible ranges around under-�ve and adult mortality rates the 1000 draws were constrained such that each life table produced estimates within these speci�ed ranges. The range of 1000 life tables pro- duced by these multiple draws reflects some of the uncertainty around the projected trends in mortality, notably the imprecise quanti�cation of systematic changes in the logit parameters over the time period captured in available vital registration data. For Member States where complete death registrations were available for the year 2004 and projections were not used, the life table uncertainty reflects the event count uncertainty, approximated by the Poisson distribution, in the estimated age-speci�c death rates arising from the observation of a �nite number of deaths in a �xed time interval of one year. For countries that did not have time series data on mortality by age and sex, the following steps were taken. First, point estimates and ranges around under-�ve and adult mortality rates for males and females were developed on a country-by-country basis (5). In the modi�ed logit life table system described (4), values on these two parameters may be used to identify a range of different life tables in relation to a global standard life table. Using the Monte Carlo simulation methods, 1000 random life tables were generated by drawing samples from normal distributions around these inputs with variances de�ned according to ranges of uncertainty. In countries where uncertainty around under-�ve and adult mortality rates was considerable because of a paucity of survey or surveillance information, wide distributions were sampled but the results were constrained based on estimates of the maximum and minimum plausible values for the point estimates. For 55 countries, mainly in sub-Saharan Africa, estimates of life tables were made by constructing counterfactual life tables excluding the mortality impact of the HIV/AIDS epidemic and then combining these life tables with exogenous estimates of the excess mortality rates attributable to HIV/AIDS. The estimates were based on back-calculation models developed as part of collaborative efforts between WHO and 158 The World Health Report 2006 the Joint United Nations Programme on HIV/AIDS (UNAIDS) to derive country-level epidemiological estimates for HIV/AIDS. In countries with substantial numbers of war deaths, estimates of their uncertainty range were also incorporated into the life table uncertainty analysis. ANNEX TABLE 2 Annex Table 2 (Annex Table 5 in last year’s report) provides a set of policy-relevant indicators on major health expenditure aggregates. The indicators include the total expenditure on health, broken down into public/general government expenditure on health and private health expenditure. Selected components are presented of public health expenditures (social security expenditure on health) and private health expenditures (health insurance and prepaid schemes and out-of-pocket expen- diture). General government expenditure on health is also presented as a ratio to total general government expenditure (GGE). Data on external resources, which are flows earmarked for health originating outside the country and treated as a �nanc- ing source, are also available. External resources represent all outside funds that �nance the above-mentioned general government health expenditure and private health expenditure. The data include the best �gures that were accessible to WHO until the end of 2005 for its 192 Member States. Subsequent updates, additional years and detailed information are available on the WHO National Health Accounts (NHA) web site at http://www.who.int/nha/en/. During the past half decade, an increasing number of countries have been releas- ing more comprehensive data on health spending: about 100 countries produced full national health accounts (for one year or more) or report expenditure on health to the Organisation for Economic Co-operation and Development (OECD), released as OECD health data. WHO publishes data collated from national and international sources and reports. Data are consolidated, triangulated and harmonized in the NHA framework, using international classi�cations and standard national accounts proce- dures. Standard accounting estimation and extrapolation techniques have been used to provide time series. As in previous years, a draft template of the estimates was sent to ministers of health seeking their comments and assistance in obtaining ad- ditional information. Their responses and those of other government agencies, such as statistical of�ces, provided valuable feedback that has improved the estimates for the health expenditure indicators reported here. WHO staff at headquarters and in regional and country of�ces facilitate this process. Years of regular consultation and discussion have established extensive communication channels with ministries of health and other agencies, domestic and international experts and networks and have also helped in developing national capacity. Measurement of expenditure on health Health accounting (HA) is a synthesis of the �nancing and spending flows recorded in the operation of a health system. It offers the potential to monitor all transac- tions from funding sources to the distribution of bene�ts according to geographical, demographic, socioeconomic and epidemiological characteristics. NHA are further related to the macroeconomic and macrosocial accounts whose methodological ap- proach they borrow. An important methodological contribution to the construction of HA is the Guide to producing national health accounts with special applications for low-income and statistical annex explanatory notes 159 middle-income countries (9), itself grounded on the OECD System of health accounts (10) principles. This methodology rests on the foundations of the United Nations System of national accounts (commonly referred to as SNA93) (11). WHO has been publishing a moving �ve-year series on NHA indicators since 2002, and updates the �gures every year with the best estimates accessible. Each �ve-year series exhibits internal consistency among the included years. Because HA is a discipline in development – not only regarding methods but also regarding imple- mentation by countries – several Member States have modi�ed previous estimates in order to improve measurement. Some of the reasons for improved estimates can be categorized into �ve groups: 1) new NHA reports, where countries make their �rst ever NHA report; 2) improved NHA reports, where an additional report offers improved estimates over preliminary NHA work; 3) new data sources, where there is access to new data such as social security data or new households expenditure survey results released; 4) improved data sources, where governments provide bet- ter data or instances of double counting were identi�ed; and 5) macro data updated. Caution is required when comparing newly published estimates with previously pub- lished series or when trying to construct a series longer than the currently available multiyear series (please refer to the web site for longer reconciled series). De�nitions Total health expenditure (THE) has been de�ned as the sum of general government expenditure on health (commonly called public expenditure on health), and private expenditure on health. General government health expenditure (GGHE) is estimated as the sum of outlays by government entities to purchase health care services and goods: notably by ministries of health and social security agencies. Private health expenditure (PvtHE) includes total outlays on health by private entities: notably commercial insurance, non-pro�t institutions, households acting as complemen- tary funders to the previously cited institutions or disbursing unilaterally on health commodities. The revenue base of these entities may comprise multiple sources, including external funds. This necessitates taking into account essential attributes of health accounting such as comprehensiveness, consistency, standardization and timeliness when building estimates. Figures are originally estimated in million national currency units (million NCU) and in current prices. GGHE comprises the outlays earmarked for health maintenance, restoration or enhancement of the health status of the population, paid for in cash or in kind by the following �nancing agents: central/federal (ministry of health or other ministries), state/provincial/regional, and local/municipal authorities; extrabudgetary agencies, principally social security schemes; direct expenditure on health care by parastatals and public �rms (which operate as though they were private sector �rms but are controlled by the government). All three can be �nanced through domestic funds or through external resources (mainly as grants passing through the government or loans channelled through the national budget). GGHE includes both recurrent and investment expenditures (including capital transfers) made during the year. The classi�cation of the functions of government (COFOG) promoted by the United Nations, the International Monetary Fund (IMF), OECD and other institutions sets the boundaries for public outlays. In many instances, 160 The World Health Report 2006 the data contained in the publications accessed are limited to those supplied by ministries of health. Expenditure on health, however, should include all expenditure when the primary intent is to improve health, regardless of the implementing entity. An effort has been made to obtain data on health expenditure by other ministries, the armed forces, prisons, schools, universities and others, to ensure that all resources accounting for health expenditures are included. Furthermore, all expenditures on health include �nal consumption, subsidies to producers, and transfers to households (chiefly reimbursements for medical and pharmaceutical bills). The �gures for social security expenditure on health include purchases of health goods and services by schemes that are mandatory and controlled by government. A major hurdle faced by accountants is the need to avoid double counting and exclude cash bene�ts for periods of sickness or loss of employment, which are classi�ed as income maintenance expenditure. Government-controlled and mandatory social security schemes that apply only to a selected group of the population, such as public sector employees only, are also included here. PvtHE has been de�ned as the sum of expenditures by the following entities: Prepaid plans and risk-pooling arrangements: the outlays of private insurance schemes and private social insurance schemes (with no government control over payment rates and participating providers but with broad guidelines from government), commercial and non-pro�t (mutual) insurance schemes, health maintenance organizations, and other agents managing prepaid medical and paramedical bene�ts (including the operating costs of these schemes). Firms’ expenditure on health: the outlays by private enterprises for medical care and health-enhancing bene�ts other than payment to social security or other pre-paid schemes. Non-pro�t institutions serving mainly households: the resources used to purchase health goods and services by entities whose status does not permit them to be a source of income, pro�t or other �nancial gain for the units that establish, control or �nance them. This includes funding from internal and external sources. Household out-of-pocket spending: the direct outlays of households, including gratuities and in-kind payments made to health practitioners and to suppliers of pharmaceuticals, therapeutic appliances and other goods and services, whose primary intent is to contribute to the restoration or the enhancement of the health status of individuals or population groups. This includes household payments to public services, non-pro�t institutions or nongovernmental organizations and non-reimbursable cost sharing, deductibles, copayments and fees for services. It excludes payments made by enterprises which deliver medical and paramedical bene�ts, mandated by law or not, to their employees and payments for overseas treatment. It also excludes transport and food costs (except those paid of�cially to the providers) and contributions to pre-paid pooling schemes. The external resources appearing in Annex Table 2 are those entering the system as a �nancing source, i.e. all external resources (grants and loans) whether passing through governments or private entities are included. The other institutions and enti- ties reported are public or private expenditures on health acting as �nancing agents. Financing agents are entities that pool health resources collected from different �nancing sources (such as households, government, external agencies, �rms and nongovernmental organizations) and pay directly for or purchase health care. statistical annex explanatory notes 161 Gross domestic product (GDP) is the value of all goods and services provided in a country by residents and non-residents without regard to their allocation among domestic and foreign claims. This (with small adjustments) corresponds to the total sum of expenditure (consumption and investment) of the private and government agents of the economy during the reference year. General government expenditure (GGE) includes consolidated direct outlays and indirect outlays (for example, subsidies to producers, transfers to households), in- cluding capital, of all levels of government (central/federal, provincial/regional/state/ district, and local/municipal authorities), social security institutions, autonomous bodies, and other extrabudgetary funds. Data sources Annex Table 2 provides both updated and revised �gures for 1999–2003. Estimates for additional years along with sources and methodology are available at http://www. who.int/nha. National sources include: national health accounts reports, public ex- penditure reports, statistical yearbooks and other periodicals, budgetary documents, national accounts reports, central bank reports, nongovernmental organization reports, academic studies, and reports and data provided by central statistical of�ces, ministries of health, ministries of �nance and economic development, plan- ning of�ces, and professional and trade associations, statistical data on of�cial web sites, and household surveys. Speci�c health accounts or comprehensive health �nancing documents and stud- ies (including both private and public sectors) are available in the following countries presented by WHO regional groupings: African Region: Algeria, Burkina Faso, Cameroon, Ethiopia, Guinea, Kenya, Malawi, Mauritius, Mozambique, Namibia, Niger, Nigeria, Rwanda, Senegal, South Africa, Togo, Uganda, United Republic of Tanzania, Zambia, Zimbabwe. Region of the Americas: Argentina, Bahamas, Bolivia, Brazil, Canada, Chile, Colombia, Costa Rica, Ecuador, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, Panama, Paraguay, Peru, Suriname, Trinidad and Tobago, United States of America, Uruguay. South-East Asia Region: Bangladesh, India, Indonesia, Sri Lanka, Thailand. European Region: Albania, Austria, Belgium, Bulgaria, Czech Republic, Denmark, Estonia, Cyprus, Finland, France, Georgia, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Kyrgyzstan, Latvia, Lithuania, Luxembourg, Netherlands, Norway, Poland, Portugal, Romania, Russian Federation, Slovakia, Slovenia, Spain, Sweden, Tajikistan, Turkey, United Kingdom. Eastern Mediterranean Region: Bahrain, Djibouti, Egypt, the Islamic Republic of Iran, Jordan, Lebanon, Morocco, Oman, Tunisia, Yemen. Western Paci�c Region: Australia, China, Japan, Malaysia, Mongolia, New Zealand, Papua New Guinea, Philippines, Republic of Korea, Samoa, Tonga, Viet Nam. OECD health data series supply GGHE and PvtHE entries for OECD’s 30 Member countries. For GGHE, a larger number of reports on expenditure on health from non-OECD countries has been made available in the recent years. This has allowed a more complete estimation than in previous World Health Reports. The IMF Gov- ernment �nance statistics now reports central government expenditure on health for over 120 countries, as well as regional and local government outlays on health 162 The World Health Report 2006 for a third of these countries. Government �nance data, together with statistical yearbooks, public �nance reports, reports from social security agencies, and status reports on the implementation of health policies, facilitate the estimation of GGHE for Member States which do not yet release this information. Most data on private expenditure on health come from NHA reports, statistical yearbooks and other periodicals, statistical data on of�cial web sites, reports of nongovernmental organizations, household expenditure surveys, academic studies, and relevant reports and data provided by central statistical of�ces, ministries of health, insurance agencies, professional and trade associations and planning coun- cils. Standard extrapolation and estimation techniques are used to obtain the �gures for missing years. Information on external resources is taken from the Development Action Com- mittee of the OECD (DAC/OECD). Where some Member States explicitly monitor the external resources entering their health system, that information has been used to validate or amend the order of magnitude derived from the DAC entries. DAC entries used by WHO relate to disbursements (which reports only bilateral flows from certain countries), wherever available, otherwise commitments are presented. For macro variables, several international references facilitate the compilation of needed estimates, including the latest estimates from IMF Government �nance sta- tistics yearbook (12), International �nancial statistics yearbook (13) and International �nancial statistics (14); the Asian Development Bank Key indicators (15); OECD health data (16); International development statistics (17); the United Nations National ac- counts statistics: main aggregates and detailed tables (18); United Nations Statistics Division, the Economic Commission for Europe of the United Nations, and United Nations Economic and Social Commission for Western Asia; The World Bank’s World development indicators, unpublished data from the IMF research department, the Caribbean Community Secretariat (CARICOM); and national series from ministries of �nance or central banks. The main sources of GDP are latest current year estimates from OECD national accounts and OECD health data for the OECD countries; for non OECD countries, the United Nations National accounts statistics and data from other United Nations agencies are used. When United Nations data are unavailable, other sources as mentioned above are used. Methodological notes Variations in the boundaries used in the original sources have been adjusted as far as possible to allow standardized de�nition. For example, in some countries, GGHE and hence THE may include expenditure on environmental health, education of health personnel and health research activities, whereas other countries treat these expenses as a memorandum item. In the tables reported here, the principles outlined in the Guide to producing national health accounts with special applications for low-income and middle-income countries (9) have been followed, which consider these expenditures as health-related and hence have not been included in THE. Inability to exclude these has sometimes led to publication of overestimated ratios of THE to GDP. Availability of new information and subsequent adjustment have then produced lower �gures than previously reported. External resources in these Annex Tables are treated differently from the Rest of the World (ROW) resources under the OECD System of Health Accounts. Under OECD, ROW funds are classi�ed under sources of �nancing (same as �nancing agents under statistical annex explanatory notes 163 NHA categories) and include only grants passing through the countries. These tables also report expenditure on health by parastatal institutions as public, while others include it as private. In some cases, expenditures reported under the government �nance classi�ca- tion are limited to those of the ministry of health rather than all expenditures on health regardless of source. In such cases, wherever possible, other series have been estimated to supplement that source. GGHE and, therefore, the �gures for THE, may sometimes be an underestimate in the cases when it has not been possible to obtain data for local government, nongovernmental organizations, other ministries and insurance expenditures. The IMF International �nancial statistics provides central government disburse- ment (CGD) which approximates GGE in many developing countries without au- tonomous local taxing power. The CGD �gures have been complemented whenever possible by data for local/municipal governments as well as some social security payments for health. Several public �nance audits, executed budgets, budget plans, statistical yearbooks, web sites, World Bank and Regional Development Bank re- ports, and academic studies have been consulted to verify GGE. The entries are not always a continuous time series for all countries, leading to a more thorough search for the relevant national publications to triangulate and complete the information. Also, previous time series have been updated when bench- marking revisions or changes in methodology to estimate particular items, especially out-of-pocket expenditures, for an extensive HA reconstruction are undertaken. Changes in ratios will occur when estimates of GDP are made using the current System of national accounts SNA93 instead of the 1968 version (SNA68). Several quality checks have been used to assess the validity of the data. The data are triangulated with information from different sources and with the macro data available from the country to obtain the best estimates. For example, the aggregate government health expenditure data are compared with total GGE, or out-of-pocket expenditure is compared with total or household private consumption expenditure. Furthermore, estimated expenditure on health is compared against inpatient care ex- penditure, pharmaceutical expenditure data and other records (including programme administration) to ensure that the outlays for which details have been compiled con- stitute the bulk of the government and private expenditure on health. The estimates obtained are thus plausible in terms of a system’s description. ANNEX TABLE 3 Annex Table 3 (Annex Table 6 in last year’s report) presents total expenditure on health and general government expenditure on health in per capita terms. The meth- odology and sources to derive THE and GGHE are those discussed in the notes to Annex Table 2. Ratios are represented in per capita terms by dividing the expenditure �gures by population �gures. The per capita �gures are expressed in US dollars at an average exchange rate (the observed annual average or year end number of units at which a currency is traded in the banking system). The per capita values in local currency units are also presented in international dollar estimates, derived by dividing these by an estimate of their purchasing power parity (PPP) compared with US dollars, i.e. a rate or measure that minimizes the consequences of differences in price levels existing between countries. OECD health data is the major source for population estimates for the 30 OECD Member countries, just as it is for other health expenditure and macroeconomic vari- 164 The World Health Report 2006 ables. All estimates of population size and structure, other than for OECD countries, are based on demographic assessments prepared by the United Nations Population Division (1). The estimates are of de facto population, and not the de jure population, in each Member State. The exchange rates have mainly been obtained from the IMF International �nancial statistics. For remaining countries, United Nations, World Bank, and Asian Development Bank reports have been used. While of�cial rates are mostly used, market exchange rates sometimes have also been used. Further, complete change in currency in a particular year have at times led to a revision of the full series. For OECD Member countries, the OECD PPP has been used to calculate interna- tional dollars. For European and central Asian countries that are part of the UNECE but are not members of OECD, the UNECE PPPs are used. For non-European and non- OECD countries, international dollars have been estimated by WHO using methods similar to those used by the World Bank. ANNEX TABLE 4 Human resources for health are de�ned as “the stock of all individuals engaged in the promotion, protection or improvement of population health� (19). However, for the purpose of the report, we focus only on paid activities, and divide the health workforce into two main groups: “health service providers� and “health management and support workers� (see Chapter 1). The indicators needed to describe the characteristics of the health workforce and monitor its development over time are often generated from a multitude of sources and cover many areas (such as profession, training level and industry of employ- ment). The data used in Annex Table 4 were compiled from four major sources: establishment surveys, household and labour force surveys, population and housing censuses and records from professional and administrative sources. The diversity of sources meant that harmonization had to be undertaken to arrive at comparable estimates of the health workforce for each Member State. The harmonization pro- cess was based on internationally standardized classi�cation systems, mainly the International Standard Classi�cation of Occupations (ISCO), but also the International Standard Classi�cation of Education (ISCED) and the International Standard Indus- trial Classi�cation of all Economic Activities (ISIC). Some dif�culties in harmonizing data based on a variety of de�nitions and clas- si�cation systems could not be solved through the application of the ISCO. For ex- ample, in order to include country-speci�c types of workers, many ministries of health apply their own national classi�cation system. Community health workers and traditional birth attendants are not captured through the standard ISCO system, but sometimes account for up to a third of the health workforce and form an important part of the infrastructure for service delivery. Therefore, for the purposes of this report, we have kept community health workers and traditional birth attendants as a separate group, whereas most of the country speci�c cadres were mapped with the common ISCO classi�cation. The following occupational categories are used in Annex Table 4: Physicians – includes generalists and specialists. Nurses – includes professional nurses (and midwives), auxiliary nurses and en- rolled nurses, and other nurses such as dental nurses or primary care nurses. Midwives – includes auxiliary midwives and enrolled midwives. Does not include traditional birth attendants, who are counted as community health workers. While statistical annex explanatory notes 165 much effort has been made, caution needs to be exercised in using the data for nurses and midwives; for some countries the available information does not clearly distinguish between the two groups. Dentists – includes dentists, dental assistants and dental technicians. Pharmacists – includes pharmacists, pharmaceutical assistants and pharma- ceutical technicians. Lab workers – includes laboratory scientists, laboratory assistants, laboratory technicians and radiographers. Environment and public health professionals – includes environmental and public health of�cers, sanitarians, hygienists, environmental and public health techni- cians, district health of�cers, malaria technicians, meat inspectors, public health supervisors and similar professions. Community health workers – includes traditional medicine practitioners, faith healers, assistant/community health education workers, community health of�c- ers, family health workers, lady health visitors, health extension package work- ers, community midwives, and traditional birth attendants. Other health workers – includes a large number of occupations, such as clinical of�cers, dieticians and nutritionists, medical assistants, occupational thera- pists, operators of medical and dentistry equipment, optometrists and opticians, physiotherapists, podiatrists, prosthetic/orthetic engineers, psychologists, respi- ratory therapists, respiratory therapy technicians, speech pathologists, trainees and interns. Health management and support workers – includes general managers, stat- isticians, teaching professionals, lawyers, accountants, medical secretaries, gardeners, computer technicians, ambulance staff, cleaning staff, building and engineering staff, skilled administrative staff and general support staff. Apart from questions concerning the harmonization of health workforce catego- ries, an additional challenge was the triangulation of various data from different sources. Generally, when data were available from more than one source, we opted for the census as a �rst choice as it provides information on both “health service pro- viders� and “health management and support workers�. However, not many recent censuses with suf�ciently detailed ISCO coding were both available and accessible. In the present data set, a total of 12 countries fall into this category: Australia, Bolivia, Brazil, Costa Rica, Honduras, Mexico, Mongolia, New Zealand, Panama, Paraguay, Thailand and Turkmenistan. For a further three, namely Estonia, the United Kingdom and the United States, the data presented in Annex Table 4 were from representative labour force or household surveys: collected in the Luxemburg Income (or Employment) Study (http://www.lisproject.org/). These surveys were as detailed as census data in terms of the occupation categories they provide and at the same time were based on ISCO classi�cation system (in the case of Estonia) or we mapped them to corresponding ISCO codes (in the cases of the UK and US surveys). For all countries in the African Region as well as for a large number of countries in South-East Asia and the Eastern Mediterranean Region, the data presented in Annex Table 4 were obtained through a special survey developed by WHO and executed through its regional and country of�ces. As much as possible, the survey attempted to obtain information on both “health service providers� and “health management and support workers� and used the ISCO system, while maintaining some country- speci�c classi�cations for selected types of occupations (23). The following is a list of countries in which the survey was implemented: 166 The World Health Report 2006 Algeria, Bahrain, Bangladesh, Benin, Bhutan, Botswana, Burkina Faso, Bu- rundi, Cameroon, Cape Verde, Central African Republic, Chad, Comoros, Congo, Côte d’Ivoire, Democratic People’s Republic of Korea, Democratic Republic of the Congo, Djibouti, Egypt, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, India, Indonesia, Iraq, the Islamic Republic of Iran, Jordan, Kenya, Lebanon, Lesotho, Liberia, Madagascar, Malawi, Maldives, Mali, Mauritania, Mauritius, Morocco, Mozambique, Myanmar, Namibia, Nepal, Niger, Nigeria, Oman, Pakistan, Rwanda, Sao Tome and Principe, Saudi Arabia, Senegal, Seychelles, Si- erra Leone, South Africa, Sri Lanka, Sudan, Swaziland, Timor-Leste, Togo, Tunisia, Uganda, United Republic of Tanzania, Yemen, Zambia, Zimbabwe. For the following countries, data were obtained from miscellaneous sources, namely records of the departments of health, lists maintained by public service commissions or other administrative sources: Argentina, Belize, Brunei, Cambodia, Chile, China, Colombia, Cook Islands, Cuba, Dominican Republic, Ecuador, El Salvador, Fiji, Finland, Jamaica, Malaysia, Nicaragua, Uruguay, Venezuela, Papua New Guinea, Philippines, Tonga, Tuvalu, Viet Nam. For the remaining countries, the required data were compiled from the OECD health data, the European health for all database (http://data.euro.who.int/hfadb/in- dex.php) or the previous version of WHO’s Global database on the health workforce. These data were the least detailed of all, containing information on only four to �ve occupations and almost always containing no information on health management and support workers. The countries for which data was obtained from these sources are the following: Afghanistan, Albania, Andorra, Angola, Antigua and Barbuda, Armenia, Austria, Azerbaijan, Bahamas, Barbados, Belarus, Belgium, Bosnia and Herzegovina, Canada, Croatia, Cyprus, Czech Republic, Denmark, Dominica, France, Georgia, Ger- many, Greece, Grenada, Guatemala, Guyana, Haiti, Hungary, Iceland, Ireland, Israel, Italy, Japan, Kazakhstan, Kiribati, Kuwait, Kyrgyzstan, Lao People’s Democratic Re- public, Latvia, Libya, Lithuania, Luxembourg, Malta, Marshall Islands, Micronesia (Federated States of), Moldova, Monaco, Nauru, Netherlands, Niue, Norway, Palau, Peru, Poland, Portugal, Qatar, Republic of Korea, Romania, Russian Federation, Samoa, San Marino, Serbia and Montenegro, Slovak Republic, Slovenia, Solomon Islands, Somalia, Spain, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Suriname, Sweden, Switzerland, Syrian Arab Republic, Tajikistan, The Former Yugoslav Republic of Macedonia, Trinidad and Tobago, Turkey, Ukraine, United Arab Emirates, Uzbekistan, Vanuatu. The table provides the best �gures that were available to WHO up to January 2006 for each of the 192 Member States. Any subsequent updates will be made available on the WHO Global atlas for the health workforce web site (www.who. int/globalatlas/autologin/hrh_login.asp). statistical annex explanatory notes 167 REFERENCES 1. United Nations Population Division. World population prospects – the 2004 revision. New York, NY, United Nations, 2005. 2. WHO mortality database. Geneva, World Health Organization, 2006. 3. Child Mortality Coordination Group. Tracking progress in the Millennium Development Goals: towards a consensus about child mortality levels and trend. Bulletin of the World Health Organization, 2006, 84:225–232. 4. Murray CJL, Ferguson BD, Lopez AD, Guillot M, Salomon JA, Ahmad O. Modi�ed logit life table system: principles, empirical validation and application. Population Studies, 2003. 57:1–18. 5. Lopez AD, Ahmad O, Guillot M, Ferguson B, Salomon J, Murray CJL et al. World mortality in 2000: life tables for 191 countries. Geneva, World Health Organization, 2002. 6. Mathers CD, Ma Fat D, Inoue M, Rao C, Lopez AD. Counting the dead and what they died of: an assessment of the global status of cause-of-death data. Bulletin of the World Health Organization, 2005, 83:171–177. 7. Hill K, Pande R, Mahy M, Jones G. Trends in child mortality in the developing world: 1990 to 1996. New York, NY, United Nations Children’s Fund, 1998. 8. Mathers CD, Bernard C, Iburg KM, Inoue M, Ma Fat D, Shibuya K. Global burden of disease in 2002: data sources, methods and results. Geneva, World Health Organization, 2003 (GPE Discussion Paper No. 54). 9. WHO/World Bank/United States Agency for International Development. Guide to producing national health accounts with special applications for low-income and middle- income countries. Geneva, World Health Organization, 2003 (http://whqlibdoc.who. int/publications/2003/9241546077.pdf, accessed 20 February 2006). 10. A system of health accounts. Paris, Organisation for Economic Co-operation and Development, 2000 (http://www.oecd.org/dataoecd/41/4/1841456.pdf, accessed 20 February 2006). 11. Organisation for Economic Co-operation and Development/International Monetary Fund/World Bank/United Nations/Eurostat. System of national accounts 1993. New York, NY, United Nations, 1994. 12. Government �nance statistics yearbook, 2004. Washington, DC, International Monetary Fund, 2004. 13. International �nancial statistics yearbook, 2005. Washington, DC, International Monetary Fund, 2005. 14. International Financial Statistics, 2005, November. 15. ADB Key indicators 2003. Manila, Asian Development Bank, 2004. 16. OECD health data 2004. Paris, Organisation for Economic Co-operation and Development 2004. 17. International development statistics 2004. Organisation for Economic Co-operation and Development, Development Assistance Committee, 2004. 18. National accounts statistics: main aggregates and detailed tables, 2001. New York, NY, United Nations, 2004. 19. The world health report 2000 – Health systems: improving performance. Geneva, World Health Organization, 2000. 20. Diallo K, Zurn P, Gupta N, Dal Poz M. Monitoring and evaluation of human resources for health: an international perspective. Human Resources for Health, 2003, 1:3. 21. Gupta N, Zurn P, Diallo K, Dal Poz MR. Uses of population census data for monitoring geographical imbalance in the health workforce: snapshots from three developing countries. International Journal for Equity in Health, 2003, 2:11. 22. Hoffmann E, Dal Poz MR, Diallo K, Zurn P, Wiskow C. De�ning the scope of human resources in health, as basis for requesting national statistics. Geneva, International Labour Organization, World Health Organization, 2003 (Unpublished technical note; available at: http://www.who.int/hrh/documents/en/). 23. Dal Poz MR, Kinfu Y, Dräger S, Kunjumen T, Diallo K. Counting health workers: de�nitions, data, methods and global results. Geneva, World Health Organization, 2006 (background paper for The world health report 2006; available at: http://www.who. int/hrh/documents/en/). 168 The World Health Report 2006 Annex Table 1 Basic indicators for all Member States Figures computed by WHO to ensure comparability;a they are not necessarily the of�cial statistics of Member States, which may use alternative rigorous methods. POPULATION ESTIMATES LIFE EXPECTANCY PROBABILITY OF DYING AT BIRTH (YEARS) (PER 1000) Under age 5 years (under-5 mortality rateb) Annual Percentage Total growth Dependency of population Total population rate ratio aged 60+ fertility (000) (%) (per 100) years rate Both sexes Both sexes 1994– 2004 1994 2004 1994 2004 1994 2004 2004 Uncertainty 2004 Uncertainty Member State 2004 1 Afghanistan 28 574 3.9 96 97 4.6 4.4 8.0 7.4 42 30 – 53 257 179 – 333 2 Albania 3 112 –0.2 61 56 8.9 11.8 2.7 2.2 72 71 – 72 19 15 – 22 3 Algeria 32 358 1.6 79 54 5.7 6.4 3.7 2.5 71 69 – 72 40 33 – 47 4 Andorra 67 0.7 46 44 20.5 21.3 1.3 1.3 80 78 – 83 7 4 – 9 5 Angola 15 490 2.6 100 96 4.1 4.0 7.0 6.7 40 33 – 46 260 230 – 288 6 Antigua and Barbuda 81 1.7 62 55 9.1 10.5 2.5 2.3 72 71 – 74 12 6 – 18 7 Argentina 38 372 1.1 63 58 13.1 13.8 2.8 2.3 75 74 – 75 18 17 – 20 8 Armenia 3 026 –0.8 60 51 12.0 14.7 2.2 1.3 68 67 – 69 32 26 – 39 9 Australia 19 942 1.2 50 48 15.4 17.0 1.8 1.7 81 81 – 81 5 5 – 6 10 Austria 8 171 0.2 49 47 19.7 22.3 1.4 1.4 79 79 – 80 5 4 – 6 11 Azerbaijan 8 355 0.8 64 51 7.9 9.3 2.7 1.8 65 64 – 67 90 73 – 106 12 Bahamas 319 1.5 57 53 7.0 9.1 2.5 2.3 73 72 – 74 13 10 – 16 13 Bahrain 716 2.4 50 44 3.9 4.3 3.2 2.4 74 72 – 75 11 10 – 12 14 Bangladesh 139 215 2.0 76 65 5.1 5.6 3.9 3.2 62 61 – 64 77 70 – 84 15 Barbados 269 0.3 53 42 14.3 13.1 1.6 1.5 75 74 – 76 12 9 – 16 16 Belarus 9 811 –0.5 53 44 17.8 18.8 1.5 1.2 68 68 – 69 10 9 – 11 17 Belgium 10 400 0.3 51 52 21.2 22.2 1.6 1.7 78 78 – 79 5 4 – 5 18 Belize 264 2.4 88 71 5.9 5.9 4.2 3.1 68 67 – 70 39 29 – 48 19 Benin 8 177 3.2 98 89 4.3 4.3 6.5 5.7 53 46 – 58 152 137 – 167 20 Bhutan 2 116 2.2 89 77 6.3 6.9 5.4 4.2 63 56 – 69 80 64 – 96 21 Bolivia 9 009 2.1 81 75 6.2 6.7 4.7 3.8 65 58 – 71 69 62 – 75 22 Bosnia and 3 909 1.0 43 44 11.8 18.9 1.5 1.3 73 72 – 75 15 12 – 19 Herzegovina 23 Botswana 1 769 1.1 82 70 3.9 5.0 3.9 3.1 40 36 – 44 116 99 – 133 24 Brazil 183 913 1.5 61 52 7.1 8.7 2.5 2.3 70 70 – 71 34 29 – 39 25 Brunei Darussalam 366 2.4 56 49 4.2 4.6 3.0 2.4 77 76 – 78 9 7 – 10 26 Bulgaria 7 780 –0.7 50 45 21.0 22.3 1.4 1.2 72 72 – 73 15 14 – 16 27 Burkina Faso 12 822 3.0 104 101 4.9 4.3 7.1 6.6 48 41 – 53 192 173 – 211 28 Burundi 7 282 1.8 100 93 4.5 4.2 6.8 6.8 45 38 – 51 190 150 – 230 29 Cambodia 13 798 2.2 98 70 4.7 5.5 5.1 4.0 54 47 – 60 141 127 – 155 30 Cameroon 16 038 2.1 93 83 5.5 5.6 5.5 4.5 50 44 – 56 149 137 – 162 31 Canada 31 958 1.0 48 45 16.0 17.5 1.7 1.5 80 80 – 80 6 5 – 6 32 Cape Verde 495 2.4 105 80 6.4 5.7 4.7 3.6 70 65 – 73 36 29 – 44 33 Central African 3 986 1.8 89 89 6.1 6.1 5.5 4.9 41 35 – 47 193 162 – 224 Republic 34 Chad 9 448 3.3 98 101 5.1 4.7 6.7 6.7 46 39 – 52 200 168 – 231 35 Chile 16 124 1.3 57 50 9.4 11.3 2.5 2.0 77 77 – 77 9 8 – 10 36 China 1 315 409 0.8 48 42 9.2 10.8 1.9 1.7 72 71 – 73 31 29 – 33 37 Colombia 44 915 1.7 64 57 6.5 7.4 2.9 2.6 73 72 – 73 21 19 – 22 38 Comoros 777 2.8 93 81 4.0 4.3 5.7 4.7 64 57 – 71 70 56 – 85 39 Congo 3 883 3.2 97 100 4.8 4.5 6.3 6.3 54 48 – 61 108 81 – 134 40 Cook Islands 18 –0.9 71 65 6.4 7.5 3.1 2.6 72 71 – 73 21 19 – 22 41 Costa Rica 4 253 2.3 66 53 7.2 8.1 2.8 2.2 77 77 – 78 13 12 – 14 42 Côte d’Ivoire 17 872 2.2 94 83 4.5 5.2 6.1 4.9 44 37 – 50 194 155 – 235 43 Croatia 4 540 –0.3 47 49 19.2 21.9 1.5 1.3 75 75 – 76 7 6 – 8 44 Cuba 11 245 0.4 45 43 12.0 14.9 1.6 1.6 78 77 – 78 7 6 – 8 45 Cyprus 826 1.4 57 48 14.7 16.5 2.2 1.6 79 78 – 80 5 4 – 6 annex table 1 169 LIFE EXPECTANCY AT BIRTH (YEARS) PROBABILITY OF DYING (PER 1000) Under age 5 years (under-5 mortality rateb) Between ages 15 and 60 years (adult mortality rate) Males Females Males Females Males Females 2004 Uncertainty 2004 Uncertainty 2004 Uncertainty 2004 Uncertainty 2004 Uncertainty 2004 Uncertainty 1 42 31 – 52 42 29 – 55 258 183 – 338 256 176 – 328 509 311 – 760 448 212 – 716 2 69 68 – 69 74 73 – 75 19 15 – 22 18 15 – 22 171 158 – 185 96 82 – 111 3 69 68 – 71 72 70 – 73 41 33 – 48 39 32 – 46 153 138 – 167 124 109 – 140 4 77 74 – 80 83 81 – 85 7 4 – 10 6 4 – 9 108 73 – 143 46 34 – 67 5 38 32 – 44 42 34 – 49 276 246 – 305 243 215 – 270 591 458 – 754 504 324 – 697 6 70 69 – 71 75 74 – 76 14 6 – 20 10 6 – 16 191 168 – 212 120 107 – 134 7 71 71 – 71 78 78 – 79 20 19 – 22 16 15 – 18 173 168 – 179 90 87 – 94 8 65 64 – 66 72 71 – 73 34 27 – 41 30 25 – 36 248 215 – 286 111 94 – 130 9 78 78 – 79 83 83 – 83 6 5 – 7 5 4 – 5 86 83 – 88 50 48 – 52 10 76 76 – 77 82 82 – 82 5 5 – 6 5 4 – 6 114 111 – 117 55 53 – 57 11 63 62 – 64 68 67 – 69 94 75 – 112 85 70 – 99 205 178 – 233 113 97 – 134 12 70 69 – 71 76 75 – 77 14 11 – 17 12 9 – 14 256 238 – 274 145 135 – 155 13 73 71 – 74 75 73 – 76 11 10 – 12 11 10 – 12 112 98 – 127 82 67 – 97 14 62 60 – 63 63 61 – 64 81 74 – 89 73 66 – 79 251 223 – 282 258 233 – 283 15 71 70 – 72 78 78 – 79 12 9 – 15 13 9 – 16 191 173 – 211 105 94 – 116 16 63 62 – 63 74 74 – 75 11 10 – 12 9 7 – 10 377 358 – 396 135 124 – 147 17 75 75 – 76 81 81 – 82 5 5 – 6 4 4 – 5 122 119 – 125 65 63 – 67 18 65 63 – 68 72 71 – 73 44 34 – 56 33 25 – 40 243 204 – 290 135 122 – 151 19 52 46 – 58 53 46 – 59 152 137 – 166 153 137 – 167 388 252 – 551 350 224 – 528 20 62 56 – 68 65 57 – 71 80 63 – 95 80 64 – 96 255 114 – 418 196 92 – 365 21 63 56 – 70 66 59 – 72 70 63 – 76 68 62 – 74 248 106 – 426 184 87 – 346 22 70 68 – 71 77 76 – 78 17 13 – 21 14 10 – 17 188 160 – 216 88 76 – 101 23 40 37 – 43 40 36 – 44 123 106 – 141 109 92 – 125 786 717 – 839 770 698 – 826 24 67 67 – 67 74 73 – 74 38 32 – 43 31 26 – 35 237 228 – 246 127 118 – 135 25 76 74 – 77 78 78 – 79 10 8 – 11 8 6 – 9 107 89 – 125 81 70 – 93 26 69 69 – 69 76 76 – 76 17 15 – 18 13 12 – 14 217 213 – 220 92 90 – 95 27 47 41 – 52 48 40 – 55 193 175 – 213 191 171 – 209 472 351 – 631 410 256 – 600 28 42 36 – 49 47 39 – 54 196 154 – 237 184 146 – 223 593 450 – 737 457 317 – 616 29 51 45 – 56 58 50 – 64 154 138 – 169 127 115 – 140 430 293 – 580 276 154 – 466 30 50 45 – 55 51 44 – 57 156 143 – 170 143 130 – 155 444 316 – 582 432 305 – 586 31 78 78 – 78 83 82 – 83 6 6 – 6 5 5 – 6 91 89 – 93 57 55 – 58 32 67 62 – 71 71 68 – 75 38 30 – 45 35 28 – 42 209 127 – 322 139 85 – 212 33 40 35 – 46 41 35 – 48 201 169 – 233 185 155 – 214 667 530 – 781 624 490 – 745 34 45 38 – 51 48 40 – 54 212 177 – 245 188 158 – 217 497 370 – 669 422 286 – 601 35 74 73 – 74 81 80 – 81 10 9 – 11 9 8 – 9 133 125 – 144 66 63 – 69 36 70 70 – 71 74 73 – 74 27 25 – 29 36 33 – 39 158 148 – 167 99 90 – 108 37 68 68 – 69 77 77 – 78 24 21 – 26 17 16 – 19 226 216 – 237 93 86 – 100 38 62 55 – 69 67 59 – 73 76 61 – 92 64 51 – 77 254 109 – 433 182 87 – 352 39 53 47 – 60 55 48 – 62 113 85 – 140 103 78 – 127 442 297 – 586 390 259 – 524 40 70 69 – 71 75 74 – 75 24 23 – 25 17 16 – 18 158 141 – 178 104 95 – 114 41 75 75 – 76 80 79 – 80 14 13 – 15 11 10 – 13 124 119 – 128 71 68 – 75 42 41 35 – 47 47 41 – 53 225 181 – 271 162 128 – 196 585 462 – 733 500 376 – 634 43 72 72 – 72 79 79 – 79 8 7 – 9 7 5 – 8 160 156 – 164 66 63 – 69 44 75 75 – 76 80 79 – 80 8 7 – 9 7 6 – 8 131 123 – 139 85 81 – 89 45 77 76 – 78 82 80 – 83 5 4 – 6 5 4 – 7 94 84 – 104 47 38 – 56 170 The World Health Report 2006 Annex Table 1 Basic indicators for all Member States Figures computed by WHO to ensure comparability;a they are not necessarily the of�cial statistics of Member States, which may use alternative rigorous methods. POPULATION ESTIMATES LIFE EXPECTANCY PROBABILITY OF DYING AT BIRTH (YEARS) (PER 1000) Under age 5 years (under-5 mortality rateb) Annual Percentage Total growth Dependency of population Total population rate ratio aged 60+ fertility (000) (%) (per 100) years rate Both sexes Both sexes 1994– 2004 1994 2004 1994 2004 1994 2004 2004 Uncertainty 2004 Uncertainty Member State 2004 46 Czech Republic 10 229 –0.1 48 41 18.0 19.6 1.5 1.2 76 76 – 76 5 4 – 5 47 Democratic Korea People’s 22 384 0.8 47 47 7.9 10.9 2.2 2.0 66 58 – 74 55 30 – 81 Republic of 48 Democratic Republic of 55 853 2.5 99 100 4.4 4.3 6.7 6.7 44 38 – 51 205 176 – 235 the Congo 49 Denmark 5 414 0.4 48 51 20.0 20.7 1.8 1.8 78 77 – 78 5 4 – 6 50 Djibouti 779 2.7 86 81 4.1 4.6 6.0 4.9 56 49 – 62 126 106 – 144 51 Dominica 79 0.5 62 55 9.1 10.5 2.2 2.0 74 73 – 75 14 11 – 17 52 Dominican Republic 8 768 1.5 70 59 5.2 6.1 3.1 2.7 67 66 – 68 32 29 – 35 53 Ecuador 13 040 1.5 70 63 6.5 8.1 3.3 2.7 72 72 – 73 26 22 – 30 54 Egypt 72 642 1.9 77 63 6.4 7.1 3.8 3.2 68 67 – 68 36 33 – 40 55 El Salvador 6 762 2.0 74 66 6.8 7.5 3.4 2.8 71 70 – 72 28 24 – 32 56 Equatorial Guinea 492 2.4 89 93 6.3 6.0 5.9 5.9 43 37 – 50 204 177 – 232 57 Eritrea 4 232 3.3 93 89 4.0 3.9 6.1 5.4 60 53 – 67 82 74 – 91 58 Estonia 1 335 –1.0 52 47 18.9 21.5 1.5 1.4 72 71 – 73 8 6 – 11 59 Ethiopia 75 600 2.6 95 91 4.4 4.6 6.6 5.7 50 43 – 56 166 137 – 196 60 Fiji 841 1.0 65 56 5.0 6.2 3.3 2.9 69 67 – 70 20 18 – 22 61 Finland 5 235 0.3 50 50 18.8 20.9 1.8 1.7 79 79 – 79 4 4 – 5 62 France 60 257 0.4 53 53 20.3 20.9 1.7 1.9 80 79 – 80 5 4 – 5 63 Gabon 1 362 2.3 92 81 7.2 6.2 5.0 3.9 57 51 – 64 91 81 – 102 64 Gambia 1 478 3.2 84 79 5.2 5.9 5.5 4.6 57 50 – 63 122 105 – 140 65 Georgia 4 518 –1.3 53 50 15.9 18.0 1.8 1.4 74 71 – 75 45 40 – 49 66 Germany 82 645 0.2 46 49 20.6 24.8 1.3 1.3 79 79 – 79 5 5 – 5 67 Ghana 21 664 2.3 89 76 5.0 5.6 5.3 4.2 57 50 – 63 112 97 – 128 68 Greece 11 098 0.5 47 48 21.1 22.9 1.3 1.2 79 79 – 79 5 4 – 6 69 Grenada 102 0.3 62 55 9.1 10.5 2.6 2.4 68 67 – 69 21 16 – 27 70 Guatemala 12 295 2.3 95 91 5.6 6.1 5.3 4.5 68 67 – 69 45 40 – 50 71 Guinea 9 202 2.4 89 90 5.4 5.6 6.4 5.8 53 47 – 59 155 140 – 170 72 Guinea–Bissau 1 540 2.9 96 102 5.3 4.8 7.1 7.1 47 40 – 53 203 183 – 223 73 Guyana 750 0.3 64 53 6.9 7.3 2.5 2.2 63 59 – 67 64 35 – 94 74 Haiti 8 407 1.4 90 72 5.8 6.0 4.6 3.9 55 48 – 61 117 100 – 134 75 Honduras 7 048 2.6 89 77 4.7 5.5 4.7 3.6 67 64 – 71 41 37 – 45 76 Hungary 10 124 –0.2 48 45 19.3 20.5 1.6 1.3 73 72 – 73 8 7 – 9 77 Iceland 292 1.0 55 51 15.0 15.6 2.2 2.0 81 80 – 81 3 3 – 3 78 India 1 087 124 1.7 68 60 7.0 7.8 3.7 3.0 62 62 – 63 85 77 – 94 79 Indonesia 220 077 1.3 61 52 6.8 8.2 2.8 2.3 67 66 – 68 38 35 – 42 80 Iran, Islamic Republic 68 803 1.2 90 52 6.1 6.4 3.7 2.1 70 69 – 71 38 30 – 46 of 81 Iraq 28 057 3.0 88 79 4.6 4.5 5.6 4.7 55 50 – 61 125 75 – 177 82 Ireland 4 080 1.3 57 45 15.2 15.0 1.9 1.9 78 77 – 79 6 5 – 7 83 Israel 6 601 2.4 65 61 13.0 13.1 2.9 2.8 80 80 – 80 6 5 – 6 84 Italy 58 033 0.1 46 51 22.1 25.3 1.2 1.3 81 80 – 81 5 4 – 5 85 Jamaica 2 639 0.7 71 65 9.7 10.1 2.8 2.4 72 71 – 74 20 16 – 24 86 Japan 127 923 0.2 44 50 19.9 25.6 1.5 1.3 82 82 – 82 4 4 – 4 87 Jordan 5 561 3.1 80 69 4.2 5.0 4.9 3.4 71 70 – 72 27 23 – 30 88 Kazakhstan 14 839 –0.8 58 47 9.6 11.4 2.3 1.9 61 60 – 62 73 55 – 92 89 Kenya 33 467 2.4 98 84 4.2 4.1 5.2 5.0 51 45 – 56 120 109 – 131 90 Kiribati 97 2.2 69 60 5.8 6.5 4.6 4.1 65 64 – 66 65 55 – 75 annex table 1 171 LIFE EXPECTANCY AT BIRTH (YEARS) PROBABILITY OF DYING (PER 1000) Under age 5 years (under-5 mortality rateb) Between ages 15 and 60 years (adult mortality rate) Males Females Males Females Males Females 2004 Uncertainty 2004 Uncertainty 2004 Uncertainty 2004 Uncertainty 2004 Uncertainty 2004 Uncertainty 46 73 72 – 73 79 79 – 79 5 4 – 6 4 4 – 5 161 158 – 163 69 67 – 71 47 65 57 – 72 68 59 – 75 56 31 – 82 54 29 – 81 231 87 – 402 168 68 – 341 48 42 36 – 47 47 39 – 54 217 186 – 249 192 165 – 221 576 436 – 713 446 286 – 607 49 75 75 – 76 80 80 – 80 5 5 – 7 5 4 – 6 117 110 – 125 72 68 – 75 50 54 48 – 60 57 50 – 63 131 111 – 150 120 101 – 137 373 237 – 521 312 193 – 468 51 72 71 – 73 76 75 – 77 13 11 – 14 15 11 – 20 204 187 – 221 122 103 – 143 52 64 63 – 65 70 69 – 71 34 31 – 38 30 27 – 33 280 246 – 312 169 144 – 194 53 70 69 – 70 75 75 – 76 29 24 – 33 24 20 – 28 210 197 – 223 128 119 – 137 54 66 65 – 66 70 69 – 70 36 32 – 40 36 33 – 40 239 229 – 250 158 150 – 165 55 68 67 – 69 74 73 – 75 30 25 – 34 26 22 – 30 244 211 – 278 138 127 – 152 56 42 37 – 49 44 38 – 52 213 183 – 244 195 169 – 219 577 436 – 707 522 368 – 665 57 58 52 – 65 62 55 – 68 89 79 – 98 75 67 – 83 345 196 – 498 281 170 – 427 58 66 66 – 67 78 77 – 78 10 8 – 11 6 4 – 9 301 277 – 328 108 97 – 119 59 49 42 – 55 51 44 – 58 175 141 – 209 158 131 – 183 451 315 – 620 389 260 – 559 60 66 65 – 67 71 70 – 73 21 19 – 23 19 17 – 21 270 244 – 297 169 151 – 187 61 75 75 – 75 82 82 – 82 5 4 – 6 3 3 – 4 137 134 – 141 62 60 – 65 62 76 76 – 76 83 83 – 84 5 4 – 6 4 4 – 5 132 127 – 138 60 58 – 62 63 55 49 – 61 59 53 – 66 102 91 – 114 80 70 – 90 411 270 – 557 344 218 – 482 64 55 49 – 61 59 52 – 65 129 111 – 148 115 99 – 132 344 199 – 499 263 152 – 437 65 70 68 – 72 77 75 – 79 51 46 – 56 38 34 – 42 161 127 – 196 60 48 – 83 66 76 76 – 76 82 82 – 82 5 5 – 6 5 4 – 5 112 111 – 113 58 57 – 58 67 56 50 – 62 58 51 – 63 113 98 – 131 111 95 – 125 349 208 – 509 319 209 – 477 68 77 76 – 77 82 81 – 82 6 5 – 7 4 4 – 5 110 106 – 115 46 44 – 48 69 66 65 – 67 69 68 – 70 24 18 – 30 19 14 – 24 256 234 – 277 218 200 – 237 70 65 64 – 66 71 70 – 72 45 40 – 49 45 40 – 51 276 238 – 316 152 124 – 179 71 52 47 – 58 55 47 – 61 160 144 – 175 150 135 – 165 364 228 – 523 319 188 – 494 72 45 39 – 51 48 40 – 55 212 191 – 234 194 175 – 213 482 351 – 641 413 264 – 587 73 62 59 – 66 64 60 – 68 64 36 – 93 64 34 – 96 291 242 – 354 258 202 – 328 74 53 47 – 60 56 49 – 62 122 104 – 139 112 96 – 128 417 269 – 563 358 242 – 499 75 65 61 – 69 70 67 – 73 42 37 – 46 40 36 – 43 258 180 – 352 159 103 – 229 76 69 68 – 69 77 77 – 77 9 8 – 10 7 7 – 8 249 239 – 260 108 103 – 114 77 79 78 – 80 83 82 – 83 3 3 – 4 2 2 – 2 79 70 – 89 52 48 – 55 78 61 61 – 62 63 63 – 64 81 74 – 90 89 80 – 98 275 259 – 293 202 186 – 220 79 65 65 – 66 68 67 – 69 41 37 – 45 36 33 – 39 239 222 – 256 200 186 – 216 80 68 66 – 69 72 71 – 73 39 31 – 48 36 29 – 44 190 173 – 207 118 108 – 129 81 51 45 – 57 61 56 – 66 130 82 – 183 120 69 – 170 452 336 – 539 201 173 – 235 82 75 74 – 76 81 80 – 81 7 6 – 8 5 4 – 7 105 95 – 116 60 55 – 66 83 78 78 – 78 82 82 – 82 6 5 – 6 6 5 – 6 91 88 – 93 48 46 – 51 84 78 77 – 78 84 83 – 84 5 4 – 6 4 4 – 5 91 88 – 94 47 45 – 49 85 70 68 – 72 74 73 – 75 21 16 – 25 19 16 – 23 188 159 – 222 120 104 – 135 86 79 79 – 79 86 86 – 86 4 4 – 4 3 3 – 4 92 92 – 93 45 45 – 46 87 69 68 – 70 73 73 – 74 28 24 – 31 26 23 – 29 187 169 – 207 119 111 – 128 88 56 55 – 57 67 66 – 68 83 62 – 105 62 46 – 77 424 394 – 451 187 170 – 205 89 51 45 – 56 50 45 – 56 129 118 – 142 110 99 – 120 477 350 – 618 502 389 – 627 90 63 62 – 64 67 66 – 69 66 57 – 76 64 53 – 74 297 265 – 330 175 152 – 205 172 The World Health Report 2006 Annex Table 1 Basic indicators for all Member States Figures computed by WHO to ensure comparability;a they are not necessarily the of�cial statistics of Member States, which may use alternative rigorous methods. POPULATION ESTIMATES LIFE EXPECTANCY PROBABILITY OF DYING AT BIRTH (YEARS) (PER 1000) Under age 5 years (under-5 mortality rateb) Annual Percentage Total growth Dependency of population Total population rate ratio aged 60+ fertility (000) (%) (per 100) years rate Both sexes Both sexes 1994– 2004 1994 2004 1994 2004 1994 2004 2004 Uncertainty 2004 Uncertainty Member State 2004 91 Kuwait 2 606 4.1 48 36 2.1 3.0 3.0 2.3 77 76 – 79 12 9 – 15 92 Kyrgyzstan 5 204 1.4 76 62 8.0 7.7 3.4 2.6 63 63 – 64 68 54 – 82 93 Lao People’s 5 792 2.4 91 81 5.6 5.3 5.7 4.7 59 57 – 62 83 69 – 98 Democratic Republic 94 Latvia 2 318 –0.9 52 47 19.0 22.3 1.5 1.3 71 71 – 72 11 9 – 13 95 Lebanon 3 540 1.4 64 57 9.5 10.2 2.9 2.3 70 69 – 71 31 28 – 34 96 Lesotho 1 798 0.7 95 79 6.9 7.4 4.5 3.5 41 38 – 46 82 68 – 95 97 Liberia 3 241 4.6 97 97 3.9 3.7 6.9 6.8 42 34 – 49 235 191 – 279 98 Libyan Arab Jamahiriya 5 740 2.0 75 52 4.7 6.3 3.8 2.9 72 68 – 75 20 17 – 23 99 Lithuania 3 443 –0.6 51 48 17.3 20.5 1.7 1.3 72 72 – 72 10 8 – 11 100 Luxembourg 459 1.4 46 49 18.3 18.3 1.7 1.7 79 78 – 79 6 5 – 7 101 Madagascar 18 113 3.0 92 90 4.8 4.8 6.1 5.3 57 50 – 63 123 108 – 137 102 Malawi 12 608 2.4 91 101 4.7 4.6 6.7 6.0 41 37 – 46 175 159 – 191 103 Malaysia 24 894 2.3 66 59 5.9 6.8 3.5 2.8 72 71 – 72 12 11 – 14 104 Maldives 321 2.8 99 81 5.3 5.1 5.8 4.1 67 66 – 68 46 31 – 58 105 Mali 13 124 2.9 103 104 4.5 4.3 7.3 6.8 46 38 – 52 219 197 – 240 106 Malta 400 0.7 51 46 15.7 18.3 2.0 1.5 79 78 – 79 6 5 – 7 107 Marshall Islands 60 1.7 69 60 5.8 6.5 5.0 4.4 62 60 – 64 59 43 – 74 108 Mauritania 2 980 2.9 89 87 5.4 5.3 6.1 5.7 58 50 – 64 125 107 – 144 109 Mauritius 1 233 1.1 51 46 8.5 9.4 2.2 2.0 72 71 – 72 15 12 – 19 110 Mexico 105 699 1.5 69 58 6.2 7.6 3.0 2.3 74 74 – 74 28 27 – 28 111 Micronesia, Federated 110 0.4 89 74 5.6 4.9 4.7 4.3 70 68 – 72 23 16 – 30 States of 112 Monaco 35 1.1 53 53 20.3 20.9 1.7 1.8 82 80 – 83 4 3 – 6 113 Mongolia 2 614 1.0 77 54 5.8 5.7 3.1 2.4 65 64 – 66 52 42 – 64 114 Morocco 31 020 1.6 71 57 6.3 6.8 3.4 2.7 71 70 – 72 43 35 – 51 115 Mozambique 19 424 2.4 92 90 5.0 5.2 6.1 5.4 45 40 – 51 152 133 – 170 116 Myanmar 50 004 1.3 68 54 6.8 7.4 3.6 2.3 59 51 – 66 105 72 – 138 117 Namibia 2 009 2.3 91 84 5.1 5.2 5.5 3.8 54 49 – 58 63 53 – 75 118 Nauru 13 2.5 69 60 5.8 6.5 4.3 3.8 61 56 – 67 30 24 – 36 119 Nepal 26 591 2.3 83 76 5.4 5.7 4.8 3.6 61 60 – 62 76 68 – 84 120 Netherlands 16 226 0.5 46 48 17.7 18.9 1.6 1.7 79 79 – 79 5 5 – 6 121 New Zealand 3 989 1.0 53 51 15.4 16.5 2.0 2.0 80 79 – 80 6 5 – 7 122 Nicaragua 5 376 2.1 93 75 4.4 4.8 4.4 3.2 69 69 – 70 38 32 – 44 123 Niger 13 499 3.5 103 104 3.5 3.3 8.2 7.8 41 32 – 50 259 208 – 309 124 Nigeria 128 709 2.4 96 91 4.7 4.8 6.5 5.7 46 40 – 51 197 176 – 218 125 Niue 1 –2.1 71 65 6.4 7.5 3.4 2.8 71 68 – 73 36 36 – 36 126 Norway 4 598 0.6 55 53 20.2 19.8 1.9 1.8 80 79 – 80 4 4 – 5 127 Oman 2 534 1.8 76 60 3.1 4.0 6.0 3.6 74 70 – 77 13 11 – 14 128 Pakistan 154 794 2.3 90 74 5.5 5.8 5.5 4.1 62 60 – 64 101 86 – 116 129 Palau 20 1.6 69 60 5.8 6.5 1.6 1.4 68 67 – 69 27 20 – 35 130 Panama 3 175 2.0 63 58 7.4 8.6 2.8 2.7 76 75 – 76 24 21 – 26 131 Papua New Guinea 5 772 2.4 79 76 4.0 3.9 4.9 3.9 60 58 – 62 93 75 – 110 132 Paraguay 6 017 2.5 83 71 5.2 5.6 4.4 3.8 72 71 – 73 24 20 – 28 133 Peru 27 562 1.6 69 61 6.4 7.6 3.5 2.8 71 70 – 72 29 25 – 33 134 Philippines 81 617 2.0 75 65 5.1 6.0 4.0 3.1 68 68 – 69 34 29 – 39 135 Poland 38 559 0.0 52 42 15.6 16.7 1.8 1.2 75 75 – 75 8 7 – 8 annex table 1 173 LIFE EXPECTANCY AT BIRTH (YEARS) PROBABILITY OF DYING (PER 1000) Under age 5 years (under-5 mortality rateb) Between ages 15 and 60 years (adult mortality rate) Males Females Males Females Males Females 2004 Uncertainty 2004 Uncertainty 2004 Uncertainty 2004 Uncertainty 2004 Uncertainty 2004 Uncertainty 91 76 76 – 77 78 76 – 80 12 10 – 15 11 8 – 15 72 66 – 78 54 44 – 59 92 59 59 – 60 67 67 – 68 72 57 – 87 63 50 – 76 336 316 – 355 162 145 – 178 93 58 56 – 61 60 58 – 62 88 72 – 103 78 65 – 93 331 275 – 386 300 267 – 335 94 66 66 – 66 76 76 – 77 11 9 – 13 11 9 – 13 300 293 – 307 115 110 – 120 95 68 67 – 69 72 72 – 73 35 32 – 38 26 23 – 29 198 174 – 222 136 121 – 151 96 39 36 – 43 44 40 – 48 87 73 – 101 76 64 – 89 845 772 – 892 728 650 – 795 97 39 33 – 46 44 35 – 52 249 205 – 296 220 176 – 261 596 451 – 747 477 310 – 656 98 70 66 – 73 75 72 – 77 20 17 – 23 19 16 – 22 186 118 – 276 109 70 – 164 99 66 66 – 67 78 78 – 78 10 9 – 12 9 7 – 10 304 298 – 310 102 98 – 107 100 76 75 – 76 81 80 – 82 6 5 – 8 5 5 – 6 118 109 – 127 59 52 – 67 101 55 49 – 61 59 51 – 65 128 113 – 143 117 103 – 131 338 198 – 510 270 150 – 444 102 41 37 – 46 41 36 – 47 179 161 – 195 172 156 – 187 663 560 – 768 638 526 – 748 103 69 68 – 70 74 74 – 75 14 12 – 16 11 10 – 13 200 182 – 220 109 98 – 120 104 66 65 – 67 68 67 – 68 47 32 – 60 44 31 – 56 186 159 – 215 140 126 – 156 105 44 37 – 50 47 39 – 53 230 205 – 252 208 187 – 228 490 356 – 670 414 253 – 605 106 76 76 – 77 81 81 – 82 7 6 – 8 5 4 – 6 82 78 – 87 48 44 – 51 107 60 58 – 62 64 62 – 66 66 48 – 82 52 38 – 66 327 297 – 356 275 250 – 295 108 55 49 – 62 60 52 – 66 134 115 – 155 115 99 – 132 325 166 – 493 246 128 – 421 109 69 68 – 69 75 75 – 75 17 13 – 20 14 11 – 17 217 201 – 234 112 106 – 119 110 72 72 – 72 77 77 – 77 31 30 – 31 25 24 – 25 161 160 – 163 94 93 – 94 111 68 67 – 70 71 70 – 73 26 18 – 33 19 14 – 26 202 177 – 228 169 146 – 191 112 78 77 – 80 85 83 – 87 5 4 – 7 3 3 – 6 105 85 – 124 45 32 – 58 113 61 60 – 62 69 68 – 70 60 47 – 72 45 36 – 55 303 277 – 330 185 163 – 210 114 69 68 – 70 73 72 – 74 47 39 – 56 38 31 – 45 157 146 – 169 102 90 – 113 115 44 39 – 50 46 41 – 52 154 135 – 173 150 131 – 168 627 502 – 739 549 427 – 665 116 56 49 – 63 63 54 – 69 116 82 – 153 93 63 – 122 334 174 – 510 219 110 – 399 117 52 48 – 56 55 51 – 60 70 59 – 81 57 46 – 69 548 467 – 629 489 411 – 568 118 58 52 – 65 65 61 – 70 35 28 – 43 24 19 – 29 448 283 – 596 303 184 – 417 119 61 60 – 62 61 60 – 62 74 66 – 81 79 70 – 87 297 274 – 320 285 264 – 306 120 77 77 – 77 81 81 – 82 6 5 – 6 5 4 – 5 89 87 – 91 63 62 – 65 121 77 77 – 78 82 82 – 82 7 6 – 8 6 5 – 7 95 92 – 98 62 59 – 65 122 67 67 – 68 71 71 – 72 41 35 – 47 35 30 – 40 214 199 – 228 151 135 – 168 123 42 33 – 50 41 31 – 50 256 205 – 308 262 211 – 310 506 351 – 714 478 252 – 725 124 45 40 – 51 46 39 – 52 198 179 – 220 195 174 – 215 513 377 – 648 478 338 – 634 125 68 65 – 70 74 71 – 76 50 50 – 50 20 20 – 20 178 139 – 222 138 107 – 178 126 77 77 – 78 82 82 – 82 4 4 – 5 4 4 – 5 93 88 – 99 57 55 – 59 127 71 68 – 75 77 74 – 79 13 11 – 15 12 10 – 14 164 106 – 244 92 58 – 137 128 62 60 – 63 63 61 – 65 102 86 – 117 100 85 – 115 222 199 – 249 198 173 – 223 129 67 66 – 67 70 69 – 71 27 19 – 34 28 20 – 37 224 213 – 234 206 186 – 228 130 73 73 – 74 78 77 – 79 26 24 – 29 22 19 – 24 139 129 – 151 82 75 – 91 131 58 56 – 60 61 59 – 63 98 79 – 116 87 71 – 103 322 293 – 352 265 240 – 293 132 70 69 – 70 74 74 – 75 25 21 – 29 23 19 – 27 176 164 – 188 127 115 – 137 133 69 68 – 70 73 72 – 74 31 27 – 35 27 23 – 31 184 164 – 208 134 118 – 152 134 65 64 – 65 72 71 – 72 40 34 – 46 28 24 – 32 269 257 – 281 149 137 – 159 135 71 71 – 71 79 79 – 79 8 8 – 9 7 6 – 8 198 193 – 203 79 76 – 82 174 The World Health Report 2006 Annex Table 1 Basic indicators for all Member States Figures computed by WHO to ensure comparability;a they are not necessarily the of�cial statistics of Member States, which may use alternative rigorous methods. POPULATION ESTIMATES LIFE EXPECTANCY PROBABILITY OF DYING AT BIRTH (YEARS) (PER 1000) Under age 5 years (under-5 mortality rateb) Annual Percentage Total growth Dependency of population Total population rate ratio aged 60+ fertility (000) (%) (per 100) years rate Both sexes Both sexes 1994– 2004 1994 2004 1994 2004 1994 2004 2004 Uncertainty 2004 Uncertainty Member State 2004 136 Portugal 10 441 0.4 49 49 20.1 22.1 1.5 1.5 78 77 – 78 5 5 – 6 137 Qatar 777 4.2 39 31 2.2 2.6 3.9 2.9 76 74 – 78 12 9 – 15 138 Republic of Korea 47 645 0.7 42 39 8.9 13.3 1.7 1.2 77 77 – 76 6 5 – 6 139 Republic of Moldova 4 218 –0.3 56 41 13.0 13.7 1.9 1.2 67 67 – 68 28 21 – 35 140 Romania 21 790 –0.5 49 44 17.1 19.2 1.4 1.3 72 72 – 72 20 19 – 21 141 Russian Federation 143 899 –0.3 50 41 16.5 17.3 1.4 1.3 65 64 – 68 16 14 – 17 142 Rwanda 8 882 4.9 110 87 3.5 3.9 6.7 5.6 46 39 – 51 203 183 – 223 143 Saint Kitts and Nevis 42 0.5 62 55 9.1 10.5 2.6 2.4 71 70 – 71 21 18 – 25 144 Saint Lucia 159 0.9 75 58 9.4 9.8 3.0 2.2 74 73 – 75 14 13 – 17 145 Saint Vincent and the 118 0.5 78 57 8.6 8.9 2.7 2.2 69 68 – 70 22 18 – 27 Grenadines 146 Samoa 184 1.0 77 83 6.3 6.5 4.7 4.3 68 67 – 69 30 24 – 36 147 San Marino 28 0.9 46 51 22.1 25.3 1.2 1.2 82 80 – 83 4 4 – 4 148 Sao Tome and Principe 153 2.0 101 79 6.5 5.8 4.8 3.9 59 51 – 65 118 89 – 148 149 Saudi Arabia 23 950 2.8 78 68 3.4 4.5 5.4 3.9 71 67 – 74 27 20 – 34 150 Senegal 11 386 2.5 98 86 4.8 4.8 6.0 4.9 55 49 – 61 137 120 – 154 151 Serbia and Montenegro 10 510 0.0 50 48 16.8 18.4 1.9 1.6 73 72 – 73 15 13 – 16 152 Seychelles 80 0.7 51 46 8.5 9.4 2.4 2.1 72 71 – 73 14 10 – 17 153 Sierra Leone 5 336 2.6 83 86 5.6 5.5 6.5 6.5 39 29 – 46 283 241 – 327 154 Singapore 4 273 2.4 39 40 9.1 11.8 1.7 1.3 80 79 – 80 3 3 – 4 155 Slovakia 5 401 0.1 51 41 15.1 16.0 1.7 1.2 74 74 – 75 8 7 – 11 156 Slovenia 1 967 0.0 45 42 17.6 20.2 1.3 1.2 77 77 – 77 4 4 – 5 157 Solomon Islands 466 2.8 88 77 4.2 4.1 5.0 4.2 68 64 – 72 56 48 – 64 158 Somalia 7 964 2.3 87 88 4.3 4.2 6.7 6.3 44 37 – 51 225 203 – 247 159 South Africa 47 208 1.4 65 58 5.2 6.6 3.2 2.8 48 45 – 51 67 57 – 78 160 Spain 42 646 0.7 46 44 20.5 21.3 1.2 1.3 80 80 – 80 5 4 – 5 161 Sri Lanka 20 570 1.0 56 46 8.7 10.5 2.3 1.9 71 70 – 73 14 12 – 16 162 Sudan 35 523 2.2 83 76 5.0 5.6 5.2 4.3 58 51 – 64 91 82 – 101 163 Suriname 446 0.8 65 58 7.7 8.9 2.7 2.6 67 66 – 69 39 34 – 44 164 Swaziland 1 034 1.0 97 82 4.3 5.3 5.1 3.8 37 34 – 42 156 137 – 176 165 Sweden 9 008 0.2 57 54 22.1 23.0 1.9 1.7 81 80 – 81 4 3 – 4 166 Switzerland 7 240 0.4 47 48 19.2 21.4 1.5 1.4 81 81 – 81 5 4 – 6 167 Syrian Arab Republic 18 582 2.6 93 68 4.3 4.7 4.4 3.3 72 71 – 73 16 15 – 18 168 Tajikistan 6 430 1.2 91 77 5.9 5.2 4.7 3.7 63 61 – 66 118 84 – 147 169 Thailand 63 694 1.0 50 45 7.3 10.2 2.0 1.9 70 70 – 71 21 18 – 24 170 The former Yugoslav 2 030 0.4 50 45 13.0 15.3 1.9 1.5 72 72 – 73 14 13 – 15 Republic of Macedonia 171 Timor–Leste 887 0.5 78 80 3.7 5.0 4.6 7.8 63 56 – 69 80 69 – 92 172 Togo 5 988 3.2 95 88 4.7 4.8 6.1 5.2 54 48 – 59 140 122 – 157 173 Tonga 102 0.6 81 73 7.5 8.7 4.4 3.4 71 70 – 71 25 20 – 29 174 Trinidad and Tobago 1 301 0.4 60 41 8.8 10.5 1.9 1.6 70 69 – 71 20 17 – 23 175 Tunisia 9 995 1.2 68 49 7.9 8.6 2.8 1.9 72 71 – 73 25 23 – 28 176 Turkey 72 220 1.6 61 54 7.2 7.9 2.8 2.4 71 70 – 72 32 29 – 35 177 Turkmenistan 4 766 1.5 79 60 6.2 6.3 3.7 2.7 60 59 – 61 103 92 – 113 178 Tuvalu 10 0.6 71 65 6.4 7.5 4.4 3.7 61 58 – 64 51 37 – 64 179 Uganda 27 821 3.2 109 112 4.1 3.9 7.1 7.1 49 44 – 55 138 124 – 151 180 Ukraine 46 989 –1.0 52 45 18.3 21.0 1.5 1.1 67 67 – 68 18 16 – 20 annex table 1 175 LIFE EXPECTANCY AT BIRTH (YEARS) PROBABILITY OF DYING (PER 1000) Under age 5 years (under-5 mortality rateb) Between ages 15 and 60 years (adult mortality rate) Males Females Males Females Males Females 2004 Uncertainty 2004 Uncertainty 2004 Uncertainty 2004 Uncertainty 2004 Uncertainty 2004 Uncertainty 136 74 74 – 75 81 81 – 81 6 4 – 7 5 5 – 6 144 137 – 152 61 59 – 63 137 76 75 – 78 75 74 – 77 12 10 – 15 11 9 – 15 75 66 – 85 70 56 – 85 138 73 73 – 74 80 79 – 80 5 4 – 5 7 6 – 7 151 146 – 156 55 54 – 58 139 64 63 – 64 71 71 – 71 32 24 – 40 24 18 – 30 300 287 – 313 150 141 – 159 140 68 68 – 68 76 75 – 76 22 21 – 23 18 17 – 18 232 229 – 234 100 99 – 102 141 59 58 – 64 72 71 – 72 18 16 – 19 14 13 – 15 485 455 – 507 180 168 – 180 142 44 38 – 49 47 40 – 53 211 190 – 230 195 176 – 215 518 399 – 672 435 289 – 608 143 69 68 – 70 72 71 – 73 21 17 – 24 22 19 – 25 197 182 – 213 145 120 – 175 144 71 71 – 72 77 76 – 78 15 13 – 18 13 12 – 15 209 194 – 224 116 102 – 132 145 66 65 – 67 73 72 – 74 26 23 – 29 19 14 – 25 301 266 – 338 174 155 – 191 146 66 64 – 67 70 69 – 71 42 36 – 49 17 13 – 21 235 218 – 252 203 187 – 219 147 79 76 – 79 84 82 – 86 4 4 – 8 3 3 – 3 66 54 – 86 34 27 – 37 148 57 49 – 64 60 52 – 67 122 92 – 152 114 86 – 143 301 155 – 498 236 118 – 419 149 68 64 – 73 74 70 – 76 29 22 – 37 24 18 – 31 196 117 – 296 120 77 – 183 150 54 48 – 60 57 50 – 63 141 125 – 159 132 116 – 148 358 215 – 529 288 164 – 464 151 70 70 – 70 75 75 – 76 17 15 – 19 13 11 – 14 191 183 – 200 98 94 – 102 152 67 67 – 68 78 76 – 79 14 11 – 18 13 10 – 17 232 209 – 254 83 66 – 105 153 37 29 – 44 40 30 – 48 296 250 – 340 269 232 – 313 579 428 – 778 497 284 – 745 154 77 76 – 79 82 81 – 82 4 4 – 4 3 3 – 3 92 80 – 106 51 48 – 56 155 70 70 – 71 78 78 – 79 9 7 – 11 8 6 – 10 203 193 – 214 76 72 – 81 156 73 72 – 73 81 81 – 81 5 4 – 6 4 4 – 4 158 150 – 167 67 64 – 71 157 66 62 – 70 70 66 – 73 60 51 – 68 52 44 – 59 193 125 – 265 143 83 – 207 158 43 36 – 50 45 37 – 52 222 199 – 243 228 207 – 251 524 372 – 658 428 254 – 622 159 47 44 – 50 49 46 – 53 72 62 – 83 62 52 – 74 667 602 – 733 598 519 – 669 160 77 76 – 77 83 83 – 84 5 4 – 5 4 4 – 4 113 107 – 120 45 44 – 47 161 68 66 – 70 75 74 – 76 16 14 – 19 12 10 – 13 232 183 – 278 119 104 – 133 162 56 49 – 62 60 53 – 67 98 89 – 108 84 75 – 93 390 255 – 538 304 187 – 450 163 65 63 – 66 70 69 – 72 42 37 – 48 36 32 – 41 261 224 – 301 159 135 – 183 164 36 33 – 40 39 35 – 43 163 141 – 184 150 132 – 168 823 744 – 882 741 656 – 816 165 78 78 – 78 83 83 – 83 4 3 – 4 3 3 – 4 82 80 – 84 51 49 – 52 166 78 78 – 79 83 83 – 84 5 5 – 6 5 4 – 5 87 83 – 91 49 48 – 51 167 70 69 – 71 74 74 – 75 19 17 – 20 14 13 – 15 186 171 – 201 125 115 – 134 168 62 60 – 64 64 62 – 67 120 84 – 147 115 85 – 147 166 130 – 219 139 121 – 174 169 67 67 – 68 73 73 – 74 23 19 – 26 20 17 – 23 265 243 – 287 154 135 – 174 170 69 69 – 70 76 75 – 76 16 15 – 18 12 11 – 13 198 186 – 210 84 78 – 91 171 61 54 – 67 66 58 – 72 91 78 – 104 69 60 – 79 267 123 – 430 184 84 – 357 172 52 46 – 58 56 49 – 61 151 134 – 171 128 111 – 143 401 264 – 551 327 213 – 485 173 71 70 – 72 70 70 – 71 32 26 – 36 17 14 – 21 140 135 – 144 194 187 – 201 174 67 66 – 68 73 73 – 74 24 20 – 28 15 13 – 18 257 229 – 287 156 140 – 173 175 70 69 – 71 74 73 – 75 29 26 – 31 22 20 – 24 166 153 – 178 110 99 – 124 176 69 68 – 70 73 72 – 74 33 29 – 36 31 28 – 34 180 168 – 193 112 98 – 125 177 56 55 – 56 65 64 – 66 117 105 – 128 88 79 – 97 350 327 – 374 166 145 – 188 178 61 57 – 64 62 59 – 65 50 36 – 62 52 38 – 65 325 237 – 433 277 213 – 387 179 48 43 – 53 51 45 – 57 144 130 – 157 132 119 – 144 525 398 – 654 446 326 – 592 180 62 62 – 62 73 73 – 74 21 19 – 23 15 14 – 17 386 370 – 402 144 130 – 158 176 The World Health Report 2006 Annex Table 1 Basic indicators for all Member States Figures computed by WHO to ensure comparability;a they are not necessarily the of�cial statistics of Member States, which may use alternative rigorous methods. POPULATION ESTIMATES LIFE EXPECTANCY PROBABILITY OF DYING AT BIRTH (YEARS) (PER 1000) Under age 5 years (under-5 mortality rateb) Annual Percentage Total growth Dependency of population Total population rate ratio aged 60+ fertility (000) (%) (per 100) years rate Both sexes Both sexes 1994– 2004 1994 2004 1994 2004 1994 2004 2004 Uncertainty 2004 Uncertainty Member State 2004 181 United Arab Emirates 4 284 6.4 42 31 1.9 1.7 3.6 2.5 77 77 – 78 8 6 – 9 182 United Kingdom 59 479 0.3 54 52 20.9 21.0 1.8 1.7 79 79 – 79 6 5 – 6 183 United Republic of 37 627 2.3 92 86 4.5 5.0 5.8 4.9 48 46 – 51 126 116 – 136 Tanzania 184 United States of 295 410 1.0 53 50 16.3 16.5 2.0 2.0 78 77 – 78 8 7 – 8 America 185 Uruguay 3 439 0.7 60 60 16.9 17.4 2.5 2.3 75 75 – 76 14 13 – 15 186 Uzbekistan 26 209 1.5 81 63 6.3 6.3 3.6 2.7 66 65 – 67 69 62 – 75 187 Vanuatu 207 2.1 89 78 5.2 5.1 4.8 4.0 68 65 – 72 40 29 – 51 188 Venezuela, Bolivarian 26 282 2.0 68 58 6.1 7.4 3.1 2.7 75 74 – 75 19 17 – 20 Republic of 189 Viet Nam 83 123 1.5 74 56 7.4 7.5 3.0 2.3 71 70 – 72 23 20 – 26 190 Yemen 20 329 3.4 111 96 3.8 3.7 7.4 6.0 59 52 – 65 111 97 – 125 191 Zambia 11 479 2.1 98 96 4.3 4.6 6.3 5.5 40 36 – 45 182 162 – 204 192 Zimbabwe 12 936 1.1 92 79 4.6 5.4 4.5 3.4 36 33 – 39 129 115 – 146 a See explanatory notes for sources and methods. b Under-�ve mortality rate is the probability (expressed as per 1000 live births) of a child born in a speci�c year dying before reaching �ve years of age, if subjected to current age-speci�c mortality rate. annex table 1 177 LIFE EXPECTANCY AT BIRTH (YEARS) PROBABILITY OF DYING (PER 1000) Under age 5 years (under-5 mortality rateb) Between ages 15 and 60 years (adult mortality rate) Males Females Males Females Males Females 2004 Uncertainty 2004 Uncertainty 2004 Uncertainty 2004 Uncertainty 2004 Uncertainty 2004 Uncertainty 181 76 76 – 77 79 79 – 80 8 7 – 10 7 6 – 8 89 79 – 99 67 60 – 73 182 76 76 – 77 81 81 – 81 6 6 – 7 5 5 – 6 102 99 – 104 63 61 – 64 183 47 45 – 49 49 47 – 52 134 124 – 145 117 107 – 126 551 509 – 597 524 470 – 576 184 75 75 – 76 80 80 – 80 8 8 – 9 7 7 – 7 137 130 – 145 81 80 – 83 185 71 71 – 72 79 79 – 80 16 14 – 18 12 11 – 13 172 163 – 183 87 83 – 90 186 63 63 – 64 69 68 – 70 80 72 – 88 57 51 – 62 223 209 – 237 141 125 – 157 187 67 63 – 71 69 66 – 73 40 29 – 51 40 29 – 50 212 144 – 280 170 115 – 227 188 72 71 – 73 78 77 – 78 20 18 – 22 17 15 – 19 185 171 – 198 97 90 – 104 189 69 68 – 69 74 73 – 74 24 21 – 27 22 19 – 25 197 182 – 212 122 111 – 134 190 57 51 – 63 61 54 – 67 118 103 – 132 104 91 – 117 298 152 – 474 225 110 – 403 191 40 36 – 45 40 35 – 45 190 169 – 213 173 153 – 194 683 578 – 777 656 545 – 766 192 37 35 – 40 34 30 – 38 136 125 – 148 121 105 – 142 857 802 – 904 849 791 – 902 178 The World Health Report 2006 Annex Table 2 Selected indicators of health expenditure ratios, 1999–2003 Figures computed by WHO to assure comparability;a they are not necessarily the of�cial statistics of Member States. which may use alternative methods. General government expenditure on General government expenditure Total expenditure on health health as % of Private expenditure on health as % on health as % of total government as % of gross domestic product total expenditure on healthb of total expenditure on healthb expenditure Member State 1999 2000 2001 2002 2003 1999 2000 2001 2002 2003 1999 2000 2001 2002 2003 1999 2000 2001 2002 2003 Afghanistan 3.2 2.8 3.2 6.7 6.5 1.5 1.5 1.9 41.1 39.5 98.5 98.5 98.1 58.9 60.5 1.6 1.6 1.6 7.4 7.3 Albania 6.9 6.5 6.6 6.8 6.5 45.2 42.4 42.2 41.7 41.7 54.8 57.6 57.8 58.3 58.3 8.9 8.6 8.8 9 9.2 Algeria 3.7 3.5 3.8 4.2 4.1 71.9 73.3 77.4 78.9 80.8 28.1 26.7 22.6 21.1 19.2 9 9 9.5 9.6 10 Andorra 7.3 7.5 7 7.2 7.1 67.2 65.4 68.8 68.8 68.6 32.8 34.6 31.3 31.2 31.4 31.8 30.6 28.9 30.6 33.7 Angola 3.2 2.5 3.3 2.4 2.8 45.3 82.2 84.6 80.9 84.2 54.7 17.8 15.4 19.1 15.8 2.4 3.4 5.5 4.1 5.3 Antigua and 4.5 4.5 4.6 5.4 4.5 72.2 72 70.8 72.4 70.6 27.8 28 29.2 27.6 29.4 11.8 12.1 10.8 12.1 10.8 Barbuda Argentina 9.1 8.9 9.5 8.6 8.9 56.5 55.4 53.6 52.1 48.6 43.5 44.6 46.4 47.9 51.4 15 14.7 14.3 15.2 14.7 Armenia 6 6.3 6.5 5.8 6 22.9 15.2 20.5 20 20.2 77.1 84.8 79.5 80 79.8 5.1 3.9 5.7 5.3 5.4 Australia 8.7 9 9.2 9.3 9.5 69.5 68.9 67.8 68.1 67.5 30.5 31.1 32.2 31.9 32.5 16.9 16.8 16.9 17.7 17.7 Austria 7.6 7.5 7.4 7.5 7.5 67.7 68.1 67 67.8 67.6 32.3 31.9 33 32.2 32.4 9.7 10 9.8 10 10 Azerbaijan 4.7 4.1 3.9 3.7 3.6 21 21.3 22.3 21.5 23.8 79 78.7 77.7 78.5 76.2 4.2 4.2 4.3 2.9 2.8 Bahamas 6.6 6.5 6.5 6.5 6.4 46.8 47.2 47.5 48.6 47.5 53.2 52.8 52.5 51.4 52.5 14.4 14.3 13.6 14.6 13.9 Bahrain 4.7 3.9 4.2 4.2 4.1 69.2 67 67.6 67.8 69.2 30.8 33 32.4 32.2 30.8 11.2 10 10.1 8.7 8.8 Bangladesh 3.2 3.2 3.2 3.3 3.4 27.2 25.6 25.8 29.6 31.3 72.8 74.4 74.2 70.4 68.7 4.7 4.3 4.7 5.4 5.8 Barbados 6.1 6.2 6.7 6.9 6.9 65.4 65.8 67.6 68.4 69.4 34.6 34.2 32.4 31.6 30.6 12 12 12.2 12.3 11.1 Belarus 6.1 6.1 6.6 6.4 5.5 81 80.1 75.5 73.9 71.2 19 19.9 24.5 26.1 28.8 10.4 10.7 10.7 10.1 8.3 Belgium 8.5 8.5 8.7 8.9 9.4 69.4 69.3 70.8 70.3 67.2 30.6 30.7 29.2 29.7 32.8 11.8 12.1 12.5 12.5 12.4 Belize 4.8 4.5 4.8 4.6 4.5 48.6 48 45.1 47.4 49.3 51.4 52 54.9 52.6 50.7 5.5 5.3 5 5.3 5 Benin 4.8 4.7 5 4.7 4.4 43.8 44.5 46.9 43.5 43.1 56.2 55.5 53.1 56.5 56.9 11.1 10 9.8 8 9.8 Bhutan 4.5 4.2 5.2 3.6 3.1 88.5 87.7 89.8 85.2 83.5 11.5 12.3 10.2 14.8 16.5 8.7 7.2 11.2 8.3 7.6 Bolivia 6.2 6.1 6.4 6.6 6.7 58.1 60.1 59.3 62.8 64 41.9 39.9 40.7 37.2 36 10.5 9.9 10.4 11.6 11.9 Bosnia and 10.7 9.7 9.1 9 9.5 56.7 52 48.8 49.2 50.7 43.3 48 51.2 50.8 49.3 8.9 7.8 7.9 8.6 11.4 Herzegovina Botswana 5.2 5.4 4.8 5.1 5.6 54.3 57.2 50.4 54 58.2 45.7 42.8 49.6 46 41.8 6.7 7.4 6 6.4 7.5 Brazil 7.8 7.6 7.8 7.7 7.6 42.8 41 42.9 44.8 45.3 57.2 59 57.1 55.2 54.7 9.3 8.5 9.2 9.7 10.3 Brunei Darussalam 3.7 3.4 3.5 3.5 3.5 73.1 83.5 77 78.5 80 26.9 16.5 23 21.5 20 4.7 5.1 4.5 4.7 5.2 Bulgaria 6 6.2 7.2 7.9 7.5 65.4 59.2 56.1 56.6 54.5 34.6 40.8 43.9 43.4 45.5 9.8 8.6 9.6 11.3 10.1 Burkina Faso 5.4 5.2 5 5.4 5.6 44 42.4 39.5 44.2 46.8 56 57.6 60.5 55.8 53.2 10 9.4 10.5 12.8 12.7 Burundi 3 3.1 3.1 3.1 3.1 19.9 17.9 21.6 21 23.3 80.1 82.1 78.4 79 76.7 2.8 2 2.2 2 2 Cambodia 10.8 11 10.8 10.9 10.9 10.1 14.2 14.9 17.1 19.3 89.9 85.8 85.1 82.9 80.7 7.5 10.4 9.3 9.9 11.8 Cameroon 4.9 4.4 4.5 4.6 4.2 24.4 28 27.6 27.6 28.9 75.6 72 72.4 72.4 71.1 7.2 9.6 8 8.4 8 Canada 9 8.9 9.4 9.6 9.9 70.3 70.3 70.1 69.7 69.9 29.7 29.7 29.9 30.3 30.1 14.6 15.1 15.5 16.1 16.7 Cape Verde 4.5 4.6 5 5 4.6 73.9 73.5 75.8 75.1 73.2 26.1 26.5 24.2 24.9 26.8 9 9.6 12.4 11.1 11.1 Central African 3.6 4 3.9 4 4 38 41.1 38.6 41.2 38.6 62 58.9 61.4 58.8 61.4 6.7 10 11.5 11.2 12.4 Republic Chad 6.1 6.7 6.8 6.3 6.5 33.6 42 40.9 35.5 39.9 66.4 58 59.1 64.5 60.1 11.9 13.1 13.8 9.4 10.5 Chile 7.1 6.1 6.2 6.2 6.1 39 46.4 48.1 48 48.8 61 53.6 51.9 52 51.2 10 10.7 11.6 11.8 12.7 Chinac 4.9 5.1 5.2 5.5 5.6 40.9 38.3 35.6 35.8 36.2 59.1 61.7 64.4 64.2 63.8 12.5 11.1 9.5 9.4 9.7 Colombia 9.3 7.7 7.7 7.5 7.6 76.3 80.9 80.2 82.2 84.1 23.7 19.1 19.8 17.8 15.9 23.2 21.4 18.6 19 20.5 Comoros 3.2 2.7 2.3 2.9 2.7 60.8 54.9 47.7 58 54.1 39.2 45.1 52.3 42 45.9 10.5 9.5 5 6.4 6.4 Congo 2.4 1.8 2 1.9 2 63.8 66.5 67 66.9 64.2 36.2 33.5 33 33.1 35.8 4.9 4.8 4.2 3.7 4.3 Cook Islands 3.6 4 3.8 3.6 3.8 87.1 88 87.7 87 87.9 12.9 12 12.3 13 12.1 7.7 8.2 8.6 8.6 9.6 Costa Rica 6 6.3 6.8 7.2 7.3 78 79 78.5 79.6 78.8 22 21 21.5 20.4 21.2 21 21.7 21.4 22.2 22.8 Côte d’Ivoired 5.1 4.7 3.9 3.8 3.6 17.4 19.8 18.3 31.6 27.6 82.6 80.2 81.7 68.4 72.4 4.5 5.2 4.3 6.2 5 Croatia 8.7 9.3 8.4 7.8 7.8 86.3 86.8 85.8 82.8 83.6 13.7 13.2 14.2 17.2 16.4 13.7 14.9 14.2 13.2 13.8 Cuba 6.9 7 7.1 7.2 7.3 85.5 85.8 86 86.5 86.8 14.5 14.2 14 13.5 13.2 11.1 10.8 11.4 11.2 11.2 Cypruse 5.7 5.8 5.9 6.1 6.4 42.7 41.6 42.3 44.9 49.1 57.3 58.4 57.7 55.1 50.9 6.5 6.4 6.4 6.8 7 Czech Republic 6.6 6.6 6.9 7.2 7.5 91.5 91.4 91.4 91.1 90 8.5 8.6 8.6 8.9 10 14.1 14.3 13.9 13.9 12.7 Democratic People’s 4.8 5.9 5.8 5.8 5.8 89.2 91.4 91.2 91.3 91.2 10.8 8.6 8.8 8.7 8.8 6.8 8.1 7.8 7.5 7.3 Republic of Korea Democratic 3.2 3.7 3.1 3.3 4 7.7 5.3 6.8 13.1 18.3 92.3 94.7 93.2 86.9 81.7 2.6 2.6 4.7 4.2 5.4 Republic of Congo Denmark 8.5 8.4 8.6 8.8 9 82.2 82.4 82.7 82.9 83 17.8 17.6 17.3 17.1 17 12.5 12.6 13 13.2 13.5 Djibouti 5.1 5.4 5.3 5.5 5.7 65.2 65.7 64.7 65 66.9 34.8 34.3 35.3 35 33.1 10.2 10.7 11.6 10.8 10.5 Dominica 6.2 6.2 5.9 6.3 6.3 74.3 73.6 71.3 71.3 71.3 25.7 26.4 28.7 28.7 28.7 12.8 9.5 11.3 11.9 11.6 Dominican Republic 6 6.8 6.9 7.3 7 30.3 32.1 31.9 32.3 33.2 69.7 67.9 68.1 67.7 66.8 10.5 13.1 12 12.4 12.8 Ecuador 4.7 4.1 4.8 5 5.1 39.4 31.2 33.5 38.4 38.6 60.6 68.8 66.5 61.6 61.4 9.8 6.4 8.5 9.7 8.7 Egypt 5 5.2 5.4 5.9 5.8 33.9 36.5 39.9 42.7 42.6 66.1 63.5 60.1 57.3 57.4 5.6 6.3 7.1 8.4 8.2 El Salvador 8 8 7.7 8 8.1 43.5 45.1 42.4 44.7 46.1 56.5 54.9 57.6 55.3 53.9 25.1 25 21.2 22.8 22 annex table 2 179 Social security expenditure on health as % of External resources for health as % general government Out-of-pocket expenditure as % of Private prepaid plans as % of private of total expenditure on health expenditure on health private expenditure on health expenditure on health Member State 1999 2000 2001 2002 2003 1999 2000 2001 2002 2003 1999 2000 2001 2002 2003 1999 2000 2001 2002 2003 Afghanistan 3 3.2 4.2 46.8 45.6 0 0 0 0 0 98.2 98 97.3 75.9 76.5 0 0 0 0 0 Albania 6.8 8.6 4.9 3.7 3.4 19.2 16.7 18.1 20.3 25.1 99.7 99.8 99.8 99.8 99.8 0 0 0 0 0 Algeria 0.1 0.1 0.1 0 0 40.8 35.5 33.3 29.1 28.4 97 96.7 96 95.7 95.3 2.9 3.1 3.8 4.1 4.4 Andorra 0 0 0 0 0 87.5 88.1 86.2 88 89.2 77.9 77.5 70 70.6 71.1 19.9 20.3 26.7 26.5 26.3 Angola 5.7 17.5 16.7 8.3 6.7 0 0 0 0 0 100 100 100 100 100 0 0 0 0 0 Antigua and 3.8 3.8 3.4 1 2.2 0 0 0 0 0 100 100 100 100 100 n/a n/a n/a n/a n/a Barbuda Argentina 0.3 0.3 0.3 0.3 0.2 58.7 59.3 58.5 57.9 56.8 64 63.3 62.4 60.3 55.6 31.9 32.6 31.1 32.7 38.2 Armenia 19 13 21.9 22.2 17.2 0 0 0 0 0 82.2 91 79.6 79.4 80.6 n/a n/a 0.1 0.1 n/a Australia 0 0 0 0 0 0 0 0 0 0 62.5 65.2 65.9 67.6 67.8 21.8 21.9 23.7 23.3 23.9 Austria 0 0 0 0 0 63.5 64 65.4 65.5 65.8 62.9 63.8 58.9 59.8 59.2 22.9 23 22.9 23.6 23.5 Azerbaijan 1 2.1 4.1 1.9 1.9 0 0 0 0 0 96.3 96 96.1 96.2 96.8 n/a n/a n/a n/a n/a Bahamas 0 0 0.2 0.2 0.2 1.8 1.8 1.7 1.6 1.7 40.3 40.3 40.3 40.3 40.5 58.6 58.6 58.6 58.6 58.4 Bahrain 0 0 0 0 0 0.4 0.5 0.5 0.5 0.5 72.1 68.7 65.8 62.4 61.2 22.7 25.4 24.2 24.1 22 Bangladesh 12.2 12.9 13.3 12.9 12.4 0 0 0 0 0 88.8 86.5 86 85.9 85.8 0 0 0 0.1 0.1 Barbados 4.2 4 4.4 4.2 2.7 0 0 0 0 0 77.2 77.3 76.9 77.2 77.2 22.8 22.7 23.1 22.8 22.8 Belarus 0.1 0.1 0.2 0.1 n/a 3.8 4.1 3.7 3.9 6.1 70.2 70.4 74.7 79.7 80.5 0.6 0.3 0.1 0.2 0.2 Belgium 0 0 0 0 0 87.3 87.6 87.4 88.8 88.4 80.9 80.2 79.5 80.5 66.6 6.6 6.4 6.7 6.6 6 Belize 3.1 2.9 8.5 8 7.3 0 0 12.5 21.6 22.8 100 100 100 100 100 n/a n/a n/a n/a n/a Benin 14.6 16.8 12.2 8.5 11.5 n/a n/a n/a n/a n/a 91 91 90.6 90.3 90.3 8.4 8.4 8.7 9 9 Bhutan 32.5 31.2 45.7 23.9 18.6 0 0 0 0 0 100 100 100 100 100 0 0 0 0 0 Bolivia 5.7 6 7.1 7.4 7.3 60.9 62 65.2 65 65 83.8 81.6 77.9 78.9 79.3 5.5 8.1 12 10.8 10.6 Bosnia and 3.9 5.2 3 1.8 1.5 79 78 79 83.5 77.5 100 100 100 100 100 n/a n/a n/a n/a n/a Herzegovina Botswana 2.2 1.8 2.9 3.4 2.9 n/a n/a n/a n/a n/a 30.3 31.3 31.5 29.7 28.8 22.7 20.6 20 19.6 21.8 Brazil 0.5 0.5 0.5 0.5 0.3 0 0 0 0 0 67.1 64.9 64.1 64.2 64.2 32.9 35.1 35.9 35.8 35.8 Brunei Darussalam n/a n/a n/a n/a n/a 0 0 0 0 0 100 100 100 100 100 0 0 0 0 0 Bulgaria 0.5 2 1.5 1.3 1 9.9 13 35.8 40.6 51.6 99 99 99.2 98.4 98.4 0 0 0.1 0.9 0.9 Burkina Faso 10.2 9.9 10.1 7 7.4 0.3 0.8 1.2 0.7 1 98.1 98.1 98.1 98.1 98.1 0.9 0.9 0.9 0.9 0.9 Burundi 10.7 8 10.6 10.3 14.1 n/a n/a n/a n/a n/a 100 100 100 100 100 n/a n/a n/a n/a n/a Cambodia 13.4 18.8 19.7 11.5 18.5 0 0 0 0 0 90.1 85.4 84.6 85.2 86.2 0 0 0 0 0 Cameroon 5.2 6 6.9 2.3 3.2 0.1 0.1 0.1 0.1 0.1 94.2 93.3 93.4 93.6 98.3 n/a n/a n/a n/a n/a Canada 0 0 0 0 0 1.9 2 2 2 2.1 55 53.6 51.1 50.4 49.6 37.9 39 41.6 42.1 42.3 Cape Verde 8.4 13.5 15.1 15.2 10 36.9 36.1 35.1 33.6 35.5 99.7 99.6 99.5 99.8 99.7 0.3 0.4 0.5 0.2 0.3 Central African 20 20 15.4 13.4 2.9 n/a n/a n/a n/a n/a 95.1 95.5 95.5 95.5 95.3 n/a n/a n/a n/a n/a Republic Chad 29.1 36.6 33.8 17 11.8 n/a n/a n/a n/a n/a 96.7 96.5 96.6 96.5 96.3 0.3 0.4 0.4 0.4 0.4 Chile 0.1 0.1 0.1 0 0 77.2 31.1 31.6 32.2 32.1 60.6 47.1 48 47.3 46.2 39.4 52.9 52 52.7 53.8 Chinac 0.3 0.2 0.2 0.1 0.1 54.2 57.2 55.1 54.8 53.4 94.5 95.6 93.1 90 87.6 1.7 1 1.9 3.3 5.8 Colombia 0.3 0.3 0.2 0 0 63.2 60.2 66.3 63.9 66 72.4 59 59.1 55.9 47.2 27.6 41 40.9 44.1 52.8 Comoros 47.6 35.9 26.2 43 40.5 0 0 0 0 0 100 100 100 100 100 0 0 0 0 0 Congo 2.8 2.4 2.5 2.4 2.2 0 0 0 0 0 100 100 100 100 100 n/a n/a n/a n/a n/a Cook Islands 35.9 28.4 25.8 6.8 12.2 0 0 0 0 0 100 100 100 100 100 0 0 0 0 0 Costa Rica 1 1 1.9 1.6 2.7 90.7 89.6 87.5 88.4 88.6 97.5 97.4 97.8 97.8 88.7 2.5 2.6 2.2 2.2 2.1 Côte d’Ivoired 2.7 2.9 3.5 3.7 3.4 n/a n/a n/a n/a n/a 94 93.4 92.1 90.3 90.5 6 6.6 7.9 9.7 9.5 Croatia 0.9 1 1 1 0.6 97.5 97.6 97.7 97.9 96.1 100 100 100 100 100 0 0 0 0 0 Cuba 0.2 0.2 0.3 0.2 0.2 0 0 0 0 0 76 75.6 75.2 75.2 75.2 0 0 0 0 0 Cypruse 0 0 2.8 2.6 2.3 9.5 10.9 11.9 12.5 10.7 95.3 95.3 95.6 95.7 96 4.7 4.7 4.4 4.3 4 Czech Republic 0 0 0 0 0 89.4 89.4 90.4 87.4 85.4 100 100 100 93.6 83.9 0 0 0 2.5 2.5 Democratic People’s 0.2 0.2 0.3 17.3 19.1 0 0 0 0 0 100 100 100 100 100 0 0 0 0 0 Republic of Korea Democratic 6 4.9 6.6 12.7 15.1 0 0 0 0 0 100 100 100 100 100 n/a n/a n/a n/a n/a Republic of Congo Denmark 0 0 0 0 0 0 0 0 0 0 90.4 91 92 92.8 92.5 9.6 9 8 7.2 7.5 Djibouti 22.2 26.4 31.2 31.6 31.5 11.6 12.1 12 13.3 12.9 100 100 100 100 100 n/a n/a n/a n/a n/a Dominica 2.1 1.2 0.9 0.5 0.4 0 0 0 0 0 100 100 100 100 100 n/a n/a n/a n/a n/a Dominican Republic 3 2.2 1.5 2 1.5 20.3 22.4 20.5 19.9 17.4 80.4 77.4 73.3 70.6 70.8 9.4 12.8 17.3 20 20.7 Ecuador 3.2 4.1 1.8 1 0.9 31.7 28 32.2 32 31.9 84.2 85.3 87.6 88.4 88.1 5.4 4.8 3 2.3 2.2 Egypt 1.3 1.1 1.3 0.8 0.9 32.8 32.7 30.2 24.7 27.1 93.7 93.8 93.7 93.9 93.2 0.4 0.4 0.4 0.4 0.3 El Salvador 1.5 0.9 0.8 0.7 1 44 44.2 36.3 44.5 44.1 90.2 95.6 93.6 93.9 93.5 9.6 4.2 6.4 6.1 6.3 180 The World Health Report 2006 Annex Table 2 Selected indicators of health expenditure ratios, 1999–2003 Figures computed by WHO to assure comparability;a they are not necessarily the of�cial statistics of Member States. which may use alternative methods. General government expenditure on General government expenditure Total expenditure on health health as % of Private expenditure on health as % on health as % of total government as % of gross domestic product total expenditure on healthb of total expenditure on healthb expenditure Member State 1999 2000 2001 2002 2003 1999 2000 2001 2002 2003 1999 2000 2001 2002 2003 1999 2000 2001 2002 2003 Equatorial Guinea 2.8 2 1.7 1.8 1.5 60.8 67.6 70.2 72.2 67.5 39.2 32.4 29.8 27.8 32.5 9.9 11 10.1 8.8 7 Eritrea 3.8 4.5 4.6 4.5 4.4 70.3 66.9 59.2 50.9 45.5 29.7 33.1 40.8 49.1 54.5 2.9 4.4 4.6 3.9 4 Estonia 6 5.5 5.1 5 5.3 81 77.5 78.6 77.1 77.1 19 22.5 21.4 22.9 22.9 11.4 11.1 10.7 10.6 11.2 Ethiopia 5.4 5.7 5.8 6 5.9 53 54.6 53.2 56.9 58.4 47 45.4 46.8 43.1 41.6 8.9 9.3 10.5 9.9 9.6 Fiji 3.7 3.9 3.8 4.1 3.7 65.2 65.2 66.4 66.4 61.3 34.8 34.8 33.6 33.6 38.7 7.3 8.1 7.9 8.3 7.8 Finland 6.9 6.6 6.9 7.2 7.4 75.3 75.1 75.9 76.3 76.5 24.7 24.9 24.1 23.7 23.5 10 10.2 10.7 11 11.2 France 9.3 9.3 9.4 9.7 10.1 76 75.8 75.9 76.1 76.3 24 24.2 24.1 23.9 23.7 13.3 13.5 13.7 13.8 14.2 Gabon 4.5 4.2 4.2 4.4 4.4 68.4 73.1 73 69.8 66.6 31.6 26.9 27 30.2 33.4 10.9 13.9 9.9 10.7 12.8 Gambia 7 7.9 7.8 7.5 8.1 32.3 40.5 40.1 40.9 40 67.7 59.5 59.9 59.1 60 10 14.4 9.4 12 13.9 Georgia 2.9 4.3 4.4 4.5 4 35.4 28.4 30 28.8 23.9 64.6 71.6 70 71.2 76.1 4.8 6.4 6.6 6.6 4.7 Germany 10.6 10.6 10.8 10.9 11.1 78.5 78.6 78.4 78.6 78.2 21.5 21.4 21.6 21.4 21.8 17.1 18.2 17.4 17.6 17.6 Ghana 5.5 5.4 4.8 4.7 4.5 35.3 35.3 28.8 30.5 31.8 64.7 64.7 71.2 69.5 68.2 7.8 6.8 4.2 5.4 5 Greece 9.6 9.9 10.2 9.8 9.9 53.4 52.6 54.2 51.6 51.3 46.6 47.4 45.8 48.4 48.7 10.4 10 10.9 10.1 10.1 Grenada 5.5 7.2 7.6 7.1 6.7 73.3 74 77.9 72.9 73.6 26.7 26 22.1 27.1 26.4 14.7 13.2 15.1 10.7 12.4 Guatemala 4.7 5.5 5.4 5.2 5.4 48.3 39.8 38.1 36.9 39.7 51.7 60.2 61.9 63.1 60.3 17 16.2 15.4 14.1 15.3 Guinea 4.7 4.8 4.8 5.2 5.4 13.4 13.5 18.3 14.7 16.6 86.6 86.5 81.7 85.3 83.4 3.9 3.9 4.7 4.2 4.9 Guinea-Bissau 4.8 4.1 4.3 6.2 5.6 29.7 23.7 21.3 40.8 45.8 70.3 76.3 78.7 59.2 54.2 4.6 2.2 2.1 6.6 6.9 Guyana 4.3 5.5 5.3 5 4.8 82.8 84.5 82.6 83.1 82.6 17.2 15.5 17.4 16.9 17.4 8 10.8 12.3 12.2 11.6 Haiti 6.8 6.8 7.1 7.5 7.5 36.3 36 37.7 39.4 38.1 63.7 64 62.3 60.6 61.9 18.5 20.7 23.8 23.8 23.8 Honduras 5.7 6.4 6.5 6.9 7.1 50.8 55.9 54.7 55.3 56.5 49.2 44.1 45.3 44.7 43.5 12.2 15.1 14.1 15.6 16.8 Hungary 7.4 7.1 7.4 7.8 8.4 72.4 70.7 69 70.2 72.4 27.6 29.3 31 29.8 27.6 10.7 10.6 10.5 10.4 12.1 Iceland 9.4 9.3 9.3 10 10.5 83.6 82.6 82.7 83.2 83.5 16.4 17.4 17.3 16.8 16.5 18.1 17.8 17.5 18.2 18.3 India 5.1 5 5 4.9 4.8 24.6 24.6 24.2 23.7 24.8 75.4 75.4 75.8 76.3 75.2 4.5 4.3 4.2 3.9 3.9 Indonesia 2.6 2.5 3.1 3.2 3.1 30.4 28.1 35.6 34.5 35.9 69.6 71.9 64.4 65.5 64.1 3.8 3.5 4.7 5.1 5.1 Iran, Islamic 6.2 5.8 6.3 5.8 6.5 41.1 43.2 44.5 37.7 47.3 58.9 56.8 55.5 62.3 52.7 10.9 11.7 11.5 8 10.3 Republic of Iraqf 1.9 1.7 1.6 1.6 2.7 39.6 29.1 27.1 16.8 51.8 60.4 70.9 72.9 83.2 48.2 1.2 1.3 1.2 0.7 4.2 Ireland 6.2 6.2 6.8 7 7.3 73.7 73.9 75.3 77.5 78.9 26.3 26.1 24.7 22.5 21.1 13.4 14.6 15.4 16.3 17.2 Israel 8.6 8.6 9.2 9.3 8.9 69.5 67.9 67.7 67.2 68.2 30.5 32.1 32.3 32.8 31.8 11.3 11.5 11.6 11.4 11.4 Italy 7.7 8.1 8.2 8.4 8.4 72 73.5 75.8 75.4 75.1 28 26.5 24.2 24.6 24.9 11.4 12.6 12.7 13.1 12.8 Jamaica 5.4 6.2 5.4 4.9 5.3 50.3 52.6 45.7 51.1 50.6 49.7 47.4 54.3 48.9 49.4 5.6 6.6 4.3 4.5 4.5 Japan 7.4 7.6 7.8 7.9 7.9 81.1 81.3 81.7 81.5 81 18.9 18.7 18.3 18.5 19 15.9 16.1 16.9 16.8 16.8 Jordang 8.8 9.2 9.4 9.3 9.4 48 45.2 45.7 46.3 45.2 52 54.8 54.3 53.7 54.8 10.1 9.8 9.8 9.9 8.9 Kazakhstan 4.3 4.1 3.4 3.5 3.5 51.9 50.9 56.4 53.2 57.3 48.1 49.1 43.6 46.8 42.7 8.8 9.3 8.4 9 9 Kenya 4.6 4.3 4.2 4.5 4.3 41.1 46.5 42.8 44 38.7 58.9 53.5 57.2 56 61.3 4.1 11.1 8 9.2 7.2 Kiribati 7.6 10.7 11.5 11.3 13.1 98.9 99.1 99.2 99.1 92.4 1.1 0.9 0.8 0.9 7.6 6.8 9.8 10.5 10.4 7.8 Kuwait 3.6 3.1 3.6 3.9 3.5 77.2 78.2 77.7 78.1 77.5 22.8 21.8 22.3 21.9 22.5 6.4 8.8 6.2 6.6 6.1 Kyrgyzstan 4.9 4.4 4.5 5.1 5.3 48 46.8 43 41.3 40.8 52 53.2 57 58.7 59.2 7.8 8.2 8.7 8.7 9 Lao People’s 2.4 2.5 2.7 2.9 3.2 41.5 38.7 40.5 44.5 38.5 58.5 61.3 59.5 55.5 61.5 6 4.8 5.4 7.6 6.2 Democratic Republic Latvia 6.4 6 6.2 6.3 6.4 59 55 51.2 52.1 51.3 41 45 48.8 47.9 48.7 9.1 8.9 9.1 9.3 9.4 Lebanon 11.3 11.7 11.7 10.6 10.2 27.5 28.5 30.2 30.1 29.3 72.5 71.5 69.8 69.9 70.7 9.5 7.9 10.2 8.8 8.4 Lesotho 5.4 5.8 5.6 6.5 5.2 80.9 82.6 82 83.1 79.7 19.1 17.4 18 16.9 20.3 9.1 9.7 10.1 10.9 9.5 Liberia 6.3 4.8 4.1 3.9 4.7 67.7 57.7 50.3 47.7 56.7 32.3 42.3 49.7 52.3 43.3 18.1 13 12.4 10.5 17.6 Libyan Arab 3.6 3.2 5.5 5 4.1 50.7 58.1 73.2 65.5 62.9 49.3 41.9 26.8 34.5 37.1 5.5 6 9.2 7.9 5.9 Jamahiriya Lithuania 6.3 6.5 6.3 6.5 6.6 74.9 69.7 72.6 74.9 76 25.1 30.3 27.4 25.1 24 12.2 14.6 15.2 14.2 14.7 Luxembourg 6.2 6 6.3 7.1 6.8 89.8 90.3 90.8 91.1 90.8 10.2 9.7 9.2 8.9 9.2 13.4 14 14.7 14.8 13.7 Madagascar 2.2 2.1 1.9 2.8 2.7 53.7 53 64.7 63 63.4 46.3 47 35.3 37 36.6 6.9 6.5 7 11.4 9.3 Malawi 9.8 8.6 10.5 9.4 9.3 36.9 30.2 45.2 34 35.2 63.1 69.8 54.8 66 64.8 12.2 7.5 11.7 9.1 9.1 Malaysia 3.2 3.3 3.7 3.7 3.8 51.2 52.4 55.8 55.4 58.2 48.8 47.6 44.2 44.6 41.8 6.5 6.5 6.4 6.6 6.9 Maldives 5.6 5.9 6 5.8 6.2 85.2 86.9 87.5 87.7 89 14.8 13.1 12.5 12.3 11 13.2 13.7 13.8 13.3 13.8 Mali 4 4.7 4.3 4.5 4.8 42.9 49.5 50.1 52.6 57.4 57.1 50.5 49.9 47.4 42.6 6.6 8.5 8.2 9 9.2 Malta 7 8 8 9.1 9.3 75.6 76.5 77.8 79.7 80.1 24.4 23.5 22.2 20.3 19.9 11.9 14.2 13.8 15.3 15.5 Marshall Islands 15.9 14.7 12.4 12 13.1 97.2 96.9 96.3 96.3 96.7 2.8 3.1 3.7 3.7 3.3 17.9 13.7 12.1 11.5 14.4 Mauritania 2.7 2.5 2.9 3.9 4.2 64.2 63.3 67.9 74.2 76.8 35.8 36.7 32.1 25.8 23.2 8.6 6.5 6.8 9.2 14.3 Mauritius 3.1 3.3 3.5 3.6 3.7 62 58.7 60.5 60.7 60.8 38 41.3 39.5 39.3 39.2 7.2 6.6 9 9.4 9.2 Mexico 5.6 5.6 6 6 6.2 47.8 46.6 44.8 44.9 46.4 52.2 53.4 55.2 55.1 53.6 12.2 11.4 11.9 11.6 11.7 annex table 2 181 Social security expenditure on health as % of External resources for health as % general government Out-of-pocket expenditure as % of Private prepaid plans as % of private of total expenditure on health expenditure on health private expenditure on health expenditure on health Member State 1999 2000 2001 2002 2003 1999 2000 2001 2002 2003 1999 2000 2001 2002 2003 1999 2000 2001 2002 2003 Equatorial Guinea 9.2 7.7 5.9 3.6 5.5 0 0 0 0 0 91.8 83.9 81.3 80.5 80.5 0 0 0 0 0 Eritrea 20.2 30.6 24.1 22.5 19.6 0 0 0 0 0 100 100 100 100 100 0 0 0 0 0 Estonia 3.6 0.9 0 0 0.1 82.1 86 86.1 86 84.9 74.4 88.5 88.9 87.6 88.3 n/a n/a n/a n/a n/a Ethiopia 22.6 19.3 23.4 21.7 26 0.4 0.4 0.4 0.4 0.4 79.7 79.1 79.8 79.3 78.7 0.4 0.5 0.5 0.5 0.5 Fiji 11.1 10.9 10.3 5.7 13.4 0 0 0 0 0 100 100 100 100 100 0 0 0 0 0 Finland 0 0 0 0 0 19.8 20.4 20.8 21.1 21.5 82.2 82 81.8 81.7 81.2 10.8 10.5 10.4 10 10.2 France 0 0 0 0 0 96.7 96.6 96.5 96.6 96.7 43 43.4 43.3 42.5 42.2 52.6 52.2 52.5 53.2 53.5 Gabon 2.4 1 1.6 0.7 0.7 1.7 1.6 1.7 1.7 1.7 100 100 100 100 100 n/a n/a n/a n/a n/a Gambia 29.8 35.8 30.8 18.5 21.8 0 0 0 0 0 68.1 69.3 69.6 69.2 67 n/a n/a n/a n/a n/a Georgia 6.8 8.6 4.4 10.7 5.3 48.8 44 42.8 46.5 59.2 99.5 98.9 96.9 98.2 98.2 0.5 1.1 3.1 1.8 1.8 Germany 0 0 0 0 0 87.2 87.3 87.1 87.2 87.4 50.8 49.6 49.7 48.2 47.9 38 38.7 38.6 39.9 40.2 Ghana 6.4 12.8 20.7 14.4 15.8 n/a n/a n/a n/a n/a 100 100 100 100 100 0 0 0 0 0 Greece n/a n/a n/a n/a n/a 35.4 32.3 33.2 36.6 32 69.5 94.7 95.2 95 95.4 4.1 5.3 4.8 5 4.6 Grenada n/a n/a n/a 10.5 10.3 0 0 0 0 0 100 100 100 100 100 n/a n/a n/a n/a n/a Guatemala 2.4 3.4 2.5 2.2 3.8 54.8 52.3 51 52 50.5 85.6 89.7 90 90.5 91.9 5.4 4.2 4.2 4.2 3.9 Guinea 5.5 5.8 10.5 6.3 7.3 1.8 1.8 1.5 1.7 1.5 99.4 99.4 99.4 99.5 99.4 0 0 0 0 0 Guinea-Bissau 22.4 16 15.8 35.5 26.8 1.2 2.1 3 1.5 2.2 85.1 83.7 85.2 84.1 80.2 0 0 0 0 0 Guyana 4.5 2.9 2.2 2.6 3.2 0 0 0 0 0 100 100 100 100 100 n/a n/a n/a n/a n/a Haiti 27.3 27.9 23.6 15.6 12.4 0 0 0 0 0 68.9 68.9 71 69.5 69.5 n/a n/a n/a n/a n/a Honduras 13.1 8.8 6 7.2 9.3 16.6 14.3 14.2 12.9 11.6 85.6 85.4 85.4 85.5 85.8 7.2 7.3 7.2 7.2 7.1 Hungary 0 0 0 0 0.4 83.8 83.9 83.3 81.3 83.4 90 89.8 89.3 88.2 88.9 0.3 0.6 1 1.3 2.1 Iceland 0 0 0 0 0 26.8 29.2 28.2 32.5 36.5 100 100 100 100 100 0 0 0 0 0 India 1.2 2.2 2 1.3 1.6 4.4 4.4 4.4 4.4 4.2 96.6 96.4 96.3 96.2 97 0.6 0.7 0.8 0.9 0.9 Indonesia 8.5 7.3 2.8 1.8 1.4 6.8 6.8 8 9.9 9.9 73.6 72.2 75.1 75.3 74.3 5.1 4.7 4.1 5.1 5.4 Iran, Islamic 0 0.1 0.3 0.1 0.1 39.2 38 36.6 42.6 30.9 95.3 95 94.7 95 94.8 3.9 4.2 4.5 4.3 4.4 Republic of Iraqf 1 0.9 1.5 0.6 3.8 n/a n/a n/a n/a n/a 100 100 100 100 100 n/a n/a n/a n/a n/a Ireland 0 0 0 0 0 1.1 1.2 1 0.9 0.8 53 52 48.3 60.1 61.9 30.2 29.2 25.7 24.5 29.6 Israel 3.1 4.3 5.3 4.9 3.4 63.1 60.7 62.7 59.7 61.9 94.8 86 82.9 84.6 89.1 0 0 0 0 0 Italy 0 0 0 0 0 0.1 0.1 0.3 0.1 0.2 86.7 86.2 83.9 83.2 83.3 3.4 3.4 3.7 3.7 3.8 Jamaica 2.6 1.8 3.4 4.7 1.2 0 0 0 0 0 69.5 65 66.2 61.8 64.7 25.1 30 28.8 32.5 30.8 Japan 0 0 0 0 0 81.2 80.9 80.5 80.5 80.5 90.6 90.1 89.9 93.3 90.1 1.5 1.7 1.5 1.7 1.7 Jordang 6.3 5 5.2 3.4 4.2 0.8 0.9 0.7 0.7 0.7 73.5 74.7 74.5 73.9 74 5.3 5.5 7.3 7.4 8.1 Kazakhstan 0.8 0.7 0.7 0.8 1.2 0 0 0 0 0 100 100 100 100 100 n/a n/a n/a n/a n/a Kenya 13.3 13.2 17.2 16.4 15.3 16.7 11.7 14.8 9.2 10 79.3 80.1 80.5 80 82.6 7.4 7.1 6.8 6.9 6 Kiribati n/a 1.5 2.8 1.7 0.8 0 0 0 0 0 100 100 100 100 100 0 0 0 0 0 Kuwait 0 0 0 0 0 0 0 0 0 0 96.4 94.9 95 93.8 91.2 3.6 5.1 5 6.2 8.8 Kyrgyzstan 15.9 16.3 14.3 9.9 17.3 7.1 10.4 9.4 10.6 15.2 100 100 100 100 100 n/a n/a n/a n/a n/a Lao People’s 34.5 22.5 10.1 9.5 30 0.2 0.5 0.5 0.6 1 66.3 69.6 70.3 70.6 75.5 12.6 13 12.2 11.8 9.8 Democratic Republic Latvia 0.7 0.5 0.5 0.4 0.4 50.1 57 52 49.6 82.7 100 100 99.4 99.4 94.3 0 0 0.6 0.6 5.7 Lebanon 0.7 0.2 0.2 0.1 0.1 45.5 45.2 41.8 45.3 46 82.3 80.9 80.8 79.7 79.4 15.4 16.6 16.6 17.6 17.8 Lesotho 3.6 10.8 16.2 6.4 8.2 0 0 0 0 0 20 20 19.4 18.6 18.2 n/a n/a n/a n/a n/a Liberia 55.7 43.6 31.2 25.5 32.3 0 0 0 0 0 98.5 98.5 98.5 98.5 98.5 0 0 0 0 0 Libyan Arab 0 0 0 0 0 0 0 0 0 0 100 100 100 100 100 0 0 0 0 0 Jamahiriya Lithuania 0 1.7 1.6 1.5 1.3 89.8 88.3 84.3 76.7 74.6 99.6 86.2 97 98.2 96.6 0.1 0.3 0.2 0.5 0.5 Luxembourg 0 0 0 0 0 93.1 82.6 78.9 86 88.1 72 72.6 72.7 78.3 77.3 13.6 11.3 10.2 9.8 10 Madagascar 40.5 43.3 39.1 31.6 22 n/a n/a n/a n/a n/a 89.7 90.5 87.1 91.6 91.7 10.3 9.5 12.9 8.4 8.3 Malawi 26.1 18.5 31 23 25.1 0 0 0 0 0 42.3 41.7 42 42.5 42.7 1.7 1.6 1.7 1.6 1.6 Malaysia 1 0.8 0 0 0.1 0.6 0.6 0.8 0.8 0.8 75 75.4 73.5 73.6 73.8 12.2 11.9 14.1 14.2 13.7 Maldives 7.7 3.3 1.8 3.4 0.4 21.3 20.5 24.9 23.8 22.9 100 100 100 100 100 0 0 0 0 0 Mali 18.8 24.1 20.8 3.4 13.7 24 21.8 22.9 27.7 26 89.3 88.6 89.1 89.2 89.3 0 0 0 0 0 Malta 0 0 0 0 0 77.9 70 71 62.1 64.1 89.7 90.4 89.6 89.7 89.9 10.3 9.6 10.4 10.3 10.1 Marshall Islands 22.7 24.4 47.6 22.9 16.4 32.5 53.9 54.9 51.9 17.4 100 100 100 100 100 n/a n/a n/a n/a n/a Mauritania 5.5 5.7 4.9 2.5 4.7 0 0 0 0 0 100 100 100 100 100 0 0 0 0 0 Mauritius 1.2 1.1 1.6 1.4 1 6.5 7.8 8.3 8.3 8.7 100 100 100 100 100 n/a n/a n/a n/a n/a Mexico 1.2 1 0.9 0.8 0.4 69.1 67.6 66.3 66 66.9 95.9 95.3 95 94.6 94.2 4.1 4.7 5 5.4 5.8 182 The World Health Report 2006 Annex Table 2 Selected indicators of health expenditure ratios, 1999–2003 Figures computed by WHO to assure comparability;a they are not necessarily the of�cial statistics of Member States. which may use alternative methods. General government expenditure on General government expenditure Total expenditure on health health as % of Private expenditure on health as % on health as % of total government as % of gross domestic product total expenditure on healthb of total expenditure on healthb expenditure Member State 1999 2000 2001 2002 2003 1999 2000 2001 2002 2003 1999 2000 2001 2002 2003 1999 2000 2001 2002 2003 Micronesia, 6.8 6.5 6.5 6.4 6.4 88 86.8 87 88.2 88 12 13.2 13 11.8 12 7.9 8 8.9 8.8 8.8 Federated States of Monaco 9.3 9.4 9.4 9.2 9.7 69.4 70.7 71.9 73.1 75.9 30.6 29.3 28.1 26.9 24.1 11.6 14 13.6 14.3 17.5 Mongolia 5.4 7 7.3 6.7 6.7 73.3 65.9 66.3 69.8 63.8 26.7 34.1 33.7 30.2 36.2 10.9 10.6 10.6 11.5 10.3 Moroccoh 4.6 4.7 4.9 5 5.1 30.2 30.7 32.4 32.4 33.1 69.8 69.3 67.6 67.6 66.9 4.4 4.2 4.5 5.3 6 Mozambique 4.7 5.5 4.8 5.1 4.7 63 67.8 66.2 67.6 61.7 37 32.2 33.8 32.4 38.3 12.1 12.9 10.7 11.5 10.9 Myanmar 1.8 2.2 2.1 2.8 2.8 11 13.7 12.5 18.5 19.4 89 86.3 87.5 81.5 80.6 0.8 1.2 1.3 2.3 2.5 Namibia 7 7 6.4 5.9 6.4 73.3 68.9 69.4 68.6 70 26.7 31.1 30.6 31.4 30 13.1 12.3 11.1 11 12.4 Nauru 16 13.8 12.2 12.9 12.3 89.1 88.9 88.7 88.8 88.5 10.9 11.1 11.3 11.2 11.5 9.2 9.2 9.1 9.2 8.8 Nepal 5.1 4.9 5.4 5.6 5.3 25.4 24.9 31.4 32.2 27.8 74.6 75.1 68.6 67.8 72.2 7.4 7 8.7 9.5 7.9 Netherlands 8.4 8.3 8.7 9.3 9.8 62.7 63.1 62.8 62.5 62.4 37.3 36.9 37.2 37.5 37.6 11.2 11.5 11.5 12 12.4 New Zealand 7.7 7.8 7.9 8.2 8.1 77.5 78 76.4 77.9 78.3 22.5 22 23.6 22.1 21.7 14.9 15.6 16.1 17.3 17.2 Nicaragua 5.8 7.1 7.7 7.9 7.7 54 52.5 48.6 49.4 48.4 46 47.5 51.4 50.6 51.6 11.2 13.1 12.9 15.2 11.7 Niger 4.5 4.4 4.3 4.3 4.7 49.7 52.4 53.1 52.8 53 50.3 47.6 46.9 47.2 47 12.5 12.3 12 11.5 12.4 Nigeria 5.4 4.3 5.3 5 5 29.1 33.5 31.4 25.6 25.5 70.9 66.5 68.6 74.4 74.5 5.4 4.2 3.2 3.1 3.2 Niuei 8 7.7 38.2 10.3 9.7 97 96.8 99.4 98.5 98.4 3 3.2 0.6 1.5 1.6 6.7 6.1 30.6 8.9 9.3 Norway 9.4 8.5 8.9 9.9 10.3 82.6 82.5 83.6 83.5 83.7 17.4 17.5 16.4 16.5 16.3 16.1 16.4 16.7 17.4 17.6 Oman 3.6 3.1 3.1 3.3 3.2 83.2 81 82.2 82.8 83 16.8 19 17.8 17.2 17 7.9 7.3 6.8 7.2 7 Pakistan 3.7 2.8 2.6 2.6 2.4 32.6 33 32.3 34.7 27.7 67.4 67 67.7 65.3 72.3 4 3.4 3.4 3.1 2.6 Palau 9.5 9.9 9.7 9.4 9.7 88.5 89.1 89 87.3 86.7 11.5 10.9 11 12.7 13.3 13.9 14.8 13.3 11.8 15.2 Panamaj 6.9 7.8 7.7 8 7.6 66.3 68.1 67.1 69 66.4 33.7 31.9 32.9 31 33.6 18.9 21.3 19.8 20.2 16.2 Papua New Guinea 3.5 3.6 3.7 3.5 3.4 89.3 88.3 89.5 89.8 88.9 10.7 11.7 10.5 10.2 11.1 10.3 10.5 11 11.4 10.9 Paraguay 7.2 8.4 8.4 8.3 7.3 44.9 40.2 35.2 33.3 31.5 55.1 59.8 64.8 66.7 68.5 16.7 17.5 15.9 15 14.2 Peru 4.9 4.7 4.6 4.4 4.4 53.1 53 51 48.6 48.3 46.9 47 49 51.4 51.7 12.3 12.1 12.1 12.1 10.7 Philippines 3.5 3.4 3.2 3 3.2 44.2 47.6 44.2 40 43.7 55.8 52.4 55.8 60 56.3 6.5 7.1 5.9 4.9 5.9 Poland 5.9 5.7 6 6.6 6.5 71.1 70 71.9 71.2 69.9 28.9 30 28.1 28.8 30.1 8.7 8.9 9.7 10.2 9.8 Portugal 8.7 9.2 9.4 9.3 9.6 67.6 69.5 70.6 70.5 69.7 32.4 30.5 29.4 29.5 30.3 13 14.1 14.3 14.3 14.1 Qatar 3.6 2.8 2.9 3.3 2.7 73.6 75 74.1 73.6 73.9 26.4 25 25.9 26.4 26.1 6.9 6.7 6.8 6.8 6.7 Republic of Korea 4.8 4.7 5.4 5.3 5.6 44.4 46.2 51.9 50.3 49.4 55.6 53.8 48.1 49.7 50.6 9 9.1 11.2 10.7 8.9 Republic of Moldova 6.8 6.5 6.4 7.1 7.2 45.8 51.3 51.1 57.2 54.5 54.2 48.7 48.9 42.8 45.5 8.5 9.8 11.2 12.9 11.8 Romania 5.4 5.4 5.5 5.9 6.1 62.6 65.5 64.6 63.9 62.9 37.4 34.5 35.4 36.1 37.1 9.6 9.9 10.3 10.5 10.9 Russian Federation 5.6 5.8 5.7 5.9 5.6 57.8 56.1 58.8 59.4 59 42.2 43.9 41.2 40.6 41 8.8 9.4 9.6 9.6 9.3 Rwanda 4.6 4.3 4.1 4.2 3.7 47.7 34.6 38.8 47 43.5 52.3 65.4 61.2 53 56.5 9.9 8 7.7 10.2 7.2 Saint Kitts and 5.5 5.6 5.4 5.4 5.3 60.1 63.7 64.2 63.3 63.8 39.9 36.3 35.8 36.7 36.2 10.4 10.4 10.9 9.7 11.4 Nevis Saint Lucia 4.6 4.8 5.1 5 5 68.8 69.8 68.9 68.4 68.2 31.2 30.2 31.1 31.6 31.8 10.2 10.7 11.8 10.6 10.3 Saint Vincent and 5.7 5.7 5.7 6.2 6.1 60.8 63.9 64.3 66.8 67.5 39.2 36.1 35.7 33.2 32.5 8.5 10.8 10.1 10.7 11 the Grenadines Samoa 6.3 6.2 5.7 5.8 5.4 75.3 75 74.5 78.4 79 24.7 25 25.5 21.6 21 20.3 21.3 22 24.5 20.1 San Marino 7.3 7.4 7.7 7.7 7.5 77.8 77.4 79.4 79.2 78.7 22.2 22.6 20.6 20.8 21.3 18.2 18 15.2 20.4 21 Sao Tome and 10 8.6 10.5 9 8.6 87.3 85.9 85.8 85 83.9 12.7 14.1 14.2 15 16.1 12.5 11.2 10.9 11.3 11.1 Principe Saudi Arabia 4.3 4.2 4.7 4.5 4 76.1 76.8 78.6 78.2 75.9 23.9 23.2 21.4 21.8 24.1 10.7 9.8 9.9 10.6 9.4 Senegal 4.5 4.4 4.7 5 5.1 36.2 36.4 38.5 39.8 41.8 63.8 63.6 61.5 60.2 58.2 7.8 8.1 8 9.5 9.3 Serbia-Montenegrok 9.6 7.7 7.3 7.9 9.6 59.5 63.3 67.2 72.9 75.5 40.5 36.7 32.8 27.1 24.5 12.4 13.5 12.4 12.2 16 Seychelles 5.3 5.2 5.1 5.1 5.9 74.8 75 74.7 74.9 73.2 25.2 25 25.3 25.1 26.8 6.9 6.8 8.1 7 10.2 Sierra Leone 3.1 3.8 3.4 3.5 3.5 46.1 55.5 53.7 63.6 58.3 53.9 44.5 46.3 36.4 41.7 6.9 7.6 6.4 7.9 7.9 Singapore 4.1 3.6 4.3 4.3 4.5 38.4 35.4 36.2 32.4 36.1 61.6 64.6 63.8 67.6 63.9 8.2 6.7 7 6.6 7.7 Slovakia 5.8 5.5 5.6 5.7 5.9 89.6 89.4 89.3 89.1 88.3 10.4 10.6 10.7 10.9 11.7 10.9 9.7 11.4 11.5 13.2 Slovenia 7.7 8.6 9 8.9 8.8 75.5 77.7 76.9 76.5 76.3 24.5 22.3 23.1 23.5 23.7 14 13.7 14.2 14 13.8 Solomon Islands 4.7 5.1 5.1 4.9 4.8 93 93 93.5 93.2 93.4 7 7 6.5 6.8 6.6 11.1 11.4 11.5 13.2 9.4 Somalia 2.7 2.6 2.6 n/a n/a 45 44.8 44.6 n/a n/a 55 55.2 55.4 n/a n/a 4.2 4.2 4.2 n/a n/a South Africa 8.7 8.1 8.4 8.4 8.4 41.1 42.4 41.2 40.6 38.6 58.9 57.6 58.8 59.4 61.4 10.7 10.9 11.2 11.6 10.2 Spainl 7.5 7.4 7.5 7.6 7.7 72 71.6 71.2 71.3 71.3 28 28.4 28.8 28.7 28.7 13.4 13.3 13.4 13.4 13.7 Sri Lanka 3.5 3.6 3.6 3.6 3.5 48.4 48.5 46.6 45 45 51.6 51.5 53.4 55 55 6.8 6.5 6.1 6.4 6.5 Sudan 4.3 3.8 4 4 4.3 25.5 34.4 37.1 38.1 43.2 74.5 65.6 62.9 61.9 56.8 9 8.6 9.5 8.8 9.1 Suriname 7.6 8 7.9 8.1 7.9 51.3 48.8 47.8 46.3 45.8 48.7 51.2 52.2 53.7 54.2 10.7 9.7 10.8 10.4 10.4 Swaziland 6.4 6.1 6 5.9 5.8 59 58.6 57.8 59.3 57.3 41 41.4 42.2 40.7 42.7 11.8 11.6 11.3 10.9 10.9 Sweden 8.4 8.4 8.8 9.2 9.4 85.7 84.9 84.9 85.1 85.2 14.3 15.1 15.1 14.9 14.8 12 12.5 13.1 13.4 13.6 annex table 2 183 Social security expenditure on health as % of External resources for health as % general government Out-of-pocket expenditure as % of Private prepaid plans as % of private of total expenditure on health expenditure on health private expenditure on health expenditure on health Member State 1999 2000 2001 2002 2003 1999 2000 2001 2002 2003 1999 2000 2001 2002 2003 1999 2000 2001 2002 2003 Micronesia, 11.8 11.7 11.7 11.9 n/a 0 0 0 0 0 35.7 35.7 35.7 40 40 0 0 0 0 0 Federated States of Monaco 0 0 0 0 0 98 98.1 98.2 98.3 98.6 84.8 81.8 81.8 84.6 85.3 15.2 18.2 18.2 15.4 14.7 Mongolia 18.4 22.5 21.1 12.8 3.2 26.1 24.1 31.5 37.4 37.8 55.7 42.6 41.9 84.6 91.1 0 0 0 0 0 Moroccoh 1.8 1.8 1.7 0.5 1 0 0 0 0 0 76.7 76.6 76.4 76.3 76.1 23.3 23.4 23.6 23.7 23.9 Mozambique 39.6 42.9 47.6 38.3 40.8 0 0 0 0 0 38.5 39 34.3 32 38.8 0.6 0.6 0.6 0.6 0.5 Myanmar 3.1 1.9 1.9 1 2.2 2.1 2 3.4 1.2 1.3 99.8 99.7 99.7 99.7 99.7 0 0 0 0 0 Namibia 2.4 3.8 4 4.3 5.3 1.2 1.8 2 2 1.9 21.3 18.2 20.1 20.4 19.2 74.7 77.3 75.1 74.9 76 Nauru n/a n/a n/a n/a n/a 0 0 0 0 0 100 100 100 100 100 0 0 0 0 0 Nepal 8.9 13.1 12.1 8.4 9.9 0 0 0 0 0 92.5 92.2 92.2 92.2 92.2 0 0 0 0 0 Netherlands 0 0 0 0 0 93.8 93.9 93.8 93.8 93 24.1 24.3 23.4 21.4 20.8 44.5 43 43.6 45.6 45.7 New Zealand 0 0 0 0 0 0 0 0 0 0 70.7 69.9 72 72.6 72.1 27.6 28.5 26.5 25.9 26.5 Nicaragua 10 8.4 7.7 9.3 11.2 31.5 27 31.3 29.2 26.6 93.8 92 93.1 96 95.7 4.9 7 6 4 4.1 Niger 28.6 46.6 23.1 22.7 32.8 2.6 2.8 2.6 2.4 2.2 88.9 88 88.2 88.8 89.2 6.4 7.4 7.3 7 7.2 Nigeria 13.8 16.2 5.6 6.1 5.3 0 0 0 0 0 94.8 92.7 91.4 90.4 91.2 3.4 5.1 6.5 6.7 6.7 Niuei n/a n/a 75.6 5.2 9.2 0 0 0 0 0 100 100 100 100 100 0 0 0 0 0 Norway 0 0 0 0 0 16.5 17.1 17.2 18.2 17.9 95.4 95.5 95.7 95.4 95.4 0 0 0 0 0 Oman 0 0.1 0 0 0 0 0 0 0 0 59.8 59.6 56.1 57 56.1 26.8 27 29.2 28.7 29.3 Pakistan 2.2 3.5 3.5 2 2.5 33.7 41.3 42.5 42.1 53.3 98.6 98.1 98 98 98 n/a n/a n/a n/a n/a Palau 15.9 15 16.3 10.4 15.8 0 0 0 0 0 100 100 100 100 100 0 0 0 0 0 Panamaj 1.1 1 0.5 1 0.2 51.5 50 53.5 52.3 55.5 81.9 81.3 82.3 81.6 82.2 18.1 18.7 17.7 18.4 17.8 Papua New Guinea 26.2 24.2 25 37.7 28.3 0 0 0 0 0 87 88.8 87.6 87.1 87.2 9.8 8.7 9.9 10.4 10.1 Paraguay 5.2 2.8 1.6 3.2 1.8 48.1 53 47.7 36.2 39.8 85.6 88.6 87 80.2 74.6 13.4 10.9 13.2 10.3 11.7 Peru 1.4 1.2 4.6 4.6 3.2 43.5 42.9 42.9 42.9 42.4 82.6 79.4 79.4 78.9 79 13.6 17.2 17.2 17.8 17.6 Philippines 3.7 3.5 3.7 2.8 3.8 11.4 14.7 18 22.6 21.8 77.6 77.2 78.6 78 78.2 11 11.1 10.1 10.7 10.5 Poland 0 0 0 0 n/a 83.5 82.6 83.8 86.2 86 100 100 100 88.2 87.8 n/a n/a n/a n/a n/a Portugal 0 0 0 0 0 7.1 6.5 6.5 6.4 6.5 95.3 95.7 95.6 95.6 95.7 4.3 4.3 4.4 4.4 4.3 Qatar 0 0 0 0 0 0 0 0 0 0 88.4 86.7 86.7 88.7 87.5 n/a n/a n/a n/a n/a Republic of Korea 0 0 0 0 0 78.7 79.6 81.4 81 81.7 85.9 83.5 83.2 84 82.8 3.7 5.3 4.4 3.8 4.1 Republic of Moldova 16.1 32.6 8.3 2.8 2.5 0 0 0 0 1.1 99.6 98 96.9 96 96.1 n/a n/a n/a n/a n/a Romania 3 5.5 7 3.7 3.8 86 89.4 89.5 84.3 85.8 90.1 92 94.6 88.7 90.4 9.9 8 5.4 5.5 4.7 Russian Federation 0.8 0.2 0.2 0.2 0.2 39.4 40.6 40.7 41.7 43.7 67.8 71.1 71.9 70.8 71.1 6.3 6.9 6.2 6.9 6.6 Rwanda 43 48.9 38.2 46.9 54.5 5.1 6.8 8.3 9 9.8 41.4 35.6 39.2 43.8 41.7 3.8 5.6 6.5 7.5 7.1 Saint Kitts and 5.7 5.2 5 4.8 5.7 0 0 0 0 0 100 100 100 100 100 n/a n/a n/a n/a n/a Nevis Saint Lucia 0.5 0.5 0.6 0.1 0.1 5.2 4.9 4.9 4.8 5 100 100 100 100 100 n/a n/a n/a n/a n/a Saint Vincent and 0.2 0.2 0.2 0.1 0.1 0 0 0 0 0 100 100 100 100 100 n/a n/a n/a n/a n/a the Grenadines Samoa 14.7 14.5 15.2 18.3 18.9 0.9 2.4 0.7 0.6 1.4 80.5 83.3 81.3 79.3 77.9 0 0 0 0 0 San Marino 0 0 0 0 0 97.6 94.5 96 95.5 92.6 96.5 96.7 96.7 96.8 96.8 3.5 3.3 3.3 3.2 3.2 Sao Tome and 59.9 62.5 62.9 74.9 56 0 0 0 0 0 100 100 100 100 100 0 0 0 0 0 Principe Saudi Arabia 0 0 0 0 0 n/a n/a n/a n/a n/a 32.5 30.3 30.7 30.3 28.6 39 40.8 40.1 40.4 41.6 Senegal 12.6 14 19.2 10.3 15.4 19 19.2 18.8 16.6 15.8 96.7 96.6 96.5 95.4 95.3 2.1 2.2 2.2 3.3 3.4 Serbia-Montenegrok 1.1 1.9 1.2 0.5 0.5 96.3 93.8 94.5 94.7 89.8 100 100 100 100 85.3 0 0 0 0 14.7 Seychelles 1.3 0.6 0.4 0.5 2 5.3 5.2 5.1 4.8 3.3 62.5 61.8 62.5 62.5 62.5 0 0 0 0 0 Sierra Leone 8.8 11.8 14.8 5.8 15.5 0 0 0 0 0 100 100 100 100 100 0 0 0 0 0 Singapore 0 0 0 0 0 19 23.3 20.9 23.1 21.5 97.4 97.1 97.1 97.1 97.1 0 0 0 0 0 Slovakia 0.1 0 0 0 0 94.2 94.4 95.1 96.4 93.5 100 100 100 100 100 0 0 0 0 0 Slovenia 0 0.1 0.1 0.1 0.1 87.5 79.5 78.3 79.7 82.6 39.3 38.6 41.7 40.9 41.1 60.7 61.4 58.3 58.3 58.9 Solomon Islands 7.1 16.5 16.5 40.9 68.5 0 0 0 0 0 50.2 51.6 49.2 49.7 53.1 0 0 0 0 0 Somalia 6.1 9 9.3 n/a n/a 0 0 0 n/a n/a 100 100 100 n/a n/a 0 0 0 n/a n/a South Africa 0.1 0.4 0.4 0.4 0.5 3.5 3.3 3.1 3.8 4.6 17.1 18.9 17.8 16.8 17.1 77.4 75.6 76.7 77.7 77.7 Spainl 0 0 0 0 0 41.1 41.4 41.7 7.3 7 83.3 83.1 83.1 82.6 82 13.4 13.7 13.9 14.3 14.9 Sri Lanka 2.7 2.7 3.1 1.9 2.3 0.2 0.3 0.4 0.3 0.3 86.6 86.4 87.1 88.9 88.9 3 3.9 3.4 3.2 3.2 Sudan 3.7 2.4 2.8 2.9 2.2 36.8 38.7 45.5 42.1 44.7 96.2 95.9 95.8 95.9 96.3 n/a n/a n/a n/a n/a Suriname 11.4 10.9 13.5 7.3 7 35.3 40.7 35 35.9 35.3 49.5 44 52.7 45.4 51.8 0.7 0.8 0.7 0.7 0.7 Swaziland 10.3 5.5 5.2 5.1 5.5 0 0 0 0 0 40.9 42.4 41.8 41.7 42.4 18.6 18.9 20 20 19.6 Sweden 0 0 0 0 0 0 0 0 0 0 93.8 91.1 92.2 91.6 92.1 1 1.2 1.5 1.4 2.3 184 The World Health Report 2006 Annex Table 2 Selected indicators of health expenditure ratios, 1999–2003 Figures computed by WHO to assure comparability;a they are not necessarily the of�cial statistics of Member States. which may use alternative methods. General government expenditure on General government expenditure Total expenditure on health health as % of Private expenditure on health as % on health as % of total government as % of gross domestic product total expenditure on healthb of total expenditure on healthb expenditure Member State 1999 2000 2001 2002 2003 1999 2000 2001 2002 2003 1999 2000 2001 2002 2003 1999 2000 2001 2002 2003 Switzerland 10.5 10.4 10.9 11.1 11.5 55.3 55.6 57.1 57.9 58.5 44.7 44.4 42.9 42.1 41.5 16.7 17.1 17.9 18.2 19.4 Syrian Arab 5.5 5.1 5 5 5.1 41 43 45 45.8 48.2 59 57 55 54.2 51.8 7.2 7.3 6.7 6.5 6.3 Republic Tajikistan 3.8 3.3 3.3 3.3 4.4 27.6 28.2 28.9 27.7 20.8 72.4 71.8 71.1 72.3 79.2 6.3 4.9 5.3 4.8 4.8 Thailand 3.5 3.4 3.3 3.4 3.3 54.8 56.1 56.3 60.2 61.6 45.2 43.9 43.7 39.8 38.4 10.5 10.8 10.3 11.8 13.6 The former Yugoslav Republic 6.3 6 6.1 6.8 7.1 85.2 84.6 83.1 84.7 84.5 14.8 15.4 16.9 15.3 15.5 15.1 15 12.3 14 17.1 of Macedonia Timor-Lestem 10 8.4 7.9 7.7 9.6 68.3 75.3 72.6 72.6 75.9 31.7 24.7 27.4 27.4 24.1 8.7 8.1 8.5 8.6 7.7 Togon 5.4 4.6 5.4 4.9 5.6 40 29 25.2 18.7 24.8 60 71 74.8 81.3 75.2 12.4 7.5 8.6 6.9 9.3 Tonga 6.8 6.8 7.3 6.5 6.5 75.4 74.7 75.7 74.2 85.1 24.6 25.3 24.3 25.8 14.9 14.6 13.2 11.9 17.1 21.2 Trinidad and Tobago 3.8 3.7 3.6 3.9 3.9 43.3 40.3 39.9 37.3 37.8 56.7 59.7 60.1 62.7 62.2 6.4 6.3 5.8 5.7 5.9 Tunisia 5.5 5.6 5.7 5.6 5.4 49.4 48.5 49.6 47.4 45.7 50.6 51.5 50.4 52.6 54.3 7.2 6.9 7.6 6.9 7.2 Turkey 6.4 6.6 7.5 7.2 7.6 61.1 62.9 68.2 69.5 71.6 38.9 37.1 31.8 30.5 28.4 10.3 9.8 10.3 12.1 13.9 Turkmenistan 3.5 4.5 4 3.6 3.9 69.9 72.6 69 64.3 67.4 30.1 27.4 31 35.7 32.6 12.7 12.7 12.7 12.7 12.7 Tuvaluo 9.3 11.5 7.5 31.6 6.1 88.7 90.8 86.9 96.8 83.3 11.3 9.2 13.1 3.2 16.7 5.9 5 4.2 33.5 6 Uganda 6.3 6.6 7.3 7.6 7.3 30.6 26.8 27.3 31.1 30.4 69.4 73.2 72.7 68.9 69.6 9.4 9 9.6 10.8 10.7 Ukraine 5.5 5 5 5.4 5.7 53.1 58 61 62.4 65.9 46.9 42 39 37.6 34.1 8.6 8.4 8.9 9.4 10.2 United Arab 3.8 3.2 3.7 3.4 3.3 77.5 76.6 78.3 75 74.7 22.5 23.4 21.7 25 25.3 7.9 7.6 7.7 7.8 8 Emirates United Kingdom 7.2 7.3 7.5 7.7 8 80.6 80.9 83 83.4 85.7 19.4 19.1 17 16.6 14.3 14.5 14.8 15.3 15.4 15.8 United Republic of 4.3 4.4 4.5 4.5 4.3 43.4 48.1 48.5 51.6 55.4 56.6 51.9 51.5 48.4 44.6 12.4 12.6 12.8 12.8 12.7 Tanzania United States of 13.1 13.3 14 14.7 15.2 43.8 44 44.8 44.8 44.6 56.2 56 55.2 55.2 55.4 16.7 17.1 17.7 18.2 18.5 America Uruguay 10.6 10.5 10.8 10.3 9.8 34.8 33.4 33.8 31.3 27.2 65.2 66.6 66.2 68.7 72.8 10.6 10.3 9.4 8 6.3 Uzbekistan 6 5.7 5.7 5.6 5.5 48.4 45.6 45.4 44.3 43 51.6 54.4 54.6 55.7 57 7 6.6 7.1 6.8 7.6 Vanuatu 4.2 3.9 3.8 4.1 3.9 75.4 72.8 74.3 75.2 73.8 24.6 27.2 25.7 24.8 26.2 11.5 10.1 11.1 12 12.9 Venezuela, 6.2 6.2 5.2 5 4.5 51.8 54.4 43.4 46.1 44.3 48.2 45.6 56.6 53.9 55.7 13.1 11.5 7.2 7.8 6.4 Bolivarian Republic of Viet Nam 4.9 5.3 5.5 5.1 5.4 32.7 28 29.2 28.1 27.8 67.3 72 70.8 71.9 72.2 6.7 6 6.7 5.1 5.6 Yemen 4.2 4.6 5 4.9 5.5 37.2 42.9 42.8 38.4 40.9 62.8 57.1 57.2 61.6 59.1 5.9 6.4 6.5 5.6 6 Zambia 5.7 5.5 5.8 6 5.4 48.8 50.6 56.5 56.7 51.4 51.2 49.4 43.5 43.3 48.6 9.5 9.1 10.2 10.6 11.8 Zimbabwe 8.1 7.8 9.1 8.4 7.9 48.9 48.3 38.6 37.7 35.9 51.1 51.7 61.4 62.3 64.1 10 7.4 9.3 9.8 9.2 Afghanistan, Democratic People’s Republic of Korea, Equatorial Guinea, Gabon, Guinea Bissau, Iraq, Liberia, Libya, Sao Tome and Principe, Somalia, Sudan and Turkmenistan: estimates for these countries should be read with caution as these are derived from limited sources (mostly macro data that are publicly accessible). Burkina Faso, China, Djibouti, Georgia, Guinea, India, Malaysia, Mauritius, Mongolia, Niue, Philippines, Russia, Rwanda, Samoa, Singapore, Sri Lanka, Tonga, Yemen: new NHA reports, surveys, and/or country consultations provided new bases for the estimates. For OECD countries, data are updated from the OECD health data. For Japan the 2003 ratios have been estimated by WHO. USA �gures do not as yet reflect introduction of estimates of investments in medical equipment and software and expanded estimates of investments in medical sector structures. a See explanatory notes for sources and methods. b In some cases the sum of the ratios of general government and private expenditures on health may not add to 100 because of rounding. c The estimates do not include expenditures of Hong Kong and Macao Special Administrative Regions. d The series was adjusted for the removal of social security expenditure on health, which could not be con�rmed due to incomplete information. e Expenditures on health by the social security funds have increased due to a reclassi�cation. (Note, however, that this estimate is likely to increase further due to changes in the social security scheme.) f The estimates do not include expenditures of Northern Iraq. g The public expenditure on health includes contributions from the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) to Palestinian refugees residing in Jordanian territories. annex table 2 185 Social security expenditure on health as % of External resources for health as % general government Out-of-pocket expenditure as % of Private prepaid plans as % of private of total expenditure on health expenditure on health private expenditure on health expenditure on health Member State 1999 2000 2001 2002 2003 1999 2000 2001 2002 2003 1999 2000 2001 2002 2003 1999 2000 2001 2002 2003 Switzerland 0 0 0 0 0 72.1 72.6 70.4 69.1 69.3 74.5 74.1 73.9 74.8 76 23.3 23.6 23.8 22.9 21.6 Syrian Arab 0.1 0.1 0.2 0.3 0.2 0 0 0 0 0 100 100 100 100 100 0 0 0 0 0 Republic Tajikistan 6.7 18.3 16.9 14.9 14.9 0 0 0 0 0 100 100 100 100 100 0 0 0 0 0 Thailand 0 0 0.1 0.2 0.3 29.5 30.2 34.4 30.8 32 76.4 76.8 75.7 76.3 74.8 12.6 12.8 13.6 13.4 14.6 The former Yugoslav Republic 3.7 2.7 2.5 1.8 1.7 97.4 97.4 97.1 97.4 97.8 100 100 100 100 100 n/a n/a n/a n/a n/a of Macedonia Timor-Lestem 47.9 56.4 55 45.8 48.7 n/a n/a n/a n/a n/a 30.9 30.9 25.6 25.6 25.6 0 0 0 0 0 Togon 4.9 7.1 4.8 11.4 2.3 8.1 13.4 11.6 14.4 14.6 87 86.6 87.8 87.7 88 5.1 5.4 4.3 4.3 4.1 Tonga 21.7 23.4 23.9 33.5 30.9 0 0 0 0 0 79 76.5 77.5 80 72.6 5.8 9.3 10.6 6 6 Trinidad and Tobago 8.5 7.3 7.3 6.6 1.4 0 0 0 0 0 85.8 86.3 86.4 85.8 88.6 7.5 7.2 7.2 7.5 6 Tunisia 0.7 0.7 0.7 0.2 0.4 23.3 26.7 22.3 24.5 23.5 83.8 81.7 82.6 83 83 14.4 16.6 15.7 15.3 15.3 Turkey 0 0 0 0 0 53 55.5 50.5 55 54.6 74.8 74.6 73.4 70.7 69.9 10.9 11.8 12.3 12.3 12.5 Turkmenistan 2 1 0.8 0.5 0.4 6.1 6.1 6.1 6.1 6.1 100 100 100 100 100 0 0 0 0 0 Tuvaluo 3.5 39.9 95.7 68 70.5 0 0 0 0 0 13 13 13 13 13 0 0 0 0 0 Uganda 27.6 28.3 27.4 29.1 28.5 0 0 0 0 0 61.5 56.7 51.8 51 52.8 0.2 0.1 0.2 0.2 0.2 Ukraine 0.2 0.6 0.6 3.1 0.1 0 0 0 0 0 72.5 73 75.4 76.4 78.6 1 1.4 1.7 1.6 1.6 United Arab 0 0 0 0 0 0 0 0 0 0 70.5 68.7 69.4 70.6 70.4 19 21 20.2 18.8 19.1 Emirates United Kingdom 0 0 0 0 0 0 0 0 0 0 55.2 55 62.3 64.8 76.7 16.8 16.8 19 19.7 23.3 United Republic of 29.3 32.1 34.1 29.6 21.9 0 0 5 3.2 2.6 83.5 83.6 83.8 83.5 81.1 4.5 4.5 4.5 4.7 5.4 Tanzania United States of 0 0 0 0 0 33.1 33.7 32.5 30.5 28.4 27 26.5 25.8 24.9 24.3 61.4 62.7 64.1 65.3 65.9 America Uruguay 0.1 0.5 0.8 0.6 0.4 52.6 50 47.7 48.3 48.5 26.6 25.9 24.9 25 25 73.4 74.1 75.1 75 75 Uzbekistan 0.9 1.7 3.5 4.1 3 0 0 0 0 0 96.8 96.9 97.1 95.3 95.5 0 0 0 0 0 Vanuatu 23 25.8 18.6 18.3 25.4 0 0 0 0 0 47.8 49.9 46.3 45.8 45.8 0 0 0 0 0 Venezuela, 1 0.4 0.1 0.1 0.1 25 28.5 34.2 31.4 25.2 88.5 87 87.4 87.3 95.5 4 3.7 3.7 4.1 4.5 Bolivarian Republic of Viet Nam 3.4 2.7 2.8 3.5 2.6 9.5 10.5 13.7 15.8 16.6 86.5 87.1 83.6 80.8 74.2 3.7 4.1 2.2 2.3 3.1 Yemen 8.2 8.9 9.7 7.3 8.8 n/a n/a n/a n/a n/a 96.3 96.1 96.6 96.7 95.5 n/a n/a n/a n/a n/a Zambia 8.9 18.2 13.7 18.3 44.7 0 0 0 0 0 82 81.1 74.9 72.7 68.2 n/a n/a n/a n/a n/a Zimbabwe 15.7 11.7 5.6 1.4 6.8 0 0 0 0 0 44.9 46.7 50.7 51.7 56.7 39.6 31.1 29 25.9 21 h Expenditures, previously recorded as social security spending, were re-evaluated as extrabudgetary agency spending. i THE:GDP ratio in 2001 is high because newly accessed information shows that WHO, NZAID and AusAID provided US$ 2 million for renovation of a hospital in 2001–2002. j Series adjusted for the removal of a double count in previous years. k The estimates for 1999 to 2003 do not include the expenditures of the provinces of Kosovo and Metohia, which are under the administration of the United Nations. l Social security includes the expenditure by the Instituto Nacional de la Salud in the Comunidades autónomas up to 2002. The expenditure is now channelled through the Comunidades autónomas except for the Ceuta and Melilla Ciudades Autónomas, the civil servants, and those related to work injuries and sickness. m The country came into existence in August 1999. n Togo data on health research and development and training were adjusted to harmonize with the standard methodology used for World Health Reports. o In 2002, an additional 9.3 million Tuvaluan $, mostly coming from external sources, were spent for construction of a new hospital. n/a Used when the information accessed indicates that a cell should have an entry but no estimates could be made. 0 Used when no evidence of the schemes to which the cell relates exist. Some estimates yielding a ratio below 0.04% are shown as ‘0’. 186 The World Health Report 2006 Annex Table 3 Selected national health accounts indicators: measured levels of per capita expenditure on health, 1999–2003 a Figures computed by WHO to assure comparability; they are not necessarily the of�cial statistics of Member States, which may use alternative methods. Per capita total expenditure on Per capita government expenditure health at average exchange rate Per capita total expenditure on on health at average exchange rate Per capita government expenditure (US$) health at international dollar rate (US$) on health at international dollar rate Member State 1999 2000 2001 2002 2003 1999 2000 2001 2002 2003 1999 2000 2001 2002 2003 1999 2000 2001 2002 2003 Afghanistan 4 3 3 11 11 19 9 9 24 26 <1 <1 <1 4 4 <1 <1 <1 10 10 Albania 77 78 88 99 118 289 299 336 360 366 35 33 37 41 49 131 127 142 150 153 Algeria 61 63 68 75 89 137 132 149 174 186 43 46 53 60 71 99 97 115 137 150 Andorrab 1359 1287 1296 1549 2039 1749 1895 1936 2219 2453 913 841 891 1066 1399 1176 1239 1331 1527 1683 Angola 15 16 21 18 26 43 34 48 41 49 7 13 18 15 22 20 28 41 33 41 Antigua and Barbuda 389 397 425 495 426 423 437 472 555 477 281 286 301 359 300 305 314 334 402 336 Argentina 706 689 687 233 305 1135 1121 1157 934 1067 399 382 369 121 148 641 621 621 487 518 Armenia 36 39 45 46 55 181 205 241 253 302 8 6 9 9 11 41 31 49 51 61 Australia 1849 1832 1744 1961 2519 2204 2406 2531 2693 2874 1286 1262 1183 1336 1699 1533 1657 1716 1835 1939 Austria 2029 1812 1776 1923 2358 2051 2170 2162 2240 2306 1374 1235 1189 1305 1595 1388 1479 1448 1520 1560 Azerbaijan 27 26 27 28 32 115 112 121 128 140 6 6 6 6 8 24 24 27 27 33 Bahamas 1051 1075 1088 1128 1121 1164 1166 1187 1205 1220 491 507 517 548 533 545 550 564 586 579 Bahrain 473 463 484 514 555 750 656 739 787 813 328 310 327 349 384 519 440 499 534 562 Bangladesh 12 12 12 13 14 50 54 57 61 68 3 3 3 4 4 14 14 15 18 21 Barbados 574 604 638 674 691 870 918 976 1021 1050 375 398 431 461 479 570 604 659 699 729 Belarus 73 64 82 94 99 459 501 582 601 570 59 51 62 69 71 372 401 439 444 406 Belgium 2108 1926 1945 2172 2796 2108 2282 2420 2616 2828 1462 1335 1376 1528 1880 1462 1582 1713 1840 1902 Belize 148 155 165 174 174 258 262 295 290 309 72 74 75 82 86 125 126 133 138 152 Benin 16 15 16 16 20 34 34 38 37 36 7 7 7 7 9 15 15 18 16 16 Bhutan 11 11 14 10 10 67 66 88 64 59 9 9 12 9 9 60 58 79 54 49 Bolivia 63 61 61 60 61 149 150 161 170 176 37 37 36 37 39 87 90 95 107 113 Bosnia and Herzegovina 134 112 110 126 168 302 286 285 295 327 76 58 54 62 85 171 149 139 145 166 Botswana 138 152 132 144 232 259 294 284 312 375 75 87 67 78 135 141 168 143 169 218 Brazil 243 263 224 199 212 543 558 584 592 597 104 108 96 89 96 232 228 250 265 270 Brunei Darussalam 480 443 430 428 466 641 609 643 657 681 351 370 331 336 372 469 508 495 516 545 Bulgaria 97 97 123 155 191 342 381 476 561 573 63 58 69 88 104 223 226 267 317 312 Burkina Faso 15 12 12 15 19 55 54 55 62 68 6 5 5 6 9 24 23 22 27 32 Burundi 4 3 3 3 3 14 14 15 15 15 1 1 1 1 1 3 3 3 3 4 Cambodia 29 31 31 33 33 147 162 168 179 188 3 4 5 6 6 15 23 25 31 36 Cameroon 31 29 29 32 37 62 58 62 66 64 8 8 8 9 11 15 16 17 18 19 Canada 1916 2071 2129 2225 2669 2400 2509 2705 2841 2989 1347 1457 1493 1551 1866 1687 1765 1897 1980 2090 Cape Verde 61 55 61 66 78 148 163 186 193 185 45 41 46 50 57 110 119 141 145 135 Central African Republic 10 10 10 11 12 44 50 49 51 47 4 4 4 4 5 17 20 19 21 18 Chad 11 11 12 12 16 37 40 43 44 51 4 4 5 4 7 12 17 18 16 20 Chile 342 299 272 265 282 697 631 665 686 707 133 139 131 127 137 272 293 320 329 345 China 39 43 47 54 61 169 192 212 247 278 16 17 17 19 22 69 74 75 88 101 Colombia 195 152 147 141 138 572 485 498 497 522 148 123 118 116 116 436 392 399 408 439 Comoros 11 8 7 10 11 30 25 21 27 25 6 4 3 6 6 18 14 10 16 14 Congo 17 17 16 16 19 25 20 23 22 23 11 11 10 11 12 16 13 15 15 15 Cook Islands 154 171 176 203 294 275 354 373 378 425 134 150 154 177 258 240 312 327 329 373 Costa Rica 249 258 280 295 305 457 487 532 572 616 194 204 219 235 240 356 385 418 455 486 Côte d’Ivoire 39 30 24 25 28 87 79 65 62 57 7 6 4 8 8 15 16 12 20 16 Croatia 386 380 370 392 494 742 829 801 792 838 333 330 317 325 413 640 719 688 655 701 Cuba 164 176 187 199 211 196 212 226 239 251 140 151 161 172 183 167 182 194 206 218 Cyprus 700 675 697 794 1038 905 1000 934 1101 1143 299 280 295 356 510 386 415 395 495 561 Czech Republic 379 358 408 517 667 920 962 1065 1186 1302 347 327 373 471 600 842 879 973 1080 1172 Democratic People’s Republic of Koreac 22 28 29 <1 <1 54 67 70 72 74 20 25 26 <1 <1 48 62 64 66 68 Democratic Republic of 8 10 4 3 4 12 13 10 11 14 1 1 <1 <1 1 1 1 1 1 3 Congo Denmark 2767 2478 2565 2835 3534 2297 2381 2556 2654 2762 2275 2043 2120 2352 2931 1888 1963 2113 2201 2292 Djibouti 40 41 42 43 47 61 63 64 67 72 26 27 27 28 31 40 42 41 44 48 annex table 3 187 Per capita total expenditure on Per capita government expenditure health at average exchange rate Per capita total expenditure on on health at average exchange rate Per capita government expenditure (US$) health at international dollar rate (US$) on health at international dollar rate Member State 1999 2000 2001 2002 2003 1999 2000 2001 2002 2003 1999 2000 2001 2002 2003 1999 2000 2001 2002 2003 Dominica 214 216 203 206 212 313 323 302 313 320 159 159 145 147 151 232 237 216 223 228 Dominican Republic 129 162 179 186 132 248 301 323 356 335 39 52 57 60 44 75 97 103 115 111 Ecuadord 65 54 81 95 109 173 157 193 206 220 26 17 27 37 42 68 49 65 79 85 Egypt 68 71 63 71 55 173 190 208 231 235 23 26 25 30 24 59 69 83 99 100 El Salvador 162 168 167 175 183 343 352 347 366 378 70 76 71 78 84 149 159 147 164 174 Equatorial Guinea 46 54 67 85 96 125 106 152 193 179 28 37 47 61 65 76 72 107 139 121 Eritrea 8 8 8 7 8 47 48 53 51 50 6 5 5 4 4 33 32 31 26 23 Estonia 243 220 223 263 366 524 531 540 589 682 197 170 176 203 282 424 412 424 454 526 Ethiopia 5 5 5 5 5 17 19 21 21 20 3 3 3 3 3 9 10 11 12 12 Fiji 85 80 78 93 104 194 203 205 234 220 56 52 52 62 64 126 133 136 155 135 Finland 1713 1549 1622 1831 2307 1641 1716 1857 2012 2108 1290 1164 1231 1397 1766 1236 1289 1409 1535 1613 France 2285 2070 2107 2339 2981 2306 2469 2616 2762 2902 1738 1569 1600 1780 2273 1754 1872 1986 2101 2213 Gabon 165 164 148 158 196 250 229 235 244 255 113 120 108 111 130 171 167 171 171 170 Gambia 24 25 23 20 21 76 88 92 84 96 8 10 9 8 8 24 36 37 34 38 Georgia 17 28 31 33 35 90 143 158 173 174 6 8 9 10 8 32 41 47 50 42 Germany 2730 2404 2425 2637 3204 2566 2674 2772 2912 3001 2143 1889 1901 2072 2506 2014 2101 2173 2288 2348 Ghana 22 13 12 14 16 100 102 94 95 98 8 5 4 4 5 35 36 27 29 31 Greece 1114 1032 1091 1182 1556 1469 1628 1767 1847 1997 595 543 591 610 798 785 856 958 953 1025 Grenada 206 238 296 282 289 333 470 485 464 473 151 176 231 206 212 244 347 378 338 348 Guatemala 79 96 100 104 112 188 228 229 223 235 38 38 38 38 44 91 91 87 83 93 Guinea 20 18 17 19 22 74 76 81 90 95 3 2 3 3 4 10 10 15 13 16 Guinea-Bissau 8 6 6 9 9 45 38 38 49 45 2 2 1 4 4 13 9 8 20 21 Guyana 40 52 52 55 53 236 299 306 291 283 33 44 43 45 44 195 253 253 242 233 Haiti 34 31 31 29 26 75 76 79 84 84 12 11 12 12 10 27 27 30 33 32 Honduras 49 60 63 67 72 131 154 161 172 184 25 34 35 37 41 66 86 88 95 104 Hungary 345 326 375 496 684 819 857 975 1115 1269 250 231 258 348 495 593 606 673 783 919 Iceland 2858 2780 2500 2960 3821 2549 2627 2742 2943 3110 2389 2296 2068 2464 3191 2131 2169 2268 2450 2598 India 23 23 23 23 27 69 71 74 75 82 6 6 6 6 7 17 17 18 18 20 Indonesia 17 18 21 26 30 76 80 102 109 113 5 5 7 9 11 23 23 36 38 40 Iran, Islamic Republic ofe 53 66 81 116 131 373 364 415 410 498 22 28 36 44 62 153 157 184 155 235 Iraq 14 17 12 11 23 50 49 54 48 64 6 5 3 2 12 20 14 15 8 33 Ireland 1590 1568 1835 2191 2860 1624 1800 2097 2322 2496 1171 1158 1382 1698 2256 1196 1329 1580 1800 1968 Israel 1492 1637 1682 1520 1514 1717 1869 2028 1968 1911 1037 1111 1139 1021 1032 1193 1268 1373 1322 1303 Italy 1602 1519 1574 1750 2139 1859 2044 2150 2262 2266 1153 1116 1193 1320 1607 1338 1502 1630 1706 1703 Jamaica 161 191 169 157 164 196 232 210 192 216 81 100 77 80 83 99 122 96 98 109 Japan 2601 2827 2558 2450 2662 1829 1971 2092 2139 2244 2109 2298 2089 1997 2158 1483 1602 1708 1743 1818 Jordan 149 156 165 169 177 361 389 415 425 440 71 71 75 78 80 173 176 189 196 199 Kazakhstan 48 50 50 59 73 231 251 243 284 315 25 25 28 31 42 120 128 137 151 180 Kenya 16 18 18 19 20 60 61 62 66 65 7 8 8 8 8 25 28 27 29 25 Kiribati 46 58 59 65 96 137 197 215 211 253 46 57 59 64 89 135 196 213 209 233 Kuwait 521 521 525 565 580 583 494 558 588 567 402 408 408 441 449 450 387 434 459 440 Kyrgyzstan 13 12 14 16 20 123 116 126 144 161 6 6 6 7 8 59 54 54 59 66 Lao People’s Democratic 7 8 9 10 11 35 38 42 49 56 3 3 3 4 4 14 15 17 22 22 Republic Latvia 193 195 216 248 301 464 477 549 611 678 114 107 110 129 155 274 263 281 318 348 Lebanon 578 574 582 566 573 656 700 720 671 730 159 164 176 171 168 181 200 217 202 214 Lesotho 28 28 24 25 31 91 100 103 125 106 23 23 20 21 25 74 83 84 104 84 Liberia 10 8 7 7 6 26 23 21 20 17 6 5 3 3 4 18 13 10 10 10 Libyan Arab Jamahiriya 211 200 286 182 171 234 220 391 360 327 107 116 209 119 108 119 128 286 235 206 Lithuania 193 212 220 263 351 501 557 591 660 754 145 148 160 197 267 375 388 429 495 573 Luxembourg 2889 2702 2835 3423 4112 2767 2963 3169 3712 3680 2595 2439 2574 3120 3734 2485 2674 2877 3383 3341 188 The World Health Report 2006 Annex Table 3 Selected national health accounts indicators: measured levels of per capita expenditure on health, 1999–2003 a Figures computed by WHO to assure comparability; they are not necessarily the of�cial statistics of Member States, which may use alternative methods. Per capita total expenditure on Per capita government expenditure health at average exchange rate Per capita total expenditure on on health at average exchange rate Per capita government expenditure (US$) health at international dollar rate (US$) on health at international dollar rate Member State 1999 2000 2001 2002 2003 1999 2000 2001 2002 2003 1999 2000 2001 2002 2003 1999 2000 2001 2002 2003 Madagascar f 5 5 5 7 8 20 20 19 24 24 3 3 3 5 5 11 10 12 15 15 Malawi 16 13 15 15 13 47 41 48 44 46 6 4 7 5 5 17 12 22 15 16 Malaysia 112 130 138 146 163 261 294 329 342 374 58 68 77 81 95 134 154 184 190 218 Maldives 116 127 125 121 136 267 293 306 311 364 99 110 110 106 121 228 255 268 273 324 Mali 11 11 11 12 16 27 32 32 35 39 5 5 5 6 9 11 16 16 18 22 Malta 700 772 766 918 1104 1163 1209 1380 1421 1436 529 591 596 731 884 879 925 1073 1133 1150 Marshall Islands 301 275 232 229 255 554 507 437 431 477 292 266 223 221 247 538 492 421 415 461 Mauritania 10 9 10 14 17 32 32 38 53 59 7 6 7 10 13 21 20 26 39 46 Mauritius 113 127 132 143 172 281 331 373 398 430 70 74 80 87 105 174 194 226 242 261 Mexico 273 323 369 381 372 463 499 545 559 582 130 150 165 171 172 221 232 245 251 270 Micronesia, Federated 138 140 145 143 147 242 260 266 267 270 121 121 126 126 130 213 225 231 236 238 States of Monacob 3471 3097 3103 3344 4587 3508 3709 3862 3938 4487 2407 2190 2230 2445 3480 2433 2623 2775 2880 3403 Mongolia 20 26 30 29 33 99 130 140 132 140 15 17 20 20 21 72 86 93 92 90 Morocco 56 54 57 60 72 167 175 196 205 218 17 17 18 19 24 50 54 64 67 72 Mozambique 11 12 10 11 12 34 40 39 45 45 7 8 6 7 7 21 27 26 30 28 Myanmarg 134 183 228 315 394 21 28 30 44 51 15 25 29 58 77 2 4 4 8 10 Namibia 127 126 107 95 145 328 340 323 318 359 93 87 75 65 101 240 235 224 218 252 Nauru 700 645 584 654 798 951 820 742 776 763 624 573 518 580 706 848 729 658 689 675 Nepal 11 11 12 12 12 55 56 64 67 64 3 3 4 4 3 14 14 20 21 18 Netherlands 2102 1916 2067 2411 3088 2124 2270 2517 2777 2987 1318 1209 1298 1506 1926 1332 1432 1581 1735 1863 New Zealand 1155 1054 1056 1255 1618 1527 1600 1698 1844 1893 895 823 807 978 1267 1183 1248 1298 1437 1483 Nicaragua 45 57 62 61 60 142 180 203 208 208 24 30 30 30 29 77 94 98 103 101 Niger 8 6 6 7 9 27 25 26 27 30 4 3 3 4 5 14 13 14 15 16 Nigeria 17 18 19 19 22 48 39 50 49 51 5 6 6 5 6 14 13 16 12 13 Niue 440 367 1710 506 655 103 102 529 154 153 427 355 1700 499 644 100 98 526 151 150 Norway 3325 3156 3333 4143 4976 2816 3083 3286 3617 3809 2745 2604 2785 3458 4167 2325 2543 2745 3019 3189 Oman 232 254 248 265 278 378 352 376 411 419 193 206 204 219 231 315 285 309 340 348 Pakistan 16 14 12 13 13 66 51 49 50 48 5 5 4 5 4 22 17 16 18 13 Palauh 567 593 598 586 607 696 740 770 761 798 502 528 533 511 526 616 659 685 664 691 Panama 271 306 303 322 315 450 524 527 559 555 180 208 203 222 209 298 357 354 386 368 Papua New Guinea 25 26 24 22 23 127 129 138 133 132 23 23 21 20 20 113 114 124 119 118 Paraguay 105 119 102 80 75 298 345 351 336 301 47 48 36 27 24 134 139 124 112 95 Peru 98 96 93 93 98 227 227 223 225 233 52 51 48 45 47 120 120 113 109 112 Philippines 36 34 30 29 31 166 171 162 157 174 16 16 13 12 14 73 82 72 63 76 Poland 249 246 292 328 354 564 587 646 732 745 177 172 210 234 248 401 411 464 521 521 Portugal 985 951 995 1092 1348 1424 1595 1688 1754 1791 665 661 702 770 940 962 1108 1192 1237 1249 Qatar 773 816 808 871 862 834 690 745 868 685 569 612 599 640 637 614 518 552 639 506 Republic of Korea 463 513 550 607 705 729 771 932 975 1074 206 237 286 305 348 324 356 484 490 531 Republic of Moldova 19 20 22 28 34 123 122 132 160 177 9 10 11 16 18 56 63 67 92 96 Romania 87 91 101 124 159 368 386 429 491 540 54 59 65 79 100 231 253 277 314 340 Russian Federation 74 102 119 141 167 385 449 476 534 551 43 57 70 84 98 223 252 280 317 325 Rwanda 11 10 8 9 7 33 32 31 35 32 5 3 3 4 3 16 11 12 17 14 Saint Kitts and Nevis 415 453 456 466 467 606 649 652 669 670 249 289 293 295 298 364 413 419 424 427 Saint Lucia 201 212 214 216 221 266 280 285 285 294 138 148 148 148 150 183 195 196 195 200 Saint Vincent and the 164 164 169 191 194 311 318 329 371 384 100 105 109 127 131 189 203 212 248 259 Grenadines Samoa 84 83 78 84 94 198 209 208 215 209 63 62 58 66 74 149 157 155 169 165 San Marinob 2322 2103 2304 2473 2957 2695 2830 3147 3197 3133 1807 1627 1829 1958 2328 2097 2190 2498 2531 2467 Sao Tome and Principe 34 29 35 31 34 94 84 107 95 93 30 25 30 26 29 82 72 92 81 78 Saudi Arabia 329 372 387 373 366 560 578 637 607 578 251 285 304 291 277 426 444 501 474 439 Senegal 21 18 20 23 29 44 45 51 55 58 8 7 8 9 12 16 16 19 22 24 annex table 3 189 Per capita total expenditure on Per capita government expenditure health at average exchange rate Per capita total expenditure on on health at average exchange rate Per capita government expenditure (US$) health at international dollar rate (US$) on health at international dollar rate Member State 1999 2000 2001 2002 2003 1999 2000 2001 2002 2003 1999 2000 2001 2002 2003 1999 2000 2001 2002 2003 Serbia-Montenegro 76 53 80 118 181 290 253 257 294 373 45 34 54 86 136 172 160 173 214 282 Seychelles 431 405 403 456 522 548 555 535 554 599 322 304 301 342 382 410 417 400 415 439 Sierra Leone 5 5 6 7 7 19 24 25 32 34 2 3 3 4 4 9 13 13 21 20 Singapore 847 820 888 894 964 961 925 1079 1101 1156 325 290 321 290 348 369 328 390 357 417 Slovakia 218 208 216 256 360 577 597 641 716 777 196 186 193 228 318 517 533 573 638 687 Slovenia 831 823 889 982 1218 1211 1421 1571 1616 1669 628 640 683 751 930 915 1105 1208 1237 1274 Solomon Islands 44 41 40 31 28 110 103 98 89 87 41 38 37 28 26 103 96 92 83 81 Somalia 9 8 8 n/a n/a 18 18 18 n/a n/a 4 4 4 n/a n/a 8 8 8 n/a n/a South Africa 257 236 216 198 295 595 579 626 649 669 105 100 89 80 114 244 245 258 263 258 Spain 1133 1038 1083 1211 1541 1459 1529 1618 1735 1853 816 743 771 864 1098 1051 1095 1152 1237 1321 Sri Lanka 28 29 28 30 31 104 113 114 120 121 14 14 13 13 14 50 55 53 54 55 Sudan 13 13 15 17 21 42 40 44 47 54 3 5 6 7 9 11 14 16 18 23 Suriname 157 163 138 175 182 246 261 287 304 309 80 80 66 81 83 126 127 137 141 142 Swaziland 87 83 73 68 107 305 302 308 315 324 51 48 42 40 61 180 177 178 187 185 Sweden 2396 2280 2173 2495 3149 2119 2273 2404 2596 2704 2054 1936 1845 2123 2684 1816 1929 2040 2210 2305 Switzerland 3881 3572 3774 4220 5035 3016 3177 3357 3658 3776 2148 1986 2156 2444 2945 1669 1767 1917 2118 2209 Syrian Arab Republici 59 59 57 58 59 113 106 107 108 116 24 26 26 26 28 46 46 48 50 56 Tajikistan 7 5 6 6 11 41 39 44 48 71 2 1 2 2 2 11 11 13 13 15 Thailand 71 68 62 68 76 217 223 226 242 260 39 38 35 41 47 119 125 127 146 160 The former Yugoslav 115 108 103 127 161 312 320 313 356 389 98 91 86 107 136 266 270 260 302 329 Republic of Macedonia Timor-Leste 37 37 41 38 39 101 101 111 108 125 25 28 30 27 30 69 76 80 78 95 Togo 16 11 13 13 16 59 49 58 54 62 7 3 3 2 4 24 14 15 10 15 Tonga 101 97 94 87 102 256 277 309 286 300 76 73 71 65 87 193 207 234 212 255 Trinidad and Tobago 204 235 245 265 316 354 389 393 459 532 88 95 98 99 120 153 157 157 171 201 Tunisia 122 114 118 120 137 343 367 396 396 409 60 55 59 57 63 169 178 196 187 187 Turkey 179 194 158 190 257 395 453 463 470 528 109 122 108 132 184 242 285 316 327 378 Turkmenistan 31 49 59 67 89 171 233 217 195 221 21 36 41 43 60 120 169 150 125 149 Tuvalu 137 165 107 600 142 113 149 99 377 74 121 149 93 581 119 100 135 86 365 62 Uganda 16 16 17 18 18 55 60 70 75 75 5 4 5 5 5 17 16 19 23 23 Ukraine 35 32 39 47 60 197 194 222 255 305 19 18 24 29 40 105 113 135 159 201 United Arab Emirates 681 704 737 650 661 727 634 713 631 623 528 539 577 487 493 564 485 558 473 465 United Kingdom 1755 1756 1837 2031 2428 1700 1840 2044 2231 2389 1415 1420 1524 1693 2081 1370 1488 1696 1860 2047 United Republic of 11 12 12 12 12 23 25 27 28 29 5 6 6 6 7 10 12 13 15 16 Tanzania United States of America 4335 4588 4934 5324 5711 4335 4588 4934 5324 5711 1897 2017 2212 2387 2548 1897 2017 2212 2387 2548 Uruguay 668 631 597 373 323 972 962 976 832 824 233 211 202 117 88 338 322 330 260 224 Uzbekistan 42 32 26 21 21 143 142 149 155 159 20 14 12 10 9 69 65 68 69 68 Vanuatu 57 49 46 48 54 121 114 111 112 110 43 36 34 36 40 92 83 83 84 81 Venezuela, Bolivarian 253 299 258 183 146 354 369 320 278 231 131 162 112 84 65 184 201 139 128 102 Republic of Viet Nam 18 21 23 22 26 111 129 145 143 164 6 6 7 6 7 36 36 42 40 46 Yemen 18 24 26 27 32 61 68 78 78 89 7 10 11 10 13 22 29 33 30 37 Zambia 17 17 19 20 21 45 46 51 53 51 8 9 11 11 11 22 23 29 30 26 Zimbabwe 36 44 65 132 40 185 168 184 161 132 17 21 25 50 14 91 81 71 61 47 a See explanatory notes for sources and methods. b Andorra, Monaco, and San Marino: international dollar exchange rates for Spain, France and Italy, respectively, were used. c Exchange rate changed from 2.15 Won in 2001 to 152 Won in 2002. d Ecuador dollarized its economy in 2000. The time series has been recalculated from 1998 in dollar terms. e Exchange rate changed in 2002 from multiple to a managed floating exchange rate. Inter-bank market rate used prior to 2002. f The currency now called Ariary is worth one �fth of the Francs previously used. g The of�cial exchange was used although marked difference exists between this and the rates on the open market. h Currency was changed from Australian dollar to US dollar in 1996. The series was revised for this report. i The exchange rate used for Syrian Arab Republic is the rate for non-commercial transactions from the Central Bank of Syria. n/a Used when the information accessed indicates that a cell should have an entry but no estimates could be made. 190 The World Health Report 2006 Annex Table 4 Global distribution of health workers in WHO Member States Figures computed by WHO to ensure comparability;a they are not necessarily the of�cial statistics of Member States, which may use alternative rigorous methods. Physicians Nurses Midwives Dentists Pharmacists Density Density Density Density Density per per per per per Country Number 1000 Year Number 1000 Year Number 1000 Year Number 1000 Year Number 1000 Year Afghanistan 4104 0.19 2001 4752 0.22 2001 630 0.03 2001 525 0.02 2001 Albania 4100 1.31 2002 11473 3.62 2003 1891 0.59 1994 1390 0.45 1998 1300 0.40 1994 Algeria 35368 1.13 2002 68950 2.21 2002 799 0.03 2002 9553 0.31 2002 6333 0.20 2002 Andorra 244 3.70 2003 205 3.11 2003 10 0.15 2003 44 0.67 2003 68 1.03 2003 Angola 881 0.08 1997 13135 1.15 1997 492 0.04 1997 2 0.00 1997 24 0.00 1997 Antigua and 12 0.17 1999 233 3.28 1999 13 0.19 1997 Barbuda Argentina 108800 3.01 1998 29000 0.80 1998 28900 0.80 1998 15300 0.42 1998 Armenia 10983 3.59 2003 13320 4.35 2003 1433 0.47 2003 802 0.26 2003 126 0.04 2003 Australia 47875 2.47 2001 187837 9.71 2001 21296 1.10 2001 13956 0.72 2001 Austria 27413 3.38 2003 76161 9.38 2003 1671 0.21 2003 4037 0.50 2003 4869 0.60 2003 Azerbaijan 29687 3.55 2003 59531 7.11 2003 9803 1.17 2003 2272 0.27 2003 1842 0.22 2003 Bahamas 312 1.05 1998 1323 4.47 1998 21 0.07 1998 Bahrain 803 1.09 2004 3153 4.27 2004 396 0.54 2004 342 0.46 2004 460 0.62 2004 Bangladesh 38485 0.26 2004 20334 0.14 2004 26460 0.18 2004 2537 0.02 2004 9411 0.06 2004 Barbados 322 1.21 1999 988 3.70 1999 63 0.24 1999 Belarus 45027 4.55 2003 115116 11.63 2003 5182 0.52 2003 4315 0.44 2003 2901 0.29 2003 Belgium 46268 4.49 2002 60142 5.83 2003 6603 0.64 2001 8322 0.81 2002 11775 1.14 2002 Belize 251 1.05 2000 303 1.26 2000 32 0.13 2000 Benin 311 0.04 2004 5789 0.84 2004 12 0.00 2004 11 0.00 2004 Bhutan 118 0.05 2004 330 0.14 2004 185 0.08 2004 58 0.02 2004 79 0.03 2004 Bolivia 10329 1.22 2001 27063 3.19 2001 96 0.01 2001 5997 0.71 2001 4670 0.55 2001 Bosnia and 5576 1.34 2003 17170 4.13 2003 1229 0.30 2003 690 0.17 2003 363 0.09 2003 Herzegovina Botswana 715 0.40 2004 4753 2.65 2004 38 0.02 2004 333 0.19 2004 Brazil 198153 1.15 2000 659111 3.84 2000 190448 1.11 2000 51317 0.30 2000 Brunei Darussalam 336 1.01 2000 892 2.67 2000 404 1.21 2000 48 0.14 2000 90 0.27 2000 Bulgaria 28128 3.56 2003 29650 3.75 2003 3456 0.44 2003 6475 0.82 2003 1020 0.13 2001 Burkina Faso 789 0.06 2004 5518 0.41 2004 1732 0.13 2004 58 0.00 2004 343 0.03 2004 Burundi 200 0.03 2004 1348 0.19 2004 14 0.00 2004 76 0.01 2004 Cambodia 2047 0.16 2000 8085 0.61 2000 3040 0.23 2000 209 0.02 2000 564 0.04 2000 Cameroon 3124 0.19 2004 26042 1.60 2004 147 0.01 2004 700 0.04 2004 Canada 66583 2.14 2003 309576 9.95 2003 18265 0.59 2003 20765 0.67 2003 Cape Verde 231 0.49 2004 410 0.87 2004 11 0.02 2004 43 0.09 2004 Central African 331 0.08 2004 1188 0.30 2004 519 0.13 2004 13 0.00 2004 17 0.00 2004 Republic Chad 345 0.04 2004 2387 0.27 2004 112 0.01 2004 15 0.00 2004 37 0.00 2004 Chile 17250 1.09 2003 10000 0.63 2003 6750 0.43 2003 China 1364000 1.06 2001 1358000 1.05 2001 42000 0.03 2001 136520 0.11 2001 359000 0.28 2001 Colombia 58761 1.35 2002 23940 0.55 2002 33951 0.78 2002 Comoros 115 0.15 2004 588 0.74 2004 29 0.04 2004 41 0.05 2004 Congo 756 0.20 2004 3672 0.96 2004 12 0.00 2004 99 0.03 2004 Cook Islands 14 0.78 2001 49 2.72 2001 3 0.17 2001 10 0.56 2001 2 0.11 2001 Costa Rica 5204 1.32 2000 3631 0.92 2000 22 0.01 2000 1905 0.48 2000 2101 0.53 2000 Côte d’Ivoire 2081 0.12 2004 10180 0.60 2004 339 0.02 2004 1015 0.06 2004 Croatia 10820 2.44 2003 22372 5.05 2003 1476 0.33 2003 3085 0.70 2003 2348 0.53 2003 Cuba 66567 5.91 2002 83880 7.44 2002 9841 0.87 2002 Cyprus 1864 2.34 2002 2994 3.76 2002 650 0.82 2002 144 0.18 2002 annex table 4 191 Public and environmental Health management and health workers Community health workers Lab technicians Other health workers support workers Density Density Density Density Density per per per per per Number 1000 Year Number 1000 Year Number 1000 Year Number 1000 Year Number 1000 Year 2534 0.08 2002 1062 0.03 2002 8838 0.28 2002 5088 0.16 2002 60882 1.95 2002 3812 0.20 2001 8326 0.43 2001 35710 1.85 2001 490942 25.37 2001 294 0.40 2004 0 0.00 2004 479 0.65 2004 1278 1.73 2004 1433 1.94 2004 5743 0.04 2004 46202 0.31 2004 3794 0.03 2004 5847 0.04 2004 178 0.03 2004 88 0.01 2004 477 0.07 2004 128 0.02 2004 3281 0.47 2004 71 0.03 2004 464 0.20 2004 136 0.06 2004 121 0.05 2004 1219 0.52 2004 3939 0.46 2001 9648 1.14 2001 172 0.10 2004 277 0.15 2004 829 0.46 2004 167080 0.97 2000 44095 0.26 2000 237100 1.38 2000 839376 4.89 2000 46 0.00 2004 1291 0.10 2004 424 0.03 2004 975 0.07 2004 325 0.02 2004 657 0.09 2004 147 0.02 2004 1186 0.17 2004 2087 0.30 2004 28 0.00 2004 1793 0.11 2004 16 0.00 2004 5902 0.36 2004 9 0.02 2004 65 0.14 2004 78 0.16 2004 42 0.09 2004 74 0.16 2004 55 0.01 2004 211 0.05 2004 48 0.01 2004 367 0.09 2004 167 0.04 2004 230 0.03 2004 268 0.03 2004 317 0.04 2004 153 0.02 2004 1502 0.17 2004 109000 0.08 2001 203000 0.16 2001 1061000 0.82 2001 1077000 0.83 2001 17 0.02 2004 41 0.05 2004 63 0.08 2004 9 0.01 2004 272 0.34 2004 9 0.00 2004 124 0.03 2004 554 0.15 2004 957 0.25 2004 987 0.26 2004 1266 0.32 2000 7379 1.88 2000 23477 5.98 2000 155 0.01 2004 1165 0.07 2004 172 0.01 2004 2107 0.12 2004 192 The World Health Report 2006 Annex Table 4 Global distribution of health workers in WHO Member States Figures computed by WHO to ensure comparability;a they are not necessarily the of�cial statistics of Member States, which may use alternative rigorous methods. Physicians Nurses Midwives Dentists Pharmacists Density Density Density Density Density per per per per per Country Number 1000 Year Number 1000 Year Number 1000 Year Number 1000 Year Number 1000 Year Czech Republic 35960 3.51 2003 99351 9.71 2003 4772 0.47 2003 6737 0.66 2003 5610 0.55 2003 Democratic People’s 74597 3.29 2003 87330 3.85 2003 6084 0.27 2003 8315 0.37 2003 13497 0.60 2003 Republic of Korea Democratic Republic of the 5827 0.11 2004 28789 0.53 2004 159 0.00 2004 1200 0.02 2004 Congo Denmark 15653 2.93 2002 55425 10.36 2002 1200 0.22 2002 4437 0.83 2002 2638 0.49 2002 Djibouti 129 0.18 2004 257 0.36 2004 39 0.05 2004 10 0.01 2004 18 0.03 2004 Dominica 38 0.50 1997 317 4.17 1997 4 0.05 1997 Dominican Republic 15670 1.88 2000 15352 1.84 2000 7000 0.84 2000 3330 0.40 2000 Ecuador 18335 1.48 2000 19549 1.57 2000 1037 0.08 2000 2062 0.17 2000 Egypt 38485 0.54 2003 146761 2.00 2004 9917 0.14 2004 7119 0.10 2004 El Salvador 7938 1.24 2002 5103 0.80 2002 3465 0.54 2002 Equatorial Guinea 153 0.30 2004 228 0.45 2004 43 0.08 2004 15 0.03 2004 130 0.26 2004 Eritrea 215 0.05 2004 2505 0.58 2004 16 0.00 2004 107 0.02 2004 Estonia 6118 4.48 2000 11618 8.50 2000 469 0.34 2000 1747 1.28 2000 580 0.42 2000 Ethiopia 1936 0.03 2003 14893 0.21 2003 651 0.01 2003 93 0.00 2003 1343 0.02 2003 Fiji 271 0.34 1999 1576 1.96 1999 32 0.04 1999 59 0.07 1999 Finland 16446 3.16 2002 74450 14.33 2002 3952 0.76 2002 6674 1.28 2002 5829 1.12 2002 France 203487 3.37 2004 437525 7.24 2004 15684 0.26 2003 40904 0.68 2004 63909 1.06 2003 Gabon 395 0.29 2004 6974 5.16 2004 66 0.05 2004 63 0.05 2004 Gambia 156 0.11 2003 1719 1.21 2003 162 0.11 2003 43 0.03 2003 48 0.03 2003 Georgia 20962 4.09 2003 17807 3.47 2003 1495 0.29 2003 1438 0.28 2003 352 0.07 2003 Germany 277885 3.37 2003 801677 9.72 2003 8559 0.10 2002 64609 0.78 2003 47956 0.58 2003 Ghana 3240 0.15 2004 19707 0.92 2004 393 0.02 2004 1388 0.06 2004 Greece 47944 4.38 2001 42129 3.86 2000 1916 0.18 2001 12394 1.13 2001 8977 0.82 2000 Grenada 41 0.50 1997 303 3.70 1997 7 0.09 1997 Guatemala 9965 0.90 1999 44986 4.05 1999 2046 0.18 1999 Guinea 987 0.11 2004 4757 0.55 2004 64 0.01 2004 60 0.01 2004 530 0.06 2004 Guinea-Bissau 188 0.12 2004 1037 0.67 2004 35 0.02 2004 22 0.01 2004 40 0.03 2004 Guyana 366 0.48 2000 1738 2.29 2000 30 0.04 2000 Haiti 1949 0.25 1998 834 0.11 1998 94 0.01 1998 Honduras 3676 0.57 2000 8333 1.29 2000 195 0.03 2000 1371 0.21 2000 926 0.14 2000 Hungary 32877 3.33 2003 87381 8.85 2003 2032 0.21 2003 5364 0.54 2003 5125 0.52 2003 Iceland 1056 3.62 2004 3954 13.63 2003 200 0.69 2003 283 1.00 2000 374 1.30 2002 India 645825 0.60 2005 865135 0.80 2004 506924 0.47 2004 61424 0.06 2004 592577 0.56 2003 Indonesia 29499 0.13 2003 135705 0.62 2003 44254 0.20 2003 6896 0.03 2003 7580 0.03 2003 Iran, Islamic 31394 0.45 2004 91365 1.31 2004 4897 0.07 2004 6587 0.09 2004 6229 0.09 2004 Republic of Iraq 17022 0.66 2004 32304 1.25 2004 1701 0.07 2004 11489 0.44 2004 13775 0.53 2004 Ireland 11141 2.79 2004 60774 15.20 2004 16486 4.27 2001 2237 0.56 2004 3898 0.97 2004 Israel 24577 3.82 2003 40280 6.26 2003 1202 0.19 2003 7510 1.17 2003 4480 0.70 2003 Italy 241000 4.20 2004 312377 5.44 2003 16523 0.29 1982 33000 0.58 2004 66119 1.15 2003 Jamaica 2253 0.85 2003 4374 1.65 2003 212 0.08 2003 Japan 251889 1.98 2002 993628 7.79 2002 24511 0.19 2000 90510 0.71 2002 154428 1.21 2002 Jordan 11398 2.03 2004 18196 3.24 2004 7270 1.29 2004 17654 3.14 2004 Kazakhstan 54613 3.54 2003 92773 6.01 2003 8018 0.52 2003 5215 0.34 2003 10390 0.67 2003 Kenya 4506 0.14 2004 37113 1.14 2004 1340 0.04 2004 3094 0.01 2004 Kiribati 24 0.30 1998 191 2.36 1998 4 0.05 1998 4 0.05 1998 annex table 4 193 Public and environmental Health management and health workers Community health workers Lab technicians Other health workers support workers Density Density Density Density Density per per per per per Number 1000 Year Number 1000 Year Number 1000 Year Number 1000 Year Number 1000 Year 2685 0.12 2003 950 0.04 2003 67957 3.00 2003 512 0.01 2004 1042 0.02 2004 15013 0.28 2004 23 0.03 2004 84 0.12 2004 159 0.22 2004 232 0.33 2004 9531 0.13 2004 20011 0.27 2004 3694 0.05 2004 5167 0.07 2004 18 0.04 2004 1275 2.51 2004 75 0.15 2004 74 0.15 2004 88 0.02 2004 248 0.06 2004 56 0.01 2004 765 0.18 2004 115 0.08 2000 44 0.03 2000 597 0.44 2000 16057 11.75 2000 1347 0.02 2003 18652 0.26 2003 2703 0.04 2003 7354 0.10 2003 10119 1.95 2002 19202 3.69 2002 150 0.11 2004 276 0.20 2004 1 0.00 2004 144 0.11 2004 33 0.02 2003 968 0.68 2003 99 0.07 2003 3 0.00 2003 391 0.27 2003 899 0.04 2004 7132 0.33 2004 19151 0.90 2004 135 0.02 2004 93 0.01 2004 268 0.03 2004 17 0.00 2004 511 0.06 2004 13 0.01 2004 4486 2.92 2004 230 0.15 2004 61 0.04 2004 38 0.02 2004 215 0.03 2000 2936 0.45 2000 325263 0.38 1991 50393 0.05 2004 15886 0.02 1991 818301 0.76 2005 6493 0.03 2003 0 0.00 2003 8882 0.04 2003 21178 0.10 2003 228095 1.04 2003 10004 0.14 2004 25242 0.36 2004 17618 0.25 2004 84207 1.21 2004 72905 1.04 2004 2601 0.10 2004 1968 0.08 2004 12103 0.47 2004 20421 0.79 2004 34273 1.33 2004 1412 0.25 2004 1000 0.18 2004 5630 1.00 2004 6529 1.16 2004 17708 3.15 2004 6496 0.20 2004 7000 0.22 2004 5610 0.17 2004 1797 0.06 2004 194 The World Health Report 2006 Annex Table 4 Global distribution of health workers in WHO Member States Figures computed by WHO to ensure comparability;a they are not necessarily the of�cial statistics of Member States, which may use alternative rigorous methods. Physicians Nurses Midwives Dentists Pharmacists Density Density Density Density Density per per per per per Country Number 1000 Year Number 1000 Year Number 1000 Year Number 1000 Year Number 1000 Year Kuwait 3589 1.53 2001 9197 3.91 2001 673 0.29 2001 722 0.31 2001 Kyrgyzstan 12902 2.51 2003 31557 6.14 2003 2663 0.52 2003 992 0.19 2003 158 0.03 2003 Lao People’s Democratic 2812 0.59 1996 4931 1.03 1996 196 0.04 1996 Republic Latvia 6940 3.01 2003 12150 5.27 2003 482 0.21 2003 1287 0.56 2003 Lebanon 11505 3.25 2001 4157 1.18 2001 4283 1.21 2001 3359 0.95 2001 Lesotho 89 0.05 2003 1123 0.62 2003 16 0.01 2003 62 0.03 2003 Liberia 103 0.03 2004 613 0.18 2004 422 0.12 2004 13 0.00 2004 35 0.01 2004 Libyan Arab 6371 1.29 1997 17779 3.60 1997 693 0.14 1997 1225 0.25 1997 Jamahiriya Lithuania 13682 3.97 2003 26229 7.62 2003 1132 0.33 2003 2372 0.69 2003 2390 0.69 2003 Luxembourg 1206 2.66 2003 4151 9.16 2003 114 0.25 2003 323 0.71 2003 371 0.82 2003 Madagascar 5201 0.29 2004 5661 0.32 2004 410 0.02 2004 175 0.01 2004 Malawi 266 0.02 2004 7264 0.59 2004 Malaysia 16146 0.70 2000 31129 1.35 2000 7711 0.34 2000 2144 0.09 2000 2333 0.10 2000 Maldives 302 0.92 2004 886 2.70 2004 14 0.04 2004 241 0.73 2004 Mali 1053 0.08 2004 6538 0.49 2004 573 0.04 2004 84 0.01 2004 351 0.03 2004 Malta 1254 3.18 2003 2298 5.83 2003 125 0.32 2003 167 0.42 2003 800 2.03 2003 Marshall Islands 24 0.47 2000 152 2.98 2000 4 0.08 2000 2 0.04 2000 Mauritania 313 0.11 2004 1893 0.64 2004 64 0.02 2004 81 0.03 2004 Mauritius 1303 1.06 2004 4550 3.69 2004 54 0.04 2004 233 0.19 2004 1428 1.16 2004 Mexico 195897 1.98 2000 88678 0.90 2000 78281 0.79 2000 3189 0.03 2000 Micronesia, 64 0.60 2000 410 3.83 2000 7 0.07 2000 14 0.13 2000 Federated States of Monaco 186 5.81 1995 454 14.19 1995 10 0.31 1995 34 1.06 1995 61 1.91 1995 Mongolia 6732 2.63 2002 8012 3.13 2002 612 0.24 2002 337 0.13 2002 1093 0.43 2002 Morocco 15991 0.51 2004 24328 0.78 2004 3091 0.10 2004 7366 0.24 2004 Mozambique 514 0.03 2004 3954 0.21 2004 2229 0.12 2004 159 0.01 2004 618 0.03 2004 Myanmar 17791 0.36 2004 19254 0.38 2004 30087 0.60 2004 1396 0.03 2004 127 0.00 2004 Namibia 598 0.30 2004 6145 3.06 2004 113 0.06 2004 288 0.14 2004 Nauru 16 1.45 1995 60 5.45 1995 Nepal 5384 0.21 2004 5664 0.22 2004 6161 0.24 2004 359 0.01 2004 358 0.01 2004 Netherlands 50854 3.15 2003 221783 13.73 2003 1940 0.12 2003 7759 0.48 2003 3134 0.19 2003 New Zealand 9027 2.37 2001 31128 8.16 2001 2121 0.56 2001 2586 0.68 2001 3495 0.92 2001 Nicaragua 2045 0.37 2003 5862 1.07 2003 243 0.04 2003 Niger 377 0.03 2004 2716 0.22 2004 21 0.00 2004 15 0.00 2004 20 0.00 2004 Nigeria 34923 0.28 2003 210306 1.70 2003 2482 0.02 2003 6344 0.05 2004 Niue 3 1.50 1996 11 5.50 1996 2 1.00 1996 2 1.00 1996 1 0.50 1996 Norway 14200 3.13 2003 67274 14.84 2003 2243 0.49 2003 3733 0.82 2003 1675 0.37 2003 Oman 3871 1.32 2004 10273 3.50 2004 16 0.01 2004 544 0.19 2004 1551 0.53 2004 Pakistan 116298 0.74 2004 71764 0.46 2004 7862 0.05 2004 8102 0.05 2004 Palau 20 1.11 1998 26 1.44 1998 1 0.06 1998 2 0.11 1998 1 0.06 1998 Panama 4431 1.50 2000 4545 1.54 2000 2231 0.76 2000 2526 0.86 2000 Papua New Guinea 275 0.05 2000 2841 0.53 2000 90 0.02 2000 Paraguay 6355 1.11 2002 9727 1.69 2002 534 0.09 2002 3182 0.55 2002 1868 0.33 2002 Peru 29799 1.17 1999 17108 0.67 1999 2809 0.11 1999 Philippines 44287 0.58 2000 127595 1.69 2000 33963 0.45 2000 8564 0.11 2000 2482 0.03 2000 Poland 95272 2.47 2003 188898 4.90 2003 21997 0.57 2002 11451 0.30 2003 25397 0.66 2003 annex table 4 195 Public and environmental Health management and health workers Community health workers Lab technicians Other health workers support workers Density Density Density Density Density per per per per per Number 1000 Year Number 1000 Year Number 1000 Year Number 1000 Year Number 1000 Year 55 0.03 2003 146 0.08 2003 23 0.01 2003 18 0.01 2003 150 0.04 2004 142 0.04 2004 218 0.06 2004 540 0.15 2004 518 0.15 2004 130 0.01 2004 385 0.02 2004 172 0.01 2004 530 0.03 2004 6036 0.34 2004 26 0.00 2004 46 0.00 2004 707 0.06 2004 919 2.80 2004 168 0.51 2004 14 0.04 2004 231 0.02 2004 1295 0.01 2004 264 0.02 2004 377 0.03 2004 652 0.05 2004 429 0.14 2004 106 0.04 2004 48 0.02 2004 1056 0.35 2004 238 0.19 2004 236 0.19 2004 324 0.26 2004 134 0.11 2004 2038 1.65 2004 282343 2.85 2000 412319 4.17 2000 85 0.03 2002 3389 1.32 2002 3758 1.47 2002 737 0.02 2004 1470 0.05 2004 975 0.03 2004 6448 0.21 2004 564 0.03 2004 941 0.05 2004 1633 0.09 2004 9517 0.50 2004 1757 0.04 2004 49531 0.99 2004 2241 0.04 2004 2077 0.04 2004 49661 0.99 2004 240 0.12 2004 481 0.24 2004 597 0.30 2004 7782 3.87 2004 172 0.01 2004 16206 0.63 2004 3209 0.12 2004 1892 0.07 2004 3696 0.97 2001 16863 4.42 2001 30987 8.12 2001 268 0.02 2004 294 0.02 2004 213 0.02 2004 513 0.04 2004 115761 0.91 2004 690 0.01 2004 1220 0.01 2004 173 0.06 2004 1049 0.36 2004 1256 0.43 2004 3898 1.33 2004 106 0.00 2004 65999 0.42 2004 9744 0.06 2004 19082 0.12 2004 203337 1.29 2004 948 0.32 2000 870 0.29 2000 8221 2.79 2000 133 0.02 2002 2235 0.39 2002 6598 1.15 2002 90788 1.20 2000 196 The World Health Report 2006 Annex Table 4 Global distribution of health workers in WHO Member States Figures computed by WHO to ensure comparability;a they are not necessarily the of�cial statistics of Member States, which may use alternative rigorous methods. Physicians Nurses Midwives Dentists Pharmacists Density Density Density Density Density per per per per per Country Number 1000 Year Number 1000 Year Number 1000 Year Number 1000 Year Number 1000 Year Portugal 34440 3.42 2003 43860 4.36 2003 824 0.08 2000 5510 0.55 2003 9543 0.95 2003 Qatar 1310 2.22 2001 2917 4.94 2001 220 0.37 2001 530 0.90 2001 Republic of Korea 75045 1.57 2003 83333 1.75 2003 8728 0.19 2000 16033 0.34 2003 50623 1.08 2000 Republic of Moldova 11246 2.64 2003 25848 6.06 2003 991 0.23 2003 1403 0.33 2003 2061 0.48 2003 Romania 42538 1.90 2003 86802 3.89 2003 5571 0.25 2003 4919 0.22 2003 1275 0.06 2003 Russian Federation 609043 4.25 2003 1153683 8.05 2003 67403 0.47 2003 45972 0.32 2003 11404 0.08 2003 Rwanda 401 0.05 2004 3593 0.42 2004 54 0.01 2004 21 0.00 2004 278 0.03 2004 Saint Kitts and 51 1.19 1997 216 5.02 1997 8 0.19 1997 Nevis Saint Lucia 749 5.17 1999 331 2.28 1999 9 0.06 1999 Saint Vincent and 101 0.87 1997 276 2.38 1997 6 0.05 1997 the Grenadines Samoa 120 0.70 1999 346 2.02 1999 3 0.02 1999 30 0.18 1999 5 0.03 1999 San Marino 1089 47.35 1990 2196 95.48 1990 8 0.35 1990 23 1.00 1990 Sao Tome and 81 0.49 2004 256 1.55 2004 52 0.32 2004 11 0.07 2004 24 0.15 2004 Principe Saudi Arabia 34261 1.37 2004 74114 2.97 2004 4235 0.17 2004 5485 0.22 2004 Senegal 594 0.06 2004 3287 0.32 2004 97 0.01 2004 85 0.01 2004 Serbia and 21738 2.06 2002 48875 4.64 2002 2864 0.27 2002 3792 0.36 2002 1980 0.19 2002 Montenegro Seychelles 121 1.51 2004 634 7.93 2004 94 1.17 2004 61 0.76 2004 Sierra Leone 168 0.03 2004 1841 0.36 2004 5 0.00 2004 340 0.07 2004 Singapore 5747 1.40 2001 17398 4.24 2001 1087 0.26 2001 1141 0.28 2001 Slovakia 17172 3.18 2003 36569 6.77 2003 1456 0.27 2003 2364 0.44 2003 2783 0.52 2003 Slovenia 4475 2.25 2002 14327 7.21 2002 654 0.33 2001 1199 0.60 2002 790 0.40 2002 Solomon Islands 54 0.13 1999 338 0.80 1999 23 0.05 1999 26 0.06 1999 28 0.07 1999 Somalia 310 0.04 1997 1486 0.19 1997 15 0.00 1997 8 0.00 1997 South Africa 34829 0.77 2004 184459 4.08 2004 5995 0.13 2004 12521 0.28 2004 Spain 135300 3.30 2003 315200 7.68 2003 6291 0.15 2001 20005 0.49 2003 35800 0.87 2003 Sri Lanka 10479 0.55 2004 30318 1.58 2004 3113 0.16 2004 1245 0.06 2004 1066 0.06 2004 Sudan 7552 0.22 2004 28704 0.84 2004 2792 0.08 2004 1082 0.03 2004 3558 0.10 2004 Suriname 191 0.45 2000 688 1.62 2000 4 0.01 2000 Swaziland 171 0.16 2004 6828 6.30 2004 32 0.03 2004 70 0.06 2004 Sweden 29122 3.28 2002 90758 10.24 2002 6247 0.70 2002 7270 0.82 2002 5885 0.66 2002 Switzerland 25921 3.61 2002 77120 10.75 2000 2033 0.28 2000 3598 0.50 2003 4322 0.60 2003 Syrian Arab 23742 1.40 2001 32938 1.94 2001 12206 0.72 2001 8862 0.52 2001 Republic Tajikistan 12697 2.03 2003 28586 4.58 2003 3780 0.61 2003 945 0.15 2003 680 0.11 2003 Thailand 22435 0.37 2000 171605 2.82 2000 872 0.01 2000 10459 0.17 2000 15480 0.25 2000 The former Yugoslav Republic of 4459 2.19 2001 10553 5.19 2001 1456 0.72 2001 1125 0.55 2001 309 0.15 2001 Macedonia Timor-Leste 79 0.10 2004 1468 1.79 2004 327 0.40 2004 45 0.05 2004 14 0.02 2004 Togo 225 0.04 2004 2141 0.43 2004 5 0.00 2004 19 0.00 2004 134 0.03 2004 Tonga 35 0.34 2001 322 3.16 2001 19 0.19 2001 33 0.32 2001 17 0.17 2001 Trinidad and Tobago 1004 0.79 1997 3653 2.87 1997 107 0.08 1997 Tunisia 13330 1.34 2004 28537 2.87 2004 2452 0.25 2004 2909 0.29 2004 Turkey 96000 1.35 2003 121000 1.70 2003 17200 0.24 2003 22500 0.32 2003 Turkmenistan 20032 4.18 2002 43359 9.04 2002 876 0.18 2002 1626 0.34 2002 Tuvalu 6 0.55 2002 29 2.64 2002 10 0.91 2002 2 0.18 2002 1 0.09 2002 Uganda 2209 0.08 2004 16221 0.61 2004 3104 0.12 2004 363 0.01 2004 688 0.03 2004 Ukraine 143202 2.95 2003 369755 7.62 2003 24496 0.50 2003 19354 0.40 2003 23576 0.48 2001 annex table 4 197 Public and environmental Health management and health workers Community health workers Lab technicians Other health workers support workers Density Density Density Density Density per per per per per Number 1000 Year Number 1000 Year Number 1000 Year Number 1000 Year Number 1000 Year 72515 0.50 2000 670768 4.61 2000 435093 2.99 2000 101 0.01 2004 12000 1.41 2004 39 0.00 2004 521 0.06 2004 1419 0.17 2004 19 0.12 2004 374 2.27 2004 51 0.31 2004 291 1.76 2004 288 1.75 2004 39073 1.57 2004 705 0.07 2004 66 0.01 2004 704 0.07 2004 564 0.05 2004 77 0.96 2004 59 0.74 2004 35 0.44 2004 136 0.03 2004 1227 0.24 2004 4 0.00 2004 2529 0.06 2004 9160 0.20 2004 1968 0.04 2004 40526 0.90 2004 28005 0.62 2004 1541 0.08 2004 1252 0.07 2004 1546 0.08 2004 112 0.01 2004 2897 0.08 2004 5797 0.17 2004 3115 0.09 2004 8667 0.25 2004 35374 1.03 2004 110 0.10 2004 4700 4.34 2004 78 0.07 2004 551 0.51 2004 374 0.35 2004 2151 0.04 2000 3601 0.06 2000 14117 0.23 2000 153563 2.52 2000 22 0.03 2004 1657 2.02 2004 36 0.04 2004 18 0.02 2004 184 0.22 2004 289 0.06 2004 475 0.09 2004 528 0.11 2004 397 0.08 2004 1335 0.27 2004 890 0.09 2004 3936 0.40 2004 10478 1.05 2004 16276 1.64 2004 7846 1.64 2002 1042 0.04 2004 1702 0.06 2004 3617 0.14 2004 6499 0.24 2004 198 The World Health Report 2006 Annex Table 4 Global distribution of health workers in WHO Member States Figures computed by WHO to ensure comparability;a they are not necessarily the of�cial statistics of Member States, which may use alternative rigorous methods. Physicians Nurses Midwives Dentists Pharmacists Density Density Density Density Density per per per per per Country Number 1000 Year Number 1000 Year Number 1000 Year Number 1000 Year Number 1000 Year United Arab 5825 2.02 2001 12045 4.18 2001 954 0.33 2001 1086 0.38 2001 Emirates United Kingdom 133641 2.30 1997 704332 12.12 1997 36399 0.63 1997 58729 1.01 1997 29726 0.51 1997 United Republic of 822 0.02 2002 13292 0.37 2002 267 0.01 2002 365 0.01 2002 Tanzania United States of 730801 2.56 2000 2669603 9.37 2000 463663 1.63 2000 249642 0.88 2000 America Uruguay 12384 3.65 2002 2880 0.85 2002 3936 1.16 2002 Uzbekistan 71623 2.74 2003 256183 9.82 2003 21270 0.82 2003 3606 0.14 2003 899 0.03 2003 Vanuatu 20 0.11 1997 428 2.35 1997 Venezuela, 48000 1.94 2001 13680 0.55 2001 Bolivarian Republic of Viet Nam 42327 0.53 2001 44539 0.56 2001 14662 0.19 2001 5977 0.08 2001 Yemen 6739 0.33 2004 13506 0.65 2004 240 0.01 2004 850 0.04 2004 2638 0.13 2004 Zambia 1264 0.12 2004 19014 1.74 2004 2996 0.27 2004 491 0.04 2004 1039 0.01 2004 Zimbabwe 2086 0.16 2004 9357 0.72 2004 310 0.02 2004 883 0.07 2004 a See explanatory notes for sources and methods. annex table 4 199 Public and environmental Health management and health workers Community health workers Lab technicians Other health workers support workers Density Density Density Density Density per per per per per Number 1000 Year Number 1000 Year Number 1000 Year Number 1000 Year Number 1000 Year 14439 0.25 1997 20035 0.34 1997 161490 2.78 1997 1231666 21.20 1997 1831 0.05 2002 1520 0.04 2002 29722 0.82 2002 689 0.02 2002 611993 2.15 2000 4177609 14.66 2000 7056080 24.76 2000 792 0.04 2004 6025 0.29 2004 4709 0.23 2004 4580 0.22 2004 10902 0.53 2004 1027 0.09 2004 1415 0.13 2004 3330 0.30 2004 10853 0.99 2004 1803 0.14 2004 917 0.07 2004 743 0.06 2004 581 0.04 2004 index 201 index A Americas, Region of the absenteeism 108, 148 critical shortages of health workforce, by region 13 accountability, with responsibility 86 health expenditure vs disease burden 9 accreditation, medical education 46 health workforce numbers, by density xvii, 5 action Angola national priorities 150–151 doctors/nurses migrating to OECD countries 100 ten-year plan 150 self-regulation of governance 121–122 admissions policies, medical education 46–48 Argentina, private medical education 46 African Region assessment and development tools, THE connection 141 critical shortages of health workforce, by region 13 asset quintiles, de�ned 20 health expenditure vs disease burden 9 audit, and feedback (randomized controlled trials) 138 health workforce numbers, by density xvii, 5 Australia, doctors/nurses trained abroad 98 pharmaceuticals 81 avian influenza, Turkey, deployment of health personnel 33 reasons why workforce migrates 99 sex distribution of health workers 6 B statutory pensionable age 110 bioethics, in conflict environments 36 see also sub-Saharan Africa births age of health workers 6 density of health workforce required for skilled statutory pensionable ages 110 attendance 11–12 age of population, demographic change, training of attendants, and maternal mortality 24 Europe and Japan 143 Botswana HIV/AIDS, safety of nurses/health workers 107 nurses/midwives migrating to OECD countries 100 Brazil, Observatory of Human Resources in Health 128 202 The World Health Report 2006 C curriculum Cameroon demands 47–48 doctors/nurses migrating to OECD countries 100 nature of competencies 48 reasons why workforce migrates 99 Canada, doctors/nurses trained abroad 98 D capacity building decentralization 126, 127 policy-making 127 delegation 23–24 tools 125, 127 density of health workforce xvii, 5 Cape Verde, professional values 74 and infant mortality rate xvi, 68 change of occupation 107–109 threshold for skilled attendance at births 11 Chile, private medical education 46 dental schools, numbers, by WHO region 44 chronic disease xix, 24–29 dentists, numbers 5 core competencies 24 disasters/emergencies 22–36 civil society organizations 123, 124 coalitions for national plans 144 classi�cation of health workforce 3 conflict/post-conflict environments 34–36 coaching 125 lack of health worker recruitment 29 Cochrane systematic reviews 138–139 planning strategies 22–31, 144–147 audit and feedback 138 see also health workforce doctors substituted by nurses 138 preparedness team 29 lay health workers 138 recruitment of workers 29 codes of conduct, and professionalism 72–73 training for emergency response 31 collaboration 135–151 disease, chronic xix, 24–29 areas of concern (imperatives) 135 doctors/nurses see health workforce; nurses/midwives catalysing knowledge and learning 135–142 driving forces xvii cooperative agreements 143 health workers/patients 27 E response to workforce crisis 143–147 Eastern Mediterranean Region stakeholder alliances 147–151 critical shortages of health workforce, by region 13 Colombia health expenditure vs disease burden 9 change team 125 health workforce numbers, by density xvii, 5 student investment recuperation 57 private medical education 46 common technical framework for human resources 137–141 sex distribution of health workforce 6 tools (THE connection) 141 statutory pensionable age 110 community health workers, research priorities 140 emergency needs see disasters/emergencies computers, handheld 80 employer power 121–122 conflict environments 34–36 enabling policies 150 injuries 24–29 levers to influence performance 82–86 protection of health systems 35 epidemiology, changing place in curriculum 47 Congo, Democratic Republic of, private Ethiopia, doctors/nurses migrating to OECD countries 100 medical education 46 European Region consumer defence organizations 123 demographic change 143 consumer groups 123 health expenditure vs disease burden 9 cooperation see collaboration health workforce numbers, by density xvii, 5 cooperative agreements 143, 149 sex distribution of health workforce 6 core competencies, long-term care 25 statutory pensionable age 110 Côte d’Ivoire, private technical education 46 European Health Management Association 73 crisis response, �nancing crisis in evidence-based medicine 122 poorest countries 143–144, 149, 150 Cuba, “medical brigades� 104 index 203 exits from health workforce xxii, xxiii, 97–112 Global Atlas of the Health Workforce 4 change of occupation 107–109 Global Fund to �ght AIDS, Tuberculosis and Malaria, migration 98–105 number of proposals 145–146 occupational risks 105–107 global and national stakeholder alliances xxvi, 147–151 retirement 109–111 Global Outbreak Alert and Response Network 29, 30 routes 98 global solidarity expertise 141 national priorities for action (2006–2015) xxv, 149 ten-year plan (2006–2015) xxv, 150 F governance 121–125 �nancing 145–150 command-and-control 122 crisis in poorest countries 143–144, 149 cooperative, national workforce policies 124 estimate of cost of shortfall (per country/region) 13–14 model 123–124 �nancial/non-�nancial incentives 84 self-regulation 121–122 global guideline 146 watchdogs and advocates 123 health expenditure vs disease burden 9 Guinea-Bissau, nurses/midwives migrating to international development assistance for health, OECD countries 100 total flows 146 Guyana, retirement policies 106 MDGs costing models 145–146 H scaling up and annual investment per country 145 Health Emergency Action Response Network 32 outsourcing 147 health information system (HIS), performance proportion of GGHE paid to health workforce 7 (Ghana and Thailand) 136 public �nancing rules/restrictions 147 Health InterNetwork Access to Research recommendations 146, 148 Initiative (HINARI) 54 sustainable, long-term donor funds 147 health technical framework, sustainable health see also salaries/wages workforce 137 Finland, doctors/nurses trained abroad 98 health workforce 1–15, 41–64, 67–95 Foundation for Advancement of International Medical absentees and ghost workers 108–109 Education and Research (FAIMER) 50 audit and feedback (Cochrane reviews) 138 France, doctors/nurses trained abroad 98 change of occupation 107–109 classi�cation 3 G shortcomings 136 gender collaboration with patients 27 and age of health workforce 6 community health workers 140 and performance of health workforce 70 crisis in poorest countries 143–144, 149 wages 76 critical shortages, by region xviii, 13 general government health expenditure (GGHE), de�ning criteria 1–4 proportion paid to health workforce 7 density Germany, doctors/nurses trained abroad 98 and infant mortality rate 68 Ghana numbers xvii, 5 doctors/nurses migrating to OECD countries 100 and survival rates xvi ghost workers 109 development health information system (HIS) 136 and assessment tools 141 supportive supervision of health workforce 74 common technical framework for human volunteers in local services 23, 26 resources 137 ghost workers 109, 147, 148 disasters/emergencies Global Alliance for Vaccines and deployment strategy 32 Immunization (GAVI) 145, 146 front-line workers 32 Health Emergency Action Response Network 32 planning strategies 22–31 204 The World Health Report 2006 health workforce (continued) health workforce (continued) distribution by health expenditure/disease burden 9 problem-solving, four areas 126 doctors, substituted by nurses (Cochrane reviews) 138 providers vs support workers xvi, 2, 4 doctors/nurses migrating to OECD countries 98, 100 providing support to human resources 104 education, health service and labour markets 56 recruitment 41–42 entry–workforce–exit xx, xxi and natural disasters 29 global numbers 4–6 retirement 109–111 hiring, public �nancing rules/restrictions 147 selection 41–43 in-service training 20–21 shortages 19–21 information limits and effects 135–136 strategic intelligence 126–127 innovations 128–129 sustainable 137 lay health workers 138 teaching, practice-based 49 Cochrane reviews 138 team management 84–86 place in local services 23, 26, 146 training 43–54 leaving see exits from health workforce trust/expectations 120–121 levers to influence performance xxi, 71–89 wages/salaries 75–80 accountability with responsibility 86 proportion of government expenditure 7 codes of conduct 72–73 worker-friendly practices 144 enabling policies 82–86 see also human resources; national workforce information and communication 80–81 strategies; training institutions infrastructure and supplies 81–82 high-priority services 19–24 job descriptions 72, 74 HIV/AIDS productivity measurement 80–81 aid and workforce constraints 144 remuneration 75–80 recruitment and attrition of health workforce 24, 58, 107 skills matching 73–75 safety of nurses/health workforce 106 supportive supervision 74, 75, 83 ILO/WHO guidelines 108 see also salaries/wages salaries, two tiers of 21 locations 8–13 shortfall in worker numbers 11 management systems and tools 142 human resources managers 4 common technical framework 137–142 measures of good performance 67–70 cooperation 141–142 microinnovations 128–129 policy-making 142–151 Millennium Development Goals (MDGs) 11, 19–24, development/diversity 142 144–145 technical skills 142 numbers providing support 104 by density xvii, 5 tools (THE connection) 141 de�cit 143 see also health workforce diversity and competencies 41–42 human resources practitioners, establishing network 141 shortages xviii, 19–21 underutilized talent xviii I occupational risks 105–107 immunization optimizing performance 58, 67–86 and density of health workforce 139 assessment 71 Global Alliance for Vaccines and Immunization 145, 146 availability 68–69, 71, 86–87 training institutions 48 competence 68–69, 71, 87 in-service training 20–21, 51 desired dimensions 68–69, 71, 86–68 incentives 79 determinants 70–71 non-�nancial 84 gender differences 70 salaries/wages 78–80 performance outcomes 54–56 India productivity 68–69, 71, 80–81, 87 Bhore report 43 responsiveness 69, 70, 71, 87 private medical education 46 index 205 Indonesia, job descriptions 74 L infant mortality Lady Health Workers, Pakistan 59 Viet Nam 68 Latin America see also births health workforce numbers, by density xvii, 5 information Pan American Health Organization (PAHO) 128 and communication 80–81 private medical education 46 health information system (HIS) 136 sex distribution of health workforce 6 limitations and their effects 135–136 see also Americas strategic, disaster situations 34 lay health workers strategic intelligence on core indicators 126–127 Cochrane reviews 138 injuries 24–29 place in local services 23, 26 innovations 128–129 research priorities 140 institutions leadership building, link with training 127 national priorities 148–149 cooperation with ministries 124 national workforce strategies xxiii, 125 investing in 127–129 ten-year plan of action 150–151 leadership issues xxiii, 125 Leadership for Change (ICN) 85 see also training institutions Lesotho Integrated Case Management Process 51 age of doctors 111 Integrated Management of Adult and Adolescent HIV/AIDS, safety of nurses/health workers 107 Illness (IMAI), training 24 nurses/midwives migrating to OECD countries 100 Integrated Management of Childhood Illness (IMCI) 51 levers (to influence performance) 71, 86–89 intercountry exchange 125 see also health workforce International Campaign to Revitalize Academic Medicine location of health workforce 8–13 (ICRAM) 43 rural–urban distribution 9 international collaboration see collaboration long-term care, core competencies 25 International Council of Nurses (ICN), Leadership for long-term planning, scenario building 129 Change 85 International Standard Classi�cation of Occupations (ISCO), coding 3 M malaria, place of volunteers 23–24 International Standard Industrial Classi�cation of all Malawi Economic Activities (ISIC) 3 Emergency Human Resources Plan 144, 146 investment, training link to institution building 127 emergency programme for recruitment 22 Ireland health workforce problem-solving 126 doctors/nurses trained abroad 98 HIV/AIDS, safety of nurses/health workers 107 exit management 106 nurses/midwives migrating to OECD countries 100 Performance Contract scheme 85 J Mali, performance-related pay 78 Japan, demographic change 143 mapping, Service Availability Mapping 10 job descriptions 72, 74 maternal mortality, training of attendants 24 Joint Learning Initiative (JLI) 11, 141 Mauritius, nurses/midwives migrating to OECD countries 100 K medical crimes 36 Kenya, nurses/midwives migrating to OECD countries 100 medical education knowledge base 135–142, 149, 150 academic education future 43 lack of information 139 accreditation programmes and private institutions 46 Kyrgyzstan, Mandatory Health Insurance Fund, quality and admissions policies 46–48 value improvement 84 curriculum demands 47–48 faculty development programmes 50 206 The World Health Report 2006 medical education (continued) national workforce strategies 119–130 history 43 cooperation, ministries and institutions 124 International Campaign to Revitalize Academic fair governance 121–125 Medicine (ICRAM) 43 investing in institutions 127–129 new trends 49 leadership xxiii, 125 student attrition 47 policies 124 training institutions summary of aims 129–130 by WHO region 44 strategic intelligence 126 key functions 43–44 trust/expectations 120–121 private 46 needs-based suf�ciency 11–12 see also health workforce; training Netherlands, scenario building and planning 129 medicalization, caesarean birth 123 New Zealand, doctors/nurses trained abroad 98 mental health services 25–26 Nigeria, doctors/nurses migrating to OECD countries 100 optimal mix 26 nurses/midwives mentoring 125 (ICN) Leadership for Change 85 Mexico, Summit on Health Research, OECD countries, staff trained abroad 98, 100 priorities for action 140 ratio to doctors xvi, 4 microinnovations 128–129, 140 training institutions, by WHO region 44 migration 98–105 see also health workforce; medical education; training impacts 101, 148 professionals in OECD countries but trained abroad 98 O providing support to human resources 104 occupational risks 105–107 international instruments 104–105 violence 105–106 push/pull factors 99 OECD countries return and reintegration of migrants 101 doctors/nurses migrating from sub-Saharan Africa 100 stemming flow to OECD countries 148 professionals trained abroad 98 strategies to manage 101–102 onchocerciasis, control programme, “piggy-backing� 23 adjust training to needs/demands 102 Oslo Consultations, stakeholder alliances 148 improve local conditions 103 responsible recruitment policies 103, 104 P Millennium Development Goals (MDGs) xix, 11, 19–24, 145 Pakistan, Lady Health Workers 59 aid and workforce constraints 144 PALTEX programme 54 cost of meeting 145 Pan American Health Organization (PAHO) 128 salaries 14 Observatory of Human Resources in Health 128 ministries of health, checks and balances 124 patients Mozambique collaboration with health workers in self-care 27 advanced planning strategies 34 safety 28 assistant surgical of�cers 128 performance improvement/appraisal doctors/nurses migrating to OECD countries 100 health information system (HIS) 136 microinnovations 128 Malawi and Zambia 85 professional values 74 see also health workforce, optimizing performance performance-related pay 78 N Peru, private medical education 46 Namibia, nurses/midwives migrating to OECD countries 100 pharmaceuticals, Africa and South-East Asia 81 national level health workforce institutions 127 pharmacists national priorities for action 148–151 numbers, by WHO region 44 global solidarity xxv, 149 training (Ohio State University) 49 ten-year plan (2006–2015) 150–151 index 207 Philippines R private nursing education 46 recruitment of health workers 41–42 temporary migration and reintegration of migrants 101 attrition 58 “piggy-backing� of control programme 23 disasters/emergencies 29 planning, ten-year plan of action (2006–2015) 150–151 evaluation of performance and policy 54 planning strategies in disasters 22–36 improving performance 58 advanced planning 34 local recruitment advantages 59 policy-making 142–151 performance outcomes 54–56 capacity building 127 pipeline model 41–42, 52 development/diversity of technical skills 142 policy-making 54–58 recruitment policies 54 self-recruitment 58–59 regulatory measures 127 targeting 108–109 poliomyelitis 23 see also migration political forces, and workforce 125 regional collaboration see collaboration political skills, leadership, and capacity building 125 remuneration see salaries/wages Portugal, doctors/nurses trained abroad 98 research practice-based teaching, and patient-focused practice 49 into training and recruitment outcomes 54–56 pre-service training (IMCI) 51 Mexico Summit, priorities for action 140 preparedness priorities related to community health workers 140 command and control approach 30 resources, Health InterNetwork Access to Research repair and prepare 35 Initiative (HINARI) 54 SARS outbreak 29 retirement 109–111 private sector management 111 employment fears 127 policies in Guyana 106 numbers 5 statutory pensionable age 110 training institutions 46 succession planning 111 salaries, vs public sector 7, 76 risk communication 30 problem-solving, four areas 126 professional development 82–83 audit and feedback 138 S salaries/wages 75–80 self-regulation 121–122 cross-country comparisons 76 professionalism differentials 76 codes of conduct 72–73 gender differences 76 and employer power 121–122 incentives 78–80 psychiatrists non-�nancial incentives 84 shortage 26–27 performance-related pay 78 training, infrastructure and technology 52–53 private vs public sector 76 public health training institutions proportion of government expenditure 7 by WHO region 44 unpaid 77 South-East Asia 45 SARS outbreak, preparedness team 29 scenario building and planning 129 Q sector boundaries 30 quality assurance, supervision and monitoring, Uganda 83 self-regulation 121–122 Service Availability Mapping (SAM) 10 sex distribution of health workers xvi, 6 simpli�cation of services 23–24 skills matching, optimizing performance 73–75 208 The World Health Report 2006 South Africa Thailand doctors/nurses migrating to OECD countries 100 health information system (HIS) 136 importance of good management 85 performance-related pay 78 occupational classi�cations (census 2001) 3 response to epidemics/disasters 31 reasons why workforce migrates 99 Rural Doctors Association 122 and UK, agreement on responsible scenario building and planning 129 recruitment policies 104 THE connection, tools for assessment and South America see Latin America development in health workforce 141 South Paci�c, University of (USP) 53 training South-East Asia Region crash courses in disasters/emergencies 34 critical shortages of health workforce, by region 13 for emergencies 31 health workforce numbers, by density xvii, 5 faculty development programmes 50 pharmaceuticals 81 IMAI 24 public health training institutions 45 in-service 20–21 sex distribution of health workforce 6 vs pre-service (IMCI) 51 statutory pensionable age 110 link to institution building 127 stakeholder alliances xxvi, 147–151 professional development 82–83 Oslo Consultations 148 professionals trained abroad in OECD countries 98 strategic intelligence 126–127 recuperation of student investment (Colombia) 57 sub-Saharan Africa traditional attendants, and maternal mortality 24 density of health workforce required for skilled training institutions attendance at births 11–12 evaluation of performance and policy 54 doctors/nurses migrating to OECD countries 100 infrastructure and technology 52–53 HIV/AIDS, safety of nurses/health workers 107 key functions 43–44 pharmaceuticals 81 numbers private sector, numbers 5 by WHO region 44 reasons why workforce migrates 99 data collection 54 see also African Region private 46 supportive supervision of health workers 74, 75, 83 regionalization of universities 53 Swaziland research into training and performance outcomes 54–56 nurses/midwives migrating to OECD countries 100 student attrition 47 safe workplace campaign 106 see also medical education Sweden, violence as health worker occupational risk 105 trust and expectations Switzerland, age of doctors 111 public 127 synergies, “piggy-backing� of control programme 23 workforce 120–121 tsunami, Thailand’s response 31 T Turkey, avian influenza, deployment of health personnel 33 task delegation 23–24 teaching U �nance and excellence 50 Uganda practice-based 49 decentralization 127 team management, health workforce 84–86 doctors/nurses migrating to OECD countries 100 technical framework for human resources 137–142 Memorandum of Understanding 142 cooperation 141–142 quality assurance, supervision and monitoring 83, 86 tools (THE connection) 141 reasons why workforce migrates 99 technology, training institutions 52–53 self-regulation of governance 121–122 ten-year plan of action (2006–2015) 150 index 209 United Kingdom Z agreement with South Africa on responsible Zambia recruitment policies 104 HIV/AIDS, safety of nurses/health workers 106, 107 doctors/nurses trained abroad 98 nurses/midwives migrating to OECD countries 100 statutory pensionable age 110 Performance Improvement Review 85 total quality management 84 safe workplace campaign 106 Zero Tolerance campaign against violence 106 Service Availability Mapping (SAM) 10 United Republic of Tanzania Zero Tolerance campaign against violence, UK 106 doctors/nurses migrating to OECD countries 100 Zimbabwe salary enhancement scheme 77 decentralization 127 skills mismatching 74 doctors/nurses migrating to OECD countries 100 United States of America reasons why workforce migrates 99 age of health workers 110 doctors/nurses trained abroad 98 skills mismatching 74 statutory pensionable age 110 total quality management 84 V Viet Nam, infant mortality, health worker density 68 violence, occupational risk 105–106 volunteers, place in local services 23, 26 W wages see salaries/wages wars see conflict environments watchdogs and advocates 123 West Indies, University of (UWI) 53 Western Paci�c Region critical shortages of health workforce, by region 13 health expenditure vs disease burden 7, 9 health workforce numbers, by density xvii, 5 sex distribution of health workforce 6 statutory pensionable age 110 world critical shortages of health workforce xviii by region 13 health expenditure 7 health workforce numbers, by density xvii, 5 World Trade Association, General Agreement on Trade in Services 105 Note: this index does not include the Statistical Annexes and their explanatory notes.