Tables -Overview Table 1 Global health workforce, by density Table 2 Ten-year plan of action XXV Tables-Chapters Table 1.1 Global health workforce, by density Table 1.2 Proportion of government health expenditure paid to health workers Table 1.3 Estimated critical shortages of doctors, nurses and midwives by wHO region Deployment of state-employed health personnel in response to avian influenza outbreak in Turkey Table 3.1 Functions of health educational institutions to generate the health workforce Table 3.2 Health professional training institutions, by WHO region Table 4.1 Dimensions of health workforce performand Human resource indicators to assess health workforce performance 71 Table 4.3 Pharmaceutical situations in public health facilities in Africa and South-East 81 Table 4.4 Tb pproaches to professional development and performance An aid to thinking through potential effects of levers on health workforce performance Health workforce performance: provisional assessment of implementation and effects of levers Table 5.1 octors and nurses trained abroad working in OECD countries Table 5.2 Doctors trained in sub-Saharan Africa working in OECD countries Table 5.3 Nurses and midwives trained in sub-Saharan africa working in OECD countries Table 5.4 Statutory pensionable age 110 Table 7.1 Short description of results of three Cochrane systematic reviews on human resources for health Table 7.2 Ten-year plan of action 150
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
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 benefit the population. When health workers leave to work elsewhere, there is a loss of hop nd 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 staffing; and between those able to make financial 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 first step towards addressing and resolving this urgent crisis Dr LEE Jong-wook Director-General World Health Organization
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 benefit 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 staffing; and between those able to make financial 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 first step towards addressing and resolving this urgent crisis. Dr LEE Jong-wook Director-General World Health Organization
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working together for health
OVerview for health " We have to work together to ensure access to a motivated WHY THE WORKFORCE IS IMPORTANT skilled, and supported In this first 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 benefits of new medicines and tech- everyone nologies. But there are unprecedented reversals LEE Jong-wook 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 HIviAIDS 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 sufficient financial 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 intemational 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 personification malnutrition has worsened with staff cutbacks 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
xv overview Why the workforce is important In this first decade of the 21st century, immense advances in human well-being coexist with extreme deprivation. In global health we are witnessing the benefits of new medicines and technologies. But there are unprecedented reversals. 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. “We have to work together to ensure access to a motivated, skilled, and supported health worker by every person in every village everywhere.” LEE Jong-wook High-Level Forum, Paris, November 2005 The world community has sufficient financial resources and technologies to tackle most of these health challenges; yet today many national health systems are weak, unresponsive, inequitable – even unsafe. What is needed now is political will to implement national plans, together with international cooperation to align resources, harness knowledge and build robust health systems for treating and preventing disease and promoting population health. Developing capable, motivated and supported health workers is essential for overcoming bottlenecks to achieve national and global health goals. Health care is a labour-intensive service industry. Health service providers are the personification of a system’s core values – they heal and care for people, ease pain and suffering, prevent disease and mitigate risk – the human link that connects knowledge to health action. At the heart of each and every health system, the workforce is central to advancing health. There is ample evidence that worker numbers and quality are positively associated with immunization coverage, outreach of primary care, and infant, child and maternal survival (see Figure 1). The quality of doctors and the density of their distribution have been shown to correlate with positive outcomes in cardiovascular diseases. Conversely, child malnutrition has worsened with staff cutbacks during health sector reform. Cutting-edge quality improvements of health care are best initiated by workers themselves because they are in the unique © Médecins Sans Frontières working together for health
xvi The World Health Report 2006 Figure 1 Health workers save lives 墨 Maternal survival Child survival Infant survival Density of health workers 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 definition 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 staffing 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 Pacific 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
xvi The World Health Report 2006 position of identifying opportunities for innovation. In health systems, workers function 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 escorting 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 definition of health systems as comprising all activities with the primary goal of improving health – inclusive of family caregivers, patient–provider partners, parttime 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 workers 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 organizations (such as nurses staffing 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 Pacific 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 competencies 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. Maternal survival Probability of survival High Low Figure 1 Health workers save lives! Low Density of health workers High Child survival Infant survival