Health Employment

and Economic Growth

An Evidence Base
Health Employment and Economic Growth
Powerful demographic and economic forces are shaping health The 17 chapters
workforce needs and demands worldwide. in this book, are

Effectively addressing current and future health workforce

grouped into
four parts: An Evidence Base
needs and demands stands as one of our foremost challenges.
It also represents an opportunity to secure a future that is • Health workforce
healthy, peaceful, and prosperous. dynamics

The contents of this book give direction and detail to a richer • Economic value Edited by
and more holistic understanding of the health workforce and investment
James Buchan
through the presentation of new evidence and solutions-
focused analysis. It sets out, under one cover, a series of • Education and Ibadat S. Dhillon
research studies and papers that were commissioned to production
provide evidence for the High-Level Commission on Health James Campbell
Employment and Economic Growth. • Addressing
inefficiencies

‘’An essential read that rightfully places investments in health workforce at the heart
of the SDG Agenda.”
— Richard Horton, Editor-in-Chief
The Lancet

“A resource of fundamental importance. Evidences the socio-economic benefits

that follow from appropriately recognizing, rewarding, and supporting women’s

Campbell
Dhillon
Buchan
work in health.”
— H.R.H. Princess Muna al-Hussein,
Princess of Jordan
Health Employment
and Economic Growth
An Evidence Base

Edited by
James Buchan
Ibadat S. Dhillon
James Campbell

i
 Health Employment and Economic Growth: An Evidence Base
ISBN 978-92-4-151240-4

© World Health Organization 2017

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17-004 WHO Health Employment and Economic Growth TEXT LowColor 9.indd 2 10/27/17 16:04
Contents
List of Tables, Boxes and Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
List of Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Introduction to Health Employment and Economic Growth:
An Evidence Base, by James Buchan, Ibadat S. Dhillon, James Campbell . . . . xv

PART I: Health Workforce Dynamics

Chapter 1 Health workforce needs, demand and shortages to 2030:
an overview of forecasted trends in the global health
labour market,
by Giorgio Cometto, Richard Scheffler, Tim Bruckner,
Jenny Liu, Akiko Maeda, Gail Tomblin-Murphy, David Hunter,
James Campbell . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Chapter 2 Women’s contributions to sustainable development
through work in health: using a gender lens to advance
a transformative 2030 agenda,
by Veronica Magar, Megan Gerecke, Ibadat S. Dhillon,
James Campbell . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Chapter 3 Achieving sustainable and appropriately trained health and
social care workers for ageing populations,
by Edward Salsberg, Leo Quigley . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Chapter 4 International migration of doctors and nurses to OECD
countries: recent trends and policy implications,
by Jean-Christophe Dumont, Gaétan Lafortune . . . . . . . . . . . . . . . . . 81
Chapter 5 Human resources for health care in the Nordic welfare
economies: successful today, but sustainable tomorrow?,
by Tyra Merker, Ivar Sønbø Kristiansen, Erik Magnus Sæther . . . . . . . . . 119
Chapter 6 Global estimates of the size of the health workforce
contributing to the health economy: the potential for
creating decent work in achieving universal health coverage,
by Xenia Scheil-Adlung, Andrea Nove . . . . . . . . . . . . . . . . . . . . . . . 139

EVIDENCE: POLICY BRIEFS

CONTENTS iii
 PART II: Economic Value and Investment
Chapter 7 Pathways: the health system, health employment,
and economic growth,
by Jeremy A. Lauer, Agnès Soucat, Edson Araújo, David Weakliam . . . 173
Chapter 8 Health and inclusive growth: changing the dialogue,
by Chris James . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
Chapter 9 Paying for needed health workers for the SDGs:
an analysis of fiscal and financial space,
by Jeremy A. Lauer, Agnès Soucat, Edson Araújo, Melanie Y. Bertram,
Tessa Edejer, Callum Brindley, Elina Dale, Amanda Tan . . . . . . . . . . . 213
Chapter 10 Evidence on the effectiveness and cost-effectiveness of
nursing and midwifery interventions: a rapid review,
by Marc Suhrcke, Yevgeniy Goryakin, Andrew Mirelman . . . . . . . . . 241

PART III: Education and Production

Chapter 11 The economics of health professional education and careers:
a health labour market perspective,
by Barbara McPake, Edson Araújo Correia, Gillian Lê . . . . . . . . . . . . 261
Chapter 12 Transforming the health workforce: unleashing the potential
of technical and vocational education and training,
by Julian Fisher, Keith Holmes, Borhene Chakroun . . . . . . . . . . . . . 281
Chapter 13 Enabling universal coverage and empowering communities
through socially accountable health workforce education,
by Björg Pálsdóttir, Nadia Cobb, Julian Fisher, John H.V. Gilbert,
Lyn Middleton, Carole Reeve, Mariela Licha Salomon, Roger Strasser . . . 307

PART IV: Addressing Inefficiencies

Chapter 14 Equipping health workers with the right skills, in the right
mix and in the right numbers, in OECD countries,
by Liliane Moreira, Gaétan Lafortune . . . . . . . . . . . . . . . . . . . . . . . 341
Chapter 15 The role of decent work in the health sector,
by Christiane Wiskow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363
Chapter 16 A hidden human resources for health challenge:
personnel posting and transfer,
by Marta Schaaf, Kabir Sheikh, Lynn Freedman, Arielle Juberg . . . . . . . . . . 387
Chapter 17 Geographical variations in outpatient physician supply
in Germany: encouraging a more even distribution of
outpatient health care services in rural and urban areas,
by Stefan Scholz, Wolfgang Greiner . . . . . . . . . . . . . . . . . . . . . . . . 407

iv Health Employment and Economic Growth: An Evidence Base

LIST OF TABLES, BOXES AND FIGURES
TABLES
CHAPTER 1
Table 1 Supply of health workers (millions), 2013 (WHO Global Health
Observatory) and 2030 (forecast) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Table 2 Estimates of health worker needs-based shortages (millions)
in countries below the SDG index threshold by region,
2013 and 2030 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Table 3 Estimates of labour market demand (millions) for
health workers in 2013 and 2030 (165 countries) . . . . . . . . . . . . . . . . 17

CHAPTER 4
Table 1 Practising doctors by place of birth in 30 OECD countries,
2000/2001 and 2010/2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Table 2 Practising nurses by place of birth in 30 OECD countries,
2000/2001 and 2010/2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Table 3 Foreign-trained doctors working in 26 OECD countries,
2000, 2006 and 2012–2014 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Table 4 Foreign-trained nurses working in 25 OECD countries,
2000, 2006 and 2012–2014 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Table 5 Trends in the expatriation rates of doctors and nurses
to OECD countries, 2000/2001 and 2010/2011 . . . . . . . . . . . . . . . . . 100
Table 6 Estimated critical shortages of doctors, nurses and
midwives, by WHO region, 2000/2001 and 2010/2011 . . . . . . . . . . . 103

CHAPTER 5
Table 1 Projections for health care personnel demand in Norway
in 2060 (in thousand FTEs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131

CHAPTER 6
Table 1 Conceptual framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Table 2 Median ratio of NHO workers to HO workers in 52
ILOSTAT countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
Table 3 WHO database categories and their ISCO code equivalents . . . . . . . . 165
Table 4 Median number of workers per 1000 population in
low-vulnerability countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169

CHAPTER 9
Table 1 Wage indexes for health workers by cadre . . . . . . . . . . . . . . . . . . . . 222

CHAPTER 11
Table 1 Search terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279
Table 2 MeSH terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280

CONTENTS v
 CHAPTER 17
Table 1 Dependent and independent variables at district level (n = 412) . . . . . . 425
Table 2 Results of the three zero-truncated, negative binomial GLMs
for GP density, specialist density and ratio of GPs–specialists . . . . . . . 427

FIGURES
CHAPTER 1
Figure 1 SDG composite index: percentage of 12 SDG tracer indicators
achieved as a function of aggregate density of doctors, nurses
and midwives per 1000 population . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

CHAPTER 2
Figure 1 Women’s share of employment in the health and social sector
versus total employment (%), by WHO region, average values
for the period 2005–2014 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Figure 2 Unadjusted gender wage gaps in mean monthly earnings
among health professionals and health associate professionals, 2005–
2014 (latest year for which data are available) . . . . . . . . . . . . . . . . . . . 36
Figure 3 Women’s share of senior positions over their share
of employment, by sector and by country, 2007 . . . . . . . . . . . . . . . . . 38

CHAPTER 3
Figure 1 Percentage of population aged 60 years and over: 2015 and 2050 . . . 55
Figure 2 Young children and older people as a percentage of global population,
1950 to 2050 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Figure 3 People-centred integrated health services delivery:
the example of Alzheimer’s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

CHAPTER 4
Figure 1 Number of foreign-born doctors and nurses in 30 OECD
countries by main region of origin, 2000/2001 and 2010/2011 . . . . . . . . 96
Figure 2 Number of foreign-born doctors and nurses in OECD
countries by 25 main countries of origin, 2000/2001
and 2010/2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Figure 3 Changes in the number of domestic graduates and inflow
of foreign-trained health workers, United States, 2001–2014 . . . . . . 106
Figure 4 Changes in the numbers of domestic graduates and inflow of
foreign-trained health workers, United Kingdom, 2000–2014 . . . . . . 107
Figure 5 Changes in numbers of new registrations of doctors
trained in Poland in three OECD countries, 2001–2012 . . . . . . . . . . . 109
Figure 6 Changes in numbers of new registrations in Italy and France
of nurses trained in Romania, 2000–2012 and 2006–2012 . . . . . . . . 110

vi Health Employment and Economic Growth: An Evidence Base

CHAPTER 5
Figure 1 Density of physicians and nurses in the Nordic countries . . . . . . . . . 124
Figure 2 Demographic development and projection for Norway . . . . . . . . . . . 127
Figure 3 Forecasting health care demand . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
Figure 4 Projected balance between supply and demand of health
care personnel in Norway in 2035 . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
Figure 5 Predicted unfunded public spending as percentage of
Norway’s mainland GDP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134

CHAPTER 6
Figure 1 Composition of workers in the global health economy
(thousands), 2015 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
Figure 2 Ratio of NHO workers to HO workers, by income group, 2015 . . . . 148
Figure 3 Numbers of formal HO workers and NHO workers
currently available and missing, 2015 . . . . . . . . . . . . . . . . . . . . . . . . 149
Figure 4 Numbers of formal HO workers and NHO workers missing
in public and private employment, by region, 2015 . . . . . . . . . . . . . . 149
Figure 5 Additional HO and NHO jobs to be created by 2030 in
public and private employment, by income group . . . . . . . . . . . . . . . 150

CHAPTER 7
Figure 1 Pathways to economic growth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
Figure 2 Knock-on effects: some virtuous cycles . . . . . . . . . . . . . . . . . . . . . . 190

CHAPTER 8
Figure 1 Gross hourly earning by age and health status in 21 European
OECD countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
Figure 2 Incidence of absenteeism and presenteeism (%) and
average absence duration (days) by mental health status,
average over 21 European OECD countries in 2010 . . . . . . . . . . . . . 200
Figure 3 Employment in health and social work as a share of total employment,
OECD countries, 2000 and 2014 (or latest year available) . . . . . . . . . 205
Figure 4 Employment growth by sector, 2000–2014 (or latest year),
OECD average . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206

CHAPTER 9
Figure 1 Fiscal and financial space, domains and interactions . . . . . . . . . . . . . 217
Figure 2 Comparison of average health worker wage indexes estimated
from ILOSTAT and from the GHED, displayed by World Bank
income group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
Figure 3 Sample statistics (mean, median, percentiles) for wage bills expressed
as a proportion of general government expenditure
on health, estimated from unpublished data in the GHED
(n = 136), displayed by World Bank income group . . . . . . . . . . . . . . 228

CONTENTS vii
 Figure 4 Number of countries where the wage bills of meeting normative health
worker targets would amount to more than 60% of
projected public spending on health in 2030 (n = 183) . . . . . . . . . . . 229
Figure 5 Number of countries where the wage bills of meeting normative health
worker targets would amount to more than 90% of projected public
spending on health in 2030 (n = 183) . . . . . . . . . . . . . . . . . . . . . . . . 230
Figure 6 Projected financing gap for wages, and % of GDP and total
health expenditure required to pay additional wage bills, in
low-income countries over the period 2016–2030, assuming
an average health worker wage index (for all cadres) of
3 times GDP per capita . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
Figure 7. Projected financing gap for wages, and % of GDP and total
health expenditure required to pay additional wage bills, in
lower middle-income countries over the period 2016–2030, assuming an
average health worker wage index (for all
cadres) of 3 times GDP per capita . . . . . . . . . . . . . . . . . . . . . . . . . . . 234

CHAPTER 11
Figure 1 Interaction between education and labour markets, and
health systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263
Figure 2 Hours-adjusted internal rate of return on additional training
for five surgical specialties and primary care medicine . . . . . . . . . . . 268
Figure 3 Growth in the remuneration of GPs and specialists, 2005–2013
(or nearest year) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
Figure 4 Founding dates of medical schools in sub-Saharan Africa
by sector . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271

CHAPTER 13
Figure 1 THEnet social accountability framework . . . . . . . . . . . . . . . . . . . . . . 328
Figure 2 Building blocks for socially accountable health workforce
education institutions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331

CHAPTER 14
Figure 1 Reported overskilling by physicians, nurses and other
occupations, PIAAC survey, 2011/2012 . . . . . . . . . . . . . . . . . . . . . . . 344
Figure 2 Reported underskilling by physicians, nurses and other
occupations, PIAAC survey, 2011/2012 . . . . . . . . . . . . . . . . . . . . . . . 345
Figure 3 Recommendations for reforms and enabling actions . . . . . . . . . . . . 347
Figure 4 Generalists as a share of all physicians, selected OECD
countries, 1995–2014 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 350
Figure 5 Share of students admitted in general medicine versus other
specializations, selected OECD countries, 2013 (or nearest year) . . . . . . 351
Figure 6 Graduates from nurse practitioners programmes,
United States, 2001–2012 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 352

viii Health Employment and Economic Growth: An Evidence Base

Figure 7 Rising number of medical graduates, selected OECD
countries, 2000–2013 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355
Figure 8 Rising number of nursing student intakes (or graduates), selected OECD
countries, 2000–2013 (index: baseline year = 100) . . . . . . . . . . . . . . 356

CHAPTER 15
Figure 1 Subcontracting of ancillary services in all public hospitals
in South Africa, 2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 372
Figure 2 Yearly change of health workers’ remuneration compared
to total health expenditure and GDP by country income
level, 2000–2010 (%) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 376
Figure 3 Female share of employment in the health and social
services sector by region, 2013 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377

CHAPTER 17
Figure 1 Physician–population ratio as physicians per 100 000
inhabitants at district level in Germany, 2010 . . . . . . . . . . . . . . . . . . 412

BOXES
CHAPTER 1
Box 1 What is the health workforce? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Box 2 Operational definitions of health workforce needs, supply
and demand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Box 3. Prior thresholds for health worker needs . . . . . . . . . . . . . . . . . . . . . . . 11

CHAPTER 3
Box 1 Examples of health system and health workforce reforms . . . . . . . . . 60
Box 2. Multidisciplinary competencies in the care of older adults at
the completion of the entry-level health professional degree . . . . . . . . 64
Box 3. Examples of educational reform . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

CHAPTER 4
Box 1 Highlights from the WHO Global Code of Practice on the
International Recruitment of Health Personnel . . . . . . . . . . . . . . . . . . 83
Box 2 Learning from new models of global governance in the area
of climate change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114

CHAPTER 6
Box 2 The forgotten workforce: female family members filling
in for shortages of long-term care workers . . . . . . . . . . . . . . . . . . . . 142

CHAPTER 8
Box 1 Labour force impact of HIV/AIDS in low- and middle-income
countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202

CONTENTS ix
 CHAPTER 12
Box 1 Transforming the health workforce in India . . . . . . . . . . . . . . . . . . . . 290
Box 2 Clinical associates in South Africa . . . . . . . . . . . . . . . . . . . . . . . . . . . 292
Box 3 People-centred and integrated health services in the Philippines . . . 294
Box 4 Apprenticeships in Benin, Malawi and the United States
of America . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298
Box 5 Measuring the return on investment in TVET . . . . . . . . . . . . . . . . . . 301

CHAPTER 13
Box 1 Social accountability within health workforce education . . . . . . . . . . 311
Box 2 Interprofessional education and collaborative practice . . . . . . . . . . . 315
Box 3 Participatory planning to integrate education and health
services in Brazil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320
Box 4 Building a career in rural and remote areas: the stepladder
programme in the Philippines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322
Box 5 Right-touch regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 326

CHAPTER 14
Box 1 Recommendations to improve health workforce planning
in OECD countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 358

CHAPTER 15
Box 1 What is decent work? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 366
Box 2 ILO Conventions and standards relevant to the health sector . . . . . . 369
Box 3 Examples of improving conditions of work and organizing
care work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373
Box 4 Raising awareness on labour rights for prospective migrant
nurses in the Philippines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 380
Box 5 Brazil: Decent Work Agenda in the health sector . . . . . . . . . . . . . . . 382

CHAPTER 16
Box 1 Irrational posting and transfer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 388

CHAPTER 17
Box 1 Regulatory planning system in Germany . . . . . . . . . . . . . . . . . . . . . . 411
Box 2 District factors possibly affecting physicians’ choice of
practice location in Germany . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413
Box 3 Factors showing a significant association with physician density . . . 419

x Health Employment and Economic Growth: An Evidence Base

List of Contributors
Edson Correia Araújo, Health, Nutrition and Population, World Bank,
Washington, DC, United States
Melanie Y. Bertram, Economic Analysis and Evaluation, World Health
Organization, Geneva, Switzerland
Callum Brindley, Health Systems Governance and Financing Department,
World Health Organization, Geneva, Switzerland
Tim Bruckner, School of Public Health, University of California, Irvine,
United States
James Buchan, World Health Organization Regional Office for Europe,
Copenhagen, Denmark
James Campbell, Health Workforce Department, World Health Organization,
Geneva, Switzerland
Giorgio Cometto, Health Workforce Department, World Health Organization,
Geneva, Switzerland
Borhene Chakroun, Division for Policies and Lifelong Learning Systems, UNESCO,
Paris, France
Nadia Cobb, Office for the Promotion of Global Healthcare Equity, Division of
Physician Assistant Studies, University of Utah School of Medicine, Salt Lake City,
Utah, United States
Elina Dale, Health Systems Governance and Financing Department,
Geneva, Switzerland
Ibadat Dhillon, Health Workforce Department, World Health Organization,
Geneva, Switzerland
Jean-Christophe Dumont, Organisation for Economic Co-operation and
Development (OECD), Paris, France
Tessa Edejer, Economic Analysis and Evaluation, Health Systems Governance and
Financing Department, Geneva, Switzerland
Julian Fisher, Department of Medical Informatics, Hannover Medical School,
Hannover, Germany

LIST OF CONTRIBUTORS xi
 Lynn Freedman, Averting Maternal Death and Disability Program, Columbia
University Mailman School of Public Health, New York, United States
Megan Gerecke, Independent Researcher, Geneva, Switzerland
John H.V. Gilbert, University of British Columbia, Canada, and Dalhousie
University, Nova Scotia, Canada
Yevgeniy Goryakin, Norwich Medical School, University of East Anglia,
United Kingdom
Wolfgang Greiner, Department of Health Economics and Health Management,
Faculty of Public Health, Bielefeld University, Bielefeld, Germany
Keith Holmes, Division for Policies and Lifelong Learning Systems, UNESCO,
Paris, France
David Hunter, Department of Statistics, International Labour Office,
Geneva, Switzerland
Chris James, Health Division, Organisation for Economic Co-operation and
Development, Paris, France
Arielle Juberg, Averting Maternal Death and Disability Program, Columbia
University Mailman School of Public Health, New York, United States
Ivar Sønbø Kristiansen, University of Oslo, Oslo Economics, Oslo, Norway
Gaétan Lafortune, Health Division, Organisation for Economic Co-operation
and Development (OECD), Paris, France
Jeremy A. Lauer, Economic Analysis and Evaluation, Health Systems Governance
and Financing Department, Geneva, Switzerland
Gillian Lê, Nossal Institute for Global Health, University of Melbourne,
Carlton, Australia
Jenny Liu, Institute for Health and Aging, Department of Social and Behavioral
Sciences, University of California, San Francisco, United States
Akiko Maeda, Health, Nutrition and Population Global Practice, World Bank,
Washington DC, United States
Veronica Magar, Gender, Equity, and Human Rights, World Health Organization,
Geneva, Switzerland
Barbara McPake, Nossal Institute for Global Health, University of Melbourne,
Carlton, Australia
Tyra Merker, Oslo Economics, Oslo, Norway

xii Health Employment and Economic Growth: An Evidence Base

Lyn Middleton, Training for Health Equity Network, Pietermaritzburg,
South Africa
Andrew Mirelman, Centre for Health Economics, University of York,
United Kingdom
Liliane Moreira, Health Division, Organisation for Economic Co-operation
and Development, Paris, France
Andrea Nove, Novametrics Ltd, Derby, United Kingdom
Björg Pálsdóttir, Training for Health Equity Network, New York, United States
Leo Quigley, George Washington University Health Workforce Institute and School
of Nursing, Washington, DC, United States
Carole Reeve, Flinders University and James Cook University, Queensland,
Australia
Erik Magnus Sæthera, Oslo Economics, Oslo, Norway
Mariela Licha Salomon, Consultant, Global Health International Advisors,
Washington DC, United States
Edward Salsberg, George Washington University Health Workforce Institute and
School of Nursing, Washington, DC, United States
Marta Schaaf, Averting Maternal Death and Disability Program, Columbia
University Mailman School of Public Health, New York, United States
Richard Scheffler, School of Public Health, Goldman School of Public Policy,
University of California, Berkeley, United States
Xenia Scheil-Adlung, International Labour Organization, Geneva, Switzerland
Stefan Scholz, Department of Health Economics and Health Management,
Faculty of Public Health, Bielefeld University, Bielefeld, Germany
Kabir Sheikh, Health Governance Hub, Public Health Foundation of India,
Delhi, India
Agnès Soucat, Health Systems Governance and Financing Department,
World Health Organization, Geneva, Switzerland
Roger Strasser, Northern Ontario School of Medicine, Lakehead and Laurentian
Universities, Canada
Marc Suhrcke, Centre for Health Economics, University of York,
United Kingdom

LIST OF CONTRIBUTORS xiii

 Amanda Tan, Economic Analysis and Evaluation, Health Systems Governance and
Financing Department, World Health Organization, Geneva, Switzerland
Gail Tomblin-Murphy, School of Nursing, Faculty of Health Professions and
Community Health and Epidemiology, Faculty of Medicine, Dalhousie University,
Halifax, Nova Scotia, Canada
David Weakliam, Global Health Programme, Health Service Executive,
Dublin, Ireland
Christiane Wiskow, Sectoral Policies Department, International Labour
Organization, Geneva, Switzerland

xiv Health Employment and Economic Growth: An Evidence Base

INTRODUCTION

Introduction to Health Employment

and Economic Growth:
An Evidence Base
James Buchan, Ibadat S. Dhillon, James Campbell

A. Context, aims and summary of this book

Health and social care in every system and in every country is labour intensive, and
must be oriented to people’s needs if it is to be effective. It is now widely recognized
that human resources for health (HRH) are a key enabler for the attainment of
universal health coverage, and for the achievement of Sustainable Development
Goal (SDG) 3 – Ensure healthy lives and promote well-being for all at all ages. As is
stressed in the Global Strategy on Human Resources for Health: Workforce 2030,1
there can be no viable national, or global, health system without an effective health
workforce.2

The Global Strategy, adopted at the Sixty-ninth World Health Assembly in May
2016, challenges the erroneous narrative of health workers as a unit of cost in
the production of health. The evidence instead presents an intersectoral agenda
on the pre-condition of equitable access to health workers in the attainment of
universal health coverage, along with a dynamic labour market understanding of
the substantive impact on education, employment, jobs and innovation in the health
and social care economy. The Global Strategy, therefore, enables governments and
other relevant stakeholders to adopt a holistic, rather than fragmented, approach
to ensuring that the health workforce contributes both to improved health and to
broader socioeconomic development.

1 Global Strategy on Human Resources for Health: Workforce 2030 http://who.int/hrh/resources/globstrathrh-2030/en/.

2 Throughout the chapters of this book, the terms “health workforce” and “human resources for health” are
considered largely synonymous and are used interchangeably.

INTRODUCTION xv
 At its core, the Global Strategy puts forward an integrated set of policy responses
necessary to take account of and respond to the dynamic and changing nature of
HRH, including the internal and international migration of health workers. The
Global Strategy highlights the importance of and need for intersectoral linkages
(between the education, health, labour and finance sectors), wider stakeholder
engagement, and effective analytical underpinning and alignment of policies across
sectors and stakeholders.

What is equally important, and is now receiving increasing recognition, is that there
can be no viable national or global economy without effective investment in the
health workforce. This reflects the overall paradigm shift from a model that frames
health system delivery and health employment as a “cost disease” to one in which the
contribution of health to economic and societal well-being is more fully recognized.
In this more complete perspective, the assessment of the contribution of the health
workforce broadens out to include its impact both as a leading source of employment
and as a socioeconomic multiplier, with particular benefits for women and youths. In
short, support for HRH is an investment in health, security and prosperity, not a cost.

The contents of this book give direction and detail to this important perspective by
presenting new evidence and analysis. It summarizes and sets out, under one cover, a
series of research studies and papers that were commissioned to provide evidence for
the High-Level Commission on Health Employment and Economic Growth.

In total, this book presents 17 commissioned policy briefs as chapters, including

contributions from over 50 authors. This editorial introduction synthesizes the key
points from this new evidence base, illustrated by examples drawn from across the
regions of the world, and reflecting the input of experts from a range of disciplines
and backgrounds.

The chapters, which were rapidly developed to retain a contemporary currency, are
evidence based and “next steps” oriented. They summarize the facts related to the
specific focus of review, but then assess them with a policy analysis lens, and provide

xvi Health Employment and Economic Growth: An Evidence Base

the evidence context for the work and policy options that were recommended by the
High-Level Commission’s Expert Group, and captured in the Commission’s report
and recommendations.

The book draws on intersectoral stakeholder contributions, reflecting the widespread

recognition and deepening understanding that sustaining an effective health
workforce is everyone’s business, and as such requires multisectoral, whole-of-
government action, backed up by broader stakeholder engagement, supported by
political leadership from the highest level.

Each chapter of the book provides new analysis and fresh perspectives on aspects
of employment in health. The chapters stand alone and can be read in isolation, but
when read in combination, the reader will benefit from additional insights. These
derive from the linkages and connections between the issues covered in each chapter,
which means that the findings and recommendations are supportive and mutually
interdependent. A gender lens, as provided at the front of the book, in particular
helps the reader better see and understand the contribution of investments in the
health workforce, as well as the reforms required.

The ordering of the chapters in the book is linked to the same health labour market
framework that informs the Global Strategy. The book begins with chapters that
speak to overall health workforce dynamics, including existing and future estimates
of the health workforce, the gendered nature of the health workforce, and patterns
of international migration. Chapters identifying the socioeconomic value of and
opportunities for investment follow. The next set of chapters point to the potential to
transform the manner in which health workers are educated and formed. The book
concludes with a set of chapters outlining options to address existing inefficiencies in
the health workforce.

Each reader will develop their own conclusions about what are the main overall
messages and priorities that emerge, but the section below sets out five key messages
worthy of consideration.

INTRODUCTION xvii
 B. What is important: five key messages

In combination, the evidence in the papers underpins five key messages that emerged
both from the analysis and from the work of the High-Level Commission. Overall, it
presents a strong argument in favour of investment in the health workforce (delivering
benefits across the SDGs), and a strong case for reform in how we invest in the health
workforce.

1. New projections on global HRH highlight a growing mismatch

between supply, need and demand, but concerted action can address
these staffing shortages

The analysis on HRH need and demand points to a growing staffing and skills
shortage in many countries, even in some high-income countries. The shortage is both
demographically driven, with population growth and ageing important factors, and
linked to the ambition of service delivery in the context of the SDG era. The analysis
additionally points to an escalating mismatch between supply, need (SDG-based)
and demand (ability to employ), with the international migration of health workers
also increasing. The analysis for the High-Level Commission further indicates that,
within a future scenario where continued fiscal and economic growth is accompanied
by an increase in priority to the health sector and the health workforce, there may
be sufficient financing in most countries to meet the wage bill for the additional
health workers required to address identified shortages. In some other, low-income,
countries, sustained development assistance from philanthropic, private and public
sources, investing in education, health, gender and labour, will be required to develop
and support the health workforce needed to deliver on the ambition of the SDGs.

2. New analysis provides evidence of health employment’s contribution

to inclusive economic growth, including in relation to women’s
economic empowerment

The new analysis undertaken for the High-Level Commission helps broaden out the
assessment of HRH to include its impact both as a leading source of current and future
employment, notably for women and youths, and as a socioeconomic multiplier. The
analysis speaks to the fact that while globally the costs of HRH have been well recognized,

xviii Health Employment and Economic Growth: An Evidence Base

their contribution to inclusive economic growth has been underappreciated and worse,
ignored. The work presented in this book is at the forefront of new analysis, pointing to
areas for further research. Taken together the case for investment in the health workforce
is strong and deserves consideration as a “best buy” that can deliver concrete returns
across the SDG agenda (including SDG 1 on poverty elimination, SDG 4 on quality
education, SDG 5 on gender equality, SDG 8 on decent work and economic growth,
and SDG 10 on reduced inequalities).

Part of this narrative is recognizing and addressing the complexity of

nongovernmental and private sector roles; leveraging the input of the private sector,
alongside public sector reform, will be essential in many contexts. It also requires full
recognition of the actual and potential contribution of women, who comprise two
thirds of the health workforce.

3. Health workforce investment will lead to inclusive economic

growth, particularly for women, provided the right policies are in
place, supported by effective governance

An inclusive approach to the health workforce is required to achieve efficiencies

and ensure equity. There is a need to invest in human capital and stimulate job
creation, both in the health workforce and more broadly in the economy, in order to
achieve the SDGs. This in turn will be more achievable if investments in the health
workforce and health sector are prioritized. Action is also required to transform
systemic gender biases in the health sector into platforms for women’s economic
empowerment.

There is tremendous scope to leverage improved employment opportunities for

women, younger entrants to the labour market, and relatively disadvantaged groups
(such as rural populations) through strategic and applied HRH recruitment, policies
and planning.

In part, this will be achieved by ensuring decent work; fulfilling labour rights;
addressing identified “market failures”, notably in current mismatches between
education, employment and population needs; appropriately recognizing and
rewarding women’s contribution; and establishing new “non-traditional” career entry

INTRODUCTION xix
 points and routes that will have a payback in terms of both increased participation
and distributed growth. This will in turn require additional efforts to build the
evidence base and effective governance.

4. Transformative education is necessary, but will have to be matched

by scale-up, particularly in the technical and vocational education
and training (TVET) sector

A transformation of the training and development of HRH is one key element of

achieving a more responsive and effective workforce. This must be underpinned
by alignment of the health (employment) and the education (training) sectors with
population health needs, through targeted funding and appropriate regulation,
informed by an understanding of labour market dynamics, internal and international
migratory flows, and current labour market failures.

That process must also be driven by an assessment of the optimal skills mix to
achieve the SDGs and a primary care-led health system, with a strong focus on
expanding socially accountable TVET. Continuous development of the workforce,
particularly in underserved areas, must also be a priority; evidence suggests that
investment in the skills and motivations of the current workforce will be one major
factor in improving HRH distribution and impact.

5. The motivation of the health workforce, two thirds of which are

women, must be encouraged and directed by equitable and effective
policy, planning, management and governance, and underpinned by
context-specific analysis

Countries must not lose sight of the need to have the basic constructs for an effective
health workforce to be in place. These include policy, planning, management and
governance, supported by analysis based on accurate and complete HRH data.
Health workforce information is an obvious area for improvement in most countries;
without it, policy-makers and managers are “working blind”.

An effective health workforce is about more than just getting the staffing numbers
right. It is about recognizing that health workforce motivation, distribution and

xx Health Employment and Economic Growth: An Evidence Base

retention are major contributors to improved access and productivity, and can only
be achieved through responsive policy, management and governance. Improved data
are also required to support effective monitoring and management of migratory
flows of health workers. Decent work, workforce stability and responsiveness,
the transformation of unpaid care roles into decent work, data on women in the
workforce, and supportive line management are key indicators of the implementation
of effective HRH policy and governance.

C. Summary
The analysis and policy options set out in the chapters of this book highlight
that the global health workforce challenge cannot be solved by supply-side solutions
alone. The findings reported here support one of the main thrusts of the Global
Strategy – namely, that the policies that must be implemented cannot be “more of
the same”, but rather must emanate from a policy-led alignment of supply, demand
and need. This in turn must be informed by improved evidence and consistent
application of processes and tools, national policy coherence (better aligning across
the education, employment, health, labour, migration, and finance sectors), and
international cooperation.

The adoption of the Global Strategy and the publication of the High-Level
Commission’s report mark a watershed, and provide the foundation for a new,
transformative direction for health workforce policy and planning. This book gives
detail to this foundation. It is now for States and all relevant stakeholders to harness
the evidence and take the lead in shaping and implementing this new direction.

The focus of our efforts must now be on accountability for change, intersectoral
action, and finding new ways of working together. It will not be sufficient for
a handful of well-intentioned actors to attempt to “do the right thing” through
uncoordinated actions; what is now required is a critical mass of reform on
employment in health that is locally focused, country led, and globally connected.

INTRODUCTION xxi
xxii Health Employment and Economic Growth: An Evidence Base
 PART I
Health Workforce
Dynamics

1
CHAPTER 1

Health workforce needs, demand

and shortages to 2030:
An overview of forecasted trends in the global
health labour market
Giorgio Cometto, Richard Scheffler, Tim Bruckner, Jenny Liu, Akiko Maeda,
Gail Tomblin-Murphy, David Hunter, James Campbell

Abstract
This chapter is based on analyses conducted by WHO and the World Bank
using the best available evidence. Variability in completeness and quality of
data required the use of assumptions, imputation and modelling techniques.
Modelled estimates identified that the growing demand for health workers
is projected to add an estimated 40 million health sector jobs to the global
economy by 2030. Most of these jobs will reside in upper middle- and
high-income countries. At the same time, modelled estimates point to the
need for over 18 million additional health workers by 2030 to meet the health
workforce requirements of the Sustainable Development Goals and universal
health coverage targets, with gaps in the supply of and demand for health
workers concentrated in low- and lower middle-income countries.

In low-income and some lower middle-income countries both demand and

supply will continue to fall short of population health needs. In these contexts,
it is necessary that investments – from both the public and private sectors – in
health worker education be accompanied by an expansion of the fiscal space to
support the creation and filling of funded positions in the health sector and the
health economy. Health workforce strategies should ensure that the expansion of
the health resources envelope leads to cost-effective resource allocation.

PART I: Health Workforce Dynamics | CHAPTER 1 3

 Introduction
In any health system, improving health service coverage and health outcomes
depends on the availability, accessibility, and capacity of health workers to deliver
quality services (1). Further, building an adequate health workforce can be a highly
cost-effective public health strategy. For instance, investing in midwifery education
and deploying graduates for community-based service delivery could yield a
16-fold return on investment in terms of lives saved and cost of caesarean sections
avoided – a “best buy” in primary health care (2). Social returns on investments in
health workers can be maximized if their services are affordable and thus financially
accessible for those in need. This can only be ensured if social health protection
schemes and systems are in place that provide for such access.

At the same time, investing in the health workforce is increasingly recognized as

an opportunity to create qualified employment opportunities, in particular for
women, further spurring economic growth and productivity. Emerging economies
are simultaneously undergoing an economic transition that will increase their health
resources envelope and a demographic transition that will see hundreds of millions
of potential new entrants into the labour force. The confluence of these factors creates
an unprecedented opportunity to design and implement health workforce strategies
that address the gaps in equitable and effective coverage that characterize many
health systems, while also unlocking economic growth potential. Taken together,
these factors are expected to contribute to a convergence in health and development
outcomes within a generation (3).

Indeed, many analyses point to the health economy – and those products, services
and activities related to health care and care for the dependent, disabled and elderly
(4) – as a driver of economic growth (5). There is also evidence that health sector
employment remains stable or even grows during economic downturns, contributing
to the resilience of national economies (6). In determining the potential for the health
economy to contribute to job creation and economic growth, it is, however, important
to have a more precise understanding of what constitutes “the health workforce”.

The International Labour Organization (ILO) adopts a model of the health workforce
(7) that (a) recognizes all workers in or contributing to the health sector based on
the concept of economic activity; (b) separately identifies specialized workers in

4 Health Employment and Economic Growth: An Evidence Base

health-specific occupations or with training in a health field; and (c) takes into account
the contributions of volunteer and family carers. The ILO approach provides a basis for
the development of internationally comparable statistics that can inform national and
international health labour market analyses (Box 1).

The available information is most complete for salaried and trained health workers
employed in the public sector; data can be more limited for health workers employed
in the private, not-for-profit or defence sectors, the self-employed, and health workers
with public health, health management, administrative or support roles. Despite
the existence of international measurement frameworks and classification systems,
the quality and quantity of information on the health workforce remains limited for
many countries, and particularly for those facing the most severe health workforce
challenges. In these contexts, there is a pressing need to improve statistical and
administrative data capacities, and infrastructure for improved health workforce
evidence.

Box 1

What is the health workforce?

The 2006 World health report (8) defined health workers as “all people engaged in
actions whose primary intent is to enhance health”. For the purposes of health work-
force planning, it is necessary to understand the types of jobs needed to provide
health care, and the requisite skills and training for those jobs. This necessitates a
focus on occupations that require specific skills in the provision of health care and
that are in severe shortage in many countries. To understand the full impact of
investment in the health sector on employment and economic growth, however,
we also need to take into consideration the wider group of workers employed in
the health sector and in those industries that support it, as well as those providing
unpaid or informal care.

(continued on page 6)

PART I: Health Workforce Dynamics | CHAPTER 1 5

 BOX 1. (continued)
What is the health workforce?

Existing frameworks (9) for the operational measurement of health workers

employed within and outside the health sector distinguish three categories of workers
relevant for health workforce analysis and planning:

a. those with health training and working in the health industry;

b. those with training in a non-health field (or with no formal training) and
working in the health industry;

c. those with health training who are either working in a non-health-care-related

industry, or who are currently unemployed or not active in the labour market.

Categories (a) and (c) together form the trained (skilled) health workforce
(active or inactive) available in a given country or region, while (a) and (b)
represent the workforce employed in the health industry. The sum of the three
elements – (a), (b) and (c) – provides the total potential health workforce
available. A fourth category, (d), encapsulates all others, that is, those workers
without training for a health occupation and not working in the health
industry.

The International Standard Classification of Education (ISCED), International Standard

Classification of Occupations (ISCO) (7) and International Standard Industrial
Classification of All Economic Activities (ISIC) (10) guide the categorization
according to, respectively, fields of education and training, the occupations, and the
industries in which they work.

The current version of the International Standard Classification of Occupations

(ISCO-08) provides a framework for the comparability of occupational
information compiled according to the various classification systems used in
different national and regional contexts. It includes both aggregate and detailed
categories for specialized health occupations, including:

6 Health Employment and Economic Growth: An Evidence Base

• “health professionals” (well trained workers in jobs that normally require
a university degree for competent performance, such as doctors, nurses,
midwives, dentists, pharmacists);

• “health associate professionals” (requiring skills at tertiary educational level

but not equivalent to a university degree, such as associate nurses, medical
and pharmaceutical technicians, traditional practitioners that do not require
formal training);

• “personal care workers in health services” (which includes health care

assistants and home-based personal care workers).

The strength of this framework is that it allows the compilation of internationally

comparable data on people with health-specific training, workers in health
occupations, and the total number of workers employed in the health industry.

A limitation, however, is that the strong focus and better data availability on
trained workers in formal employment tends to overlook and underestimate the
role of many of those who contribute to the health sector as informal workers,
regardless of training or remuneration. In addition, it does not fully take into
consideration workers in non-health sectors that contribute to the health sector,
such as those involved in the pharmaceutical sector, in transportation services
or in the construction of medical facilities. These groups, included under the
ISCO groupings in categories other than health workers, would also need to be
quantified and monitored to assess the overall employment impact of the
health sector.

Most of the existing data available on the health workforce, however, are
restricted to workers in paid employment and in many cases only to those
formally employed in health services. Data are also more frequently complete
for health professionals than for other groups.
Source: ILO.

PART I: Health Workforce Dynamics | CHAPTER 1 7

 To develop medium-term forecasts for trends in needs, supply and market-based
demand for the health workforce (Box 2), and based on data availability, analyses
typically focus on health workers with health training working in the health
industry. The analysis presented here has also adopted this approach. Growth in
the employment of trained health workers, however, will probably be accompanied
by growth in the employment of other types of health workers (for example, health
sector management and support workers) and of workers in other sectors linked to
health (for example, pharmaceutical and medical devices industries) (11). Therefore,
estimates for workers with health training represent only a subset of the total affected
workforce, and are likely to substantially underestimate the economic growth and
job creation potential of the health economy at large.

Box 2

Operational definitions of health workforce needs, supply and

demand

Need: the number of health workers required to attain the objectives of the health
system. There are various approaches to calculating this number – for example,
it is sometimes estimated based on a threshold of minimum availability of health
workers to address priority population health issues, or in relation to the specific
service delivery profile and requirements of a health system.

Supply: the number of health workers who are available in a country. Future
supply can be estimated taking into account a variety of parameters, including
education capacity, attrition and retention.

Demand: the number of health workers that the health system (both public
and private) can support in terms of funded positions or economic demand
for services. Demand correlates with the economic capacity of a country, with
higher levels of resource availability resulting in greater demand for health
services and thus for health workers to provide them.

8 Health Employment and Economic Growth: An Evidence Base

Estimates recently produced by the ILO (12) suggest that the size of the total
health workforce, and of workers employed in the broader health economy,
could be significantly larger than previously estimated. Estimation of the more
limited health workforce who have a clinical qualification is also a challenging
task, as data from various sources differ in terms of the definitions used, and the
scope and completeness of the data. The ILO estimates are based on data sources
that differ from those used by the World Health Organization (WHO) and are
higher than the WHO estimates. Further, the ILO estimates include categories
of workers that are not defined by WHO as health workers, so the results are
not directly comparable. Every effort is being made to improve the quality and
comparability of estimates by both organizations. The differences show the
range of the size of the total health workforce depending on choices about which
groups to include. They do not impact the estimation of significant needs-based
shortages, presented below.

2. Methods
The methodological approach used to estimate and forecast needs-based
shortages of health workers was guided by the overarching goal of addressing
population health needs to make progress towards universal health coverage.
Policy actions and investment decisions should focus on redressing failures in
health labour markets, including easing supply constraints, to equitably meet
population health care needs. To this end, three main analyses were conducted:
(a) estimation of the projected supply, needs and needs-based shortages of health
workers to 2030, with a special emphasis on countries falling below a minimum
threshold of health worker availability; (b) projection of labour market demand
for health workers to 2030, taking into account economic growth trends and
other relevant parameters; and (c) simulation of trends in the supply of health
workers vis-à-vis requirements in high-income countries in the Organisation for
Economic Co-operation and Development (OECD). In high-income countries,
the demand for health workers by far exceeds any needs-based thresholds, which
may attract health workers from other countries and has important implications
for global health workforce mobility patterns.

PART I: Health Workforce Dynamics | CHAPTER 1 9

 2.1 Identifying needs-based shortages of health workers
Twelve key population health indicators were selected to measure the projected
health needs of populations based upon the health targets in the Sustainable
Development Goals (SDGs): family planning, antenatal care coverage, skilled
birth attendance, DTP3 (diphtheria–tetanus–pertussis) immunization, tobacco
smoking, potable water, sanitation, antiretroviral therapy, tuberculosis treatment,
cataract surgery, diabetes, and hypertension treatment. These indicators had
been previously identified as tracers for universal health coverage in joint WHO–
World Bank research (13), and their relative importance to the composite index
of human resources for health (HRH) availability was calculated on the basis of
the proportional contribution to the global burden of disease that each service is
targeted towards. A minimum threshold of health workers required to achieve
health targets in the SDGs was then calculated. Building on previous approaches
for estimating minimum thresholds of health worker availability (Box 3), a density
threshold of health workers estimated to be needed to achieve the median level
of attainment (25%) for a composite index comprising the 12 selected indicators
above, weighted according to the global burden of disease, was derived through
regression analysis. The resulting “SDG index threshold” of 4.45 doctors, nurses
and midwives per 1000 population (Figure 1) was identified as the minimum
density representing the need for health workers. It should be noted that if a
different level in the attainment score of the 12 indicators mentioned above were
chosen (that is, the 25th and 75th percentile instead of the median value), the
threshold would vary widely, from 0.31 to 35.1 doctors, nurses and midwives per
1000 population. This broad range illustrates the sensitivity of the SDG index to
different thresholds of attainment.

This SDG index threshold advances previous methods by empirically linking health
worker density to coverage of a broader range of health services based on universal
health coverage and SDGs. However, similarly to its predecessors, it should not be
used as a benchmark for planning at national levels as it does not account for the
high degree of heterogeneity across countries (with regard to baseline conditions,
epidemiology, demography, finances, health system needs, optimal workforce
composition and skills mix), which should be examined on an individual basis
when planning the workforce needed to meet the SDGs by 2030. Further, it is also
important that the use of the SDG index threshold does not result in an exclusive

10 Health Employment and Economic Growth: An Evidence Base

Box 3

Prior thresholds for health worker needs

The 2006 World health report (8 ) identified a minimum health worker density
of 2.3 skilled health workers (physicians and nurses/midwives) per 1000
population, which was considered generally necessary to attain high coverage
(80%) of skilled birth attendance. For nearly 10 years, the 2.3 workers
per 1000 threshold has galvanized support and enabled policy-makers
and advocates to push for goals and countries to measure their progress.
However, this threshold has its limitations in the SDG era: it is based on a
single health service (assisted deliveries) that is provided episodically, and its
focus is on maternal and newborn health, whereas the SDG agenda refers to
a broader range of services, including noncommunicable diseases.

To reflect the broader nature of universal health coverage, the ILO has
developed an alternative method to identify a minimum threshold of health
worker availability, rooted in an approach that identifies vulnerable countries
in terms of their social protection systems and outcomes. Based on this
approach, reflected in the 2010/2011 World social security report (14), the
threshold, termed as a “staff access deficit indicator”, identified a minimum
workforce availability of 3.4 skilled health workers per 1000 population. This
value has subsequently been updated to 4.1 per 1000 (15). The ILO approach,
while linked more explicitly to the policy ambition of universal health
coverage in the context of broader social protection, does not have a direct
empirical link with health service coverage.

Other similar thresholds exist. For instance, a value of 5.9 skilled health
professionals (midwives, nurses and physicians) per 1000 population was
identified as the workforce requirements for the Ending Preventable Maternal
Deaths initiative, which entails reducing global maternal deaths to 50 per
100 000 live births by 2035 (16).

PART I: Health Workforce Dynamics | CHAPTER 1 11

 focus on physicians and nurses/midwives, thereby underinvesting in other cadres.
Current and future needs-based shortages in countries falling below this threshold
were estimated after taking projected trends in the supply of health workers
into account.

Figure 1

SDG composite index: percentage of 12 SDG tracer indicators achieved

as a function of aggregate density of doctors, nurses and midwives
per 1000 population

30

25
Percentage of SDG tracer indicators achieved

20

15

10

0.05 1 2 3 4 5 6 7 8 9 10

Health workers per 1000 population

2.2 Projecting global demand for health workers

The demand for health workers (physicians, nurses/midwives, and other health
workers) was estimated based on a model using per capita gross domestic product
(GDP), per capita out-of-pocket health expenditures, and population aged 65 years
and older. In this approach, demand is therefore more a function of economic
capacity than population needs. Demand for nurses/midwives was calculated
assuming a ratio of 2.5 to one physician (the average value in OECD countries).
Estimates could only be developed for 165 countries and territories with sufficient
data on the economic variables required to model demand.

12 Health Employment and Economic Growth: An Evidence Base

2.3 Health worker employment in high-income
OECD countries
The supply of and demand for health workers in high-income OECD countries vastly
exceeds – now and in the future – the needs-based thresholds described earlier.
Considering the potential impact on the global health labour market of demand-based
shortages in high-income countries, we developed a model to produce estimates of
possible scenarios of health labour market trends in these contexts. The model is based
on a population needs-based approach that determines HRH requirements in relation
to health system objectives and health services requirements (17). A stock-and-flow
approach was used to simulate future HRH supply in terms of headcounts, adjusting
current HRH stocks according to expected flows in (for example, new graduates)
and out (for example, due to retirement) of each country’s stock. These were then
adjusted according to levels of participation (providing direct patient care) and activity
(proportion of full-time hours spent providing direct patient care) for different types
of HRH cadres.

3. Findings
Table 1 displays the forecasted numbers and percentage growth of health workers
by income group and WHO region in 2013 and 2030, assuming that recent trends
in training and employing health workers will stay the same. According to the latest
available data in 2013, the global health workforce was over 43 million, including 9.8
million physicians, 20.7 million nurses/midwives, and approximately 13 million other
health workers. The global nurse/midwife to physician ratio was 2.1 : 1. Based on current
trends and under the assumptions made in the model, the supply of health workers is
estimated to grow substantially (55%), leading to an aggregate of 67.3 million health
workers by 2030, comprising approximately 13.8 million physicians, 32.3 million nurses/
midwives and 21.2 million other health workers (18).

Table 2 shows the needs-based shortages of health workers in 2013 and 2030 in
countries below the SDG index threshold. Globally, there are more than enough
health workers to meet the SDG index threshold, but due to the uneven distribution
of health workers, there are countries in all income groups with needs-based
shortages, including the majority of low- and lower middle-income countries.
“Surpluses” in countries above the threshold were not computed towards the

PART I: Health Workforce Dynamics | CHAPTER 1 13

 Table 1

Supply of health workers (millions), 2013 (WHO Global Health Observatory)

and 2030 (forecast)

2013 2030 Total

worker
INCOME Nurses/ Other Nurses/ Other %
GROUP Physicians midwives cadresa Total Physicians midwives cadres Total change
Income High 3.7 9.1 4.8 17.6 4.4 14.1 5.8 24.3 38%
Upper middle 3.9 6.6 4.3 14.7 5.4 9.5 7.8 22.6 54%
Lower middle 2.0 4.5 3.6 10.0 3.5 8.1 6.7 18.3 82%
Low 0.2 0.5 0.4 1.1 0.5 0.6 1.0 2.1 86%
WHO REGION
Africa 0.2 1.0 0.6 1.9 0.5 1.5 1.0 3.1 63%
Americas 2.0 4.7 2.6 9.4 2.4 8.2 3.4 14.0 50%
Eastern
0.8 1.3 1.0 3.1 1.3 1.8 2.2 5.3 72%
Mediterranean
Europe 2.9 6.2 3.6 12.7 3.5 8.5 4.8 16.8 32%
South-East Asia 1.1 2.9 2.2 6.2 1.9 5.2 3.7 10.9 75%
Western Pacific 2.7 4.6 3.0 10.3 4.2 7.0 6.1 17.3 68%
World 9.8 20.7 13.0 43.5 13.8 32.3 21.2 67.3 55%

Note: Absolute values are expressed in millions, rounded to the nearest 100 000. Totals may not precisely add up due
to rounding.

a. Refers to the seven other broad categories of the health workforce as defined by the WHO Global Health
Workforce Statistics database, that is, dentistry personnel, pharmaceutical personnel, laboratory health workers,
environment and public health workers, community and traditional health workers, health management and support
workers, and other health workers. A multiplier for “all other cadres” was developed based on the values of countries
with available data.

accumulation of totals. Globally, the needs-based shortage of health workers in 2013

was estimated to be about 17.4 million, of which almost 2.6 million were doctors,
over 9 million were nurses and midwives, and the remainder other health worker
cadres. While the largest absolute shortage is in South-East Asia (6.9 million) due to
the large populations of countries in this region, the largest relative shortage (after
taking into account population size) occurs in the African Region (4.2 million).
The global needs-based shortage of health care workers is projected to still exceed
14 million in 2030 (a decline of only 17%). Hence, current trends of health worker

14 Health Employment and Economic Growth: An Evidence Base

Table 2

Estimates of health worker needs-based shortages (millions) in countries

below the SDG index threshold by region, 2013 and 2030

2013 2030 Total

worker
INCOME Nurses/ Other Nurses/ Other %
GROUP Physicians midwives cadres Total Physicians midwives cadres Total change
High 0.0 0.1 0.0 0.1 0.0 0.1 0.0 0.1 –7%
Upper middle 0.1 2.6 0.9 3.7 0.2 1.4 0.2 1.8 –50%
Lower middle 1.6 4.3 3.2 9.1 1.2 3.2 2.2 6.6 –28%
Low 0.8 2.0 1.7 4.6 1.0 2.9 2.1 6.1 33%
WHO REGION
Africa 0.9 1.8 1.5 4.2 1.1 2.8 2.2 6.1 45%
Americas 0.0 0.5 0.2 0.8 0.1 0.5 0.1 0.6 –17%
Eastern
Mediterranean 0.2 0.9 0.6 1.7 0.2 1.2 0.3 1.7 –1%
Europe 0.0 0.1 0.0 0.1 0.0 0.0 0.0 0.1 –33%
South-East
Asia 1.3 3.2 2.5 6.9 1.0 1.9 1.9 4.7 –32%
Western
Pacific 0.1 2.6 1.1 3.7 0.0 1.2 0.1 1.4 –64%
World 2.6 9.0 5.9 17.4 2.3 7.6 4.6 14.5 –17%

Note: All values are expressed in millions, rounded to the nearest 100 000. Totals may not precisely add up due to
rounding.

production and employment will not have sufficient impact on reducing the needs-
based shortage of health care workers by 2030, particularly in the African Region,
where the needs-based shortage is actually forecasted to worsen, while it will remain
broadly stable in the Eastern Mediterranean Region (18).

Table 3 shows that, by 2030, there will be a global aggregate demand for some 80
million health workers (in the 165 countries and territories with sufficient data to
produce demand estimates), with the potential for the creation of approximately 40

PART I: Health Workforce Dynamics | CHAPTER 1 15

 million additional jobs (above the current estimated stock of 43.5 million in 210
WHO Member States and territories – see Table 1). The additional jobs, however,
will not necessarily be created in the regions and income groups where they are
most needed to address SDG population targets. In the African Region and in
low-income countries, a modest growth in the capacity to employ workers will lead
to a shortage in the labour market based on economic demand, but both demand
and supply will fall short of population needs. The figures in Table 3 are not directly
comparable to those of the preceding Tables 1 and 2, as they refer to a different
number of countries and territories (165 instead of 210) (19).

With regard to high-income OECD countries, our simulations indicate that, on

current trends, most countries, while having a higher availability of health workers
than the SDG index threshold, could face shortfalls of one or more types of HRH
by 2030 in relation to their specific health service delivery profiles. In contrast,
some high-income OECD countries may experience surpluses. Simulations give
aggregate shortfalls against service requirements of about 750 000 physicians,
1.1 million nurses and 50 000 midwives across the 31 included countries for
2030. These estimates are however highly sensitive to even modest changes in the
assumed future values of different planning parameters, including population
growth, population health status, average levels of service provision, HRH
productivity, and the training, participation, retention and activity of HRH:
scenario sensitivity analysis shows that by 2030 the shortfall compared to service
requirements could be in excess of 4 million health workers (1.2 million physicians,
3.2 million nurses and over 70 000 midwives) (17).

16 Health Employment and Economic Growth: An Evidence Base

Table 3

Estimates of labour market demand (millions) for

health workers in 2013 and 2030 (165 countries)

2013 2030
(165 countries) (165 countries)
WORLD BANK INCOME GROUP Demand Demand
Low 0.6 1.4
Lower middle 10.9 21.7
Upper middle 19.0 33.3
High 17.7 23.8
WHO REGION
Africa 1.1 2.4
Americas 8.8 15.3
Eastern Mediterranean 3.1 6.2
Europe 14.2 18.2
South-East Asia 6.0 12.2
Western Pacific 15.1 25.9
World 48.3 80.2

Source: Liu et al. (19).

4. Discussion

The estimates described in the preceding sections were developed on the basis of
the best evidence and data available to WHO, which was nevertheless characterized
by variability in both completeness and quality. Assumptions had to be made to
overcome challenges relating to missing data; extensive use was made of modelling
and imputation techniques, which are described in greater detail in the full analyses.
Caution is therefore warranted in interpreting the findings: the results of these
simulations should not be interpreted as predictions of what will happen; instead they
are meant to show the directions in which the HRH situation is projected to be heading
if current trends continue, and to identify the policy levers to influence these trends.

PART I: Health Workforce Dynamics | CHAPTER 1 17

 4.1 Challenges
Investment in the health workforce is lower than is often assumed (on average
33.6% of total government expenditure on health in countries with available data)
(20), hindering the sustainability of health systems. The chronic underinvestment
in education and training of health workers in some countries and the mismatch
between education strategies and health systems and population needs result in
needs-based shortages. Considering jointly the needs-based shortages of over
14 million health workers in countries currently below the threshold of 4.45
physicians, nurses and midwives per 1000 population, and the shortfall against
service requirements in high-income OECD countries (possibly in excess of
4 million), the aggregate projected global deficit of health workers against needs
(defined differently in different contexts) could exceed 18 million (range: 16–19
million) by 2030. These challenges are compounded by difficulties in deploying
health workers to rural, remote and underserved areas.

Globally, 20–40% of all health spending is wasted (21), with health workforce
inefficiencies responsible for a substantial proportion. For example, service
organization models that place excessive reliance on specialists delivering curative
care in tertiary settings are neither cost-effective nor responsive to population
needs. In addition, weaknesses in transparency and accountability can lead to
inappropriate use of resources, such as ghost workers artificially inflating health
sector wage bills (22).

Policy reforms towards a more efficient and equitable allocation of resources are often
challenged by special interests, such as protecting overrestrictive access to health
professional education, or by well intentioned but misguided macroeconomic policies
that, while aiming at promoting economic stability, can result in underinvestment in
health systems (23) and in lost opportunities for job creation, economic growth and
improved health outcomes.

4.2 Lessons learned

Past efforts in health workforce development have yielded significant results;

examples abound of countries that, by addressing their health workforce challenges,
have improved health outcomes (24, 25). In reviewing past efforts in implementing

18 Health Employment and Economic Growth: An Evidence Base

national, regional and global strategies and frameworks, the key challenge is to
mobilize political will and financial resources for the health system and its critical
HRH component in the longer term (26, 27).

Market forces in the health sector do not necessarily and automatically lead towards
desirable health outcomes; health labour markets are an example of the potential
for market failure in the pursuit of social goals. Based on current trends, by 2030
the world would face a substantial and widening mismatch between the need for,
supply of and demand for health workers (see Tables 1 to 3). Evidence also indicates
that private sector investment in health worker education and employment tends
to cluster around the most remunerative professions and those marketable at the
global level, rather than the primary health care workforce, which is most needed
and effective in improving equity in access to essential health care services (28). It is
therefore critical that public sector policies and investments directly address health
labour market failures, better aligning supply of and demand for health workers to
population health needs, and prioritize investment in the cadres that have the skills
and competencies to meet the identified needs.

Past efforts for increasing the health workforce have also revealed the limitations
of approaches simplistically focused on scaling up the supply of health workers
without taking into account health labour market realities. For instance, several
low-income countries experience underemployment of doctors and nurses, yet
they simultaneously invest substantial public funds in producing more, worsening
underemployment and reducing the efficiency of government expenditures
(29). Conversely, effective strategies need to be targeted to the specific realities
and conditions of the health labour market and to improving the productivity
of the existing health workforce. These strategies should be accompanied by the
establishment of social protection schemes to make health care affordable to the
population, which can boost health system demand for health workers.

PART I: Health Workforce Dynamics | CHAPTER 1 19

 5. Policy options

In many high-income and upper middle-income countries, economic growth and

demographic trends will drive demand for health care for ageing populations and
additional services. In many of these contexts, however, the supply of health workers will
remain constrained – a mismatch that could raise the cost of health workers, fuel broader
cost escalation in the health sector, and stimulate health worker mobility across borders.
In these settings, relaxing barriers to entry into health training and health professions may
be required, together with increasing both public sector and private sector investment in
health education geared to a more efficient and responsive skills mix. Quality standards
should be maintained and harmonized across public and private health education
institutions and reinforced with effective regulatory mechanisms to protect the public
from harm.

In low-income and some lower middle-income countries, on the other hand, both
demand and supply will continue to fall short of population needs. In these contexts
much-needed investments – from both the public and private sectors – in health
worker education should be accompanied by an expansion of the fiscal space to
create and fill funded positions in the health sector. Most funding should come from
domestic resources. However, several low-income countries and other settings affected
by complex humanitarian emergencies will still require international development
assistance for a few more decades.

Health workforce strategies should ensure that the expanded health resources envelope
leads to cost-effective resource allocation. An important strategy to inform resource
allocation will be to fully understand the health needs of populations in order to
design care delivery models that are both effective and efficient. Specifically, deploying
interprofessional primary care teams of health workers with broad-based skills should be
prioritized to avoid the pitfalls and cost escalation of overreliance on specialist and tertiary
care. This requires adopting a diverse and sustainable skills mix, and harnessing the
potential of community-based and mid-level health workers to extend service provision to
poor and marginalized populations (30, 31). In many settings, developing a national policy
to integrate community-based health workers in the health system can enable these cadres
to benefit from adequate system support and to operate more effectively within integrated
primary care teams (32, 33).

20 Health Employment and Economic Growth: An Evidence Base

6. Implementation considerations

Technical and management capacities are needed to translate political will and
decisions into effective implementation; just as capable clinicians and health
professionals are needed, so are capable professional health managers, planners and
policy-makers. All countries should have an HRH unit or department, reporting
to a senior level within the ministry of health, with the capacity, responsibility and
accountability for a standard set of core functions of HRH policy, advocacy, analysis,
planning, governance, data management and reporting (34). Crucially, this capacity
needs to be available at the appropriate administrative level: in federal countries, or
those with a decentralized health workforce administration, competency, human
capital and institutional mechanisms for the core functions described above should be
built at the subnational and local levels.

Better HRH data and evidence are required as a critical enabler to enhance advocacy,
planning, policy-making, governance and accountability at subnational, national and
global levels. All countries should invest in analytical capacity for HRH and health
system data. This should be based on policies and guidelines for standardization and
interoperability of available and appropriate HRH data, such as those given in the
WHO minimum data set for health workforce registry (35), to establish and implement
national health workforce accounts.

In parallel with country actions, there are also opportunities to strengthen and streamline
global HRH governance. For example, global health initiatives should establish
mechanisms to ensure that all grants and loans include an assessment of health workforce
implications. Their programmes should contribute to HRH capacity-building efforts at
institutional, organizational and individual levels. The recruitment of general service staff
by disease-specific programmes weakens health systems, and should be avoided through
integration of disease-specific programmes into primary health care strategies and
pre-service education. Emphasis should be given to increasing sustainable investment
and support for HRH, including both capital and recurrent costs. The implementation of
global normative and policy instruments, such as the WHO Global Code of Practice on
the International Recruitment of Health Personnel (36), and of the WHO Global Strategy
on Human Resources for Health: Workforce 2030, should be reinforced and accelerated.

PART I: Health Workforce Dynamics | CHAPTER 1 21

 Acknowledgements

The chapter incorporates four components that have been developed separately in collaboration with
other partners and institutions.

1. Health workforce requirements for universal health coverage and the Sustainable Development
Goals: background paper no. 1 to the Global Strategy on Human Resources for Health:
Workforce 2030 (commissioned and coordinated by WHO):
Authors: Richard Scheffler (University of California, USA), Giorgio Cometto (WHO) (co-first
authors), Kate Tulenko (IntraHealth International, USA), Tim Bruckner (University of California,
USA), Jenny Liu (University of California, USA), Julia Brasileiro (IntraHealth International, USA),
James Campbell (WHO).
Acknowledgements: Eric Keuffel (Temple University, USA), Alexander Preker (Health Investment and
Financing Corporation, USA), Barbara Stilwell (IntraHealth International, USA) and Rebecca Bailey
(IntraHealth International, USA) contributed to some components of the analysis of needs-based
shortages.
David Evans (University of Basel, Switzerland), Akiko Maeda (World Bank), Tomoko Ono (JICA),
Octavian Bivol (UNICEF), Gabriele Fontana (UNICEF), Gilles Dussault (IHMT, Portugal), Remco
Van de Pas (ITM, Belgium), Angelica Sousa (WHO), Amani Siyam (WHO), Karin Stenberg
(WHO), Tessa Edejer (WHO) and Xenia Scheil-Adlung (ILO) were part of the advisory group that
provided strategic direction and peer review to the analysis of needs-based shortages.
Melanie Cowan (WHO), Leanne Riley (WHO), Gretchen Stevens (WHO) and Daniel Hogan
(WHO) availed health service coverage used in the analysis.

2. Global health workforce labour market projections for 2030 (commissioned and coordinated by
the World Bank):
Authors: Jenny Liu (University of California, USA), Yevgeniy Goryakin (University of East Anglia,
United Kingdom), Akiko Maeda (World Bank), Tim Bruckner (University of California, USA), and
Richard Scheffler (University of California, USA).

3. Future human resources for health supply and requirements in high-income OECD countries
(commissioned and coordinated by WHO):
Authors: Gail Tomblin Murphy (Dalhousie University, Canada), Stephen Birch (University of
Manchester, United Kingdom), Adrian MacKenzie (Dalhousie University, Canada).
Acknowledgements: Janet Rigby (Dalhousie University, Canada) and Annette Elliott Rose
(Dalhousie University, Canada) helped obtain necessary data for analyses in high-income countries.

4. Definition and measurement of the health workforce (contributed by ILO):

David Hunter (ILO) contributed the relevant section (box 1) of this policy chapter.

22 Health Employment and Economic Growth: An Evidence Base

 Acknowledgements

The chapter incorporates four components that have been developed separately in collaboration with
other partners and institutions.

1. Health workforce requirements for universal health coverage and the Sustainable Development
Goals: background paper no. 1 to the Global Strategy on Human Resources for Health:
Workforce 2030 (commissioned and coordinated by WHO):
Authors: Richard Scheffler (University of California, USA), Giorgio Cometto (WHO) (co-first
authors), Kate Tulenko (IntraHealth International, USA), Tim Bruckner (University of California,
USA), Jenny Liu (University of California, USA), Julia Brasileiro (IntraHealth International, USA),
James Campbell (WHO).
Acknowledgements: Eric Keuffel (Temple University, USA), Alexander Preker (Health Investment and
Financing Corporation, USA), Barbara Stilwell (IntraHealth International, USA) and Rebecca Bailey
(IntraHealth International, USA) contributed to some components of the analysis of needs-based
shortages.
David Evans (University of Basel, Switzerland), Akiko Maeda (World Bank), Tomoko Ono (JICA),
Octavian Bivol (UNICEF), Gabriele Fontana (UNICEF), Gilles Dussault (IHMT, Portugal), Remco
Van de Pas (ITM, Belgium), Angelica Sousa (WHO), Amani Siyam (WHO), Karin Stenberg
(WHO), Tessa Edejer (WHO) and Xenia Scheil-Adlung (ILO) were part of the advisory group that
provided strategic direction and peer review to the analysis of needs-based shortages.
Melanie Cowan (WHO), Leanne Riley (WHO), Gretchen Stevens (WHO) and Daniel Hogan
(WHO) availed health service coverage used in the analysis.

2. Global health workforce labour market projections for 2030 (commissioned and coordinated by
the World Bank):
Authors: Jenny Liu (University of California, USA), Yevgeniy Goryakin (University of East Anglia,
United Kingdom), Akiko Maeda (World Bank), Tim Bruckner (University of California, USA), and
Richard Scheffler (University of California, USA).

3. Future human resources for health supply and requirements in high-income OECD countries
(commissioned and coordinated by WHO):
Authors: Gail Tomblin Murphy (Dalhousie University, Canada), Stephen Birch (University of
Manchester, United Kingdom), Adrian MacKenzie (Dalhousie University, Canada).
Acknowledgements: Janet Rigby (Dalhousie University, Canada) and Annette Elliott Rose
(Dalhousie University, Canada) helped obtain necessary data for analyses in high-income countries.

4. Definition and measurement of the health workforce (contributed by ILO):

David Hunter (ILO) contributed the relevant section (box 1) of this policy chapter.

General acknowledgement
James Buchan provided valuable feedback on an earlier draft of this policy chapter.

22 Health Employment and Economic Growth: An Evidence Base

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Health worker remuneration in WHO Member market forces matter? Bulletin of the World Health
States. Bulletin of the World Health Organization. Organization. 2013;91(11):841–6. doi:10.2471/
2013;91(11):808–15. doi:10.2471/BLT.13.120840. BLT.13.118794.
PMID:24347704.
30. Lewin S, Munabi-Babigumira S, Glenton C, Daniels
21. The world health report 2010 – health systems K, Bosch-Capblanch X, van Wyk BE et al. Lay health
financing: the path to universal health coverage. workers in primary and community health care for
Geneva: World Health Organization; 2010 (http:// maternal and child health and the management of
www.who.int/whr/2010/en/, accessed 23 October infectious diseases. Cochrane Database of Systematic
2016). Reviews. 2010;17(3):CD004015. PMID:20238326.

22. Dominican Republic’s health sector reinvests savings 31. Lassi Z, Cometto G, Huicho L, Bhutta ZA. Quality of
from ghost workers to improve care. IntraHealth care provided by mid-level health workers: systematic
International, 7 January 2015 (http://www.intrahealth. review and meta-analysis. Bulletin of the World Health
org/page/dominican-republics-health-sector-reinvests- Organization. 2013;91(11):824–33. doi:10.2471/
savings-from-ghost-workers-to-improve-care, BLT.13.118786. PMID:24347706.
accessed 23 October 2016).
32. McCord GC, Liu A, Singh P. Deployment of
23. Stuckler D, Basu S, Gilmore A, Batniji R, Ooms community health workers across rural sub-Saharan
G, Marphatia AA et al. An evaluation of the Africa: financial considerations and operational
International Monetary Fund’s claims about public assumptions. Bulletin of the World Health
health. International Journal of Health Services. Organization. 2013;91(4):244–53B. doi:10.2471/
2010;40(2):327–32. doi:10.2190/HS.40.2.m. BLT.12.109660. PMID:23599547.
PMID:20440976.
33. Tulenko K, Møgedal S, Afzal MM, Frymus D, Oshin
24. Campbell J, Buchan J, Cometto G, David B, Dussault A, Pate M et al. Community health workers for
G, Fogstad H et al. Human resources for health universal health-care coverage: from fragmentation
and universal health coverage: fostering equity and to synergy. Bulletin of the World Health Organization.
effective coverage. Bulletin of the World Health 2013;91(11):847–52. doi:10.2471/BLT.13.118745.
Organization. 2013;91(11):853–63. doi:10.2471/ PMID:24347709.
BLT.13.118729. PMID:24347710.
34. Global Strategy on Human Resources for Health:
25. Van Lerberghe W, Matthews Z, Achadi E, Ancona C, Workforce 2030. Geneva: World Health Organization;
Campbell J, Channon A et al. Country experience with 2016 (http://www.who.int/hrh/resources/pub_
strengthening of health systems and deployment of globstrathrh-2030/en/, accessed 24 October 2016).
midwives in countries with high maternal mortality.
Lancet. 2014;384(9949):1215–25. doi:10.1016/S0140- 35. Human resources for health information system:
6736(14)60919-3. PMID:24965819. minimum data set for health workforce registry.
Geneva: World Health Organization; 2015 (http://
26. DeLuca MA, Soucat A, editors. Transforming the www.who.int/hrh/statistics/minimun_data_set/en/,
global health workforce. New York: New York accessed 23 October 2016).
University College of Nursing; 2013.
36. Resolution WHA63.16. WHO Global Code of Practice
27. Cometto G, Boerma T, Campbell J, Dare L, Evans T. on the International Recruitment of Health Personnel.
The Third Global Forum: framing the health workforce In: Sixty-third World Health Assembly, Geneva, 21
agenda for universal health coverage. Lancet Global May 2010. Geneva: World Health Organization; 2010
Health. 2013;1(6):e324–5. doi:10.1016/S2214- (http://apps.who.int/gb/ebwha/pdf_files/WHA63/
109X(13)70082-2. PMID:25104590. A63_R16-en.pdf), accessed 23 October 2016).

28. McPake B, Squires A, Mahat A, Araújo EC,

editors. The economics of health professional
education and careers: insights from a literature
review. Washington (DC): World Bank; 2015
(https://openknowledge.worldbank.org/
bitstream/handle/10986/22576/9781464806162.
pdf?sequence=1 accessed 23 October 2016).

24 Health Employment and Economic Growth: An Evidence Base

ANNEX 1: Overview of methodology to identify
needs-based shortages of health workers

The full methods and results of this analysis were published in a background paper to
the Global Strategy on Human Resources for Health: Workforce 2030. The following is
a chapter overview of the methods adopted.

To estimate each country’s current stock of health workers, we retrieved health workforce
figures from the WHO Global Health Observatory, which was updated in 2014 and
therefore reflects to a large extent data referring to 2013. Yearly workforce density (that is,
per 1000 population) data were obtained for 210 countries and territories. For each country,
we calculated the population density of physicians and nurses/midwives for the most
recent year (since 2008) for which there were data and adjusted the number to the 2013
populations of these countries. For countries with missing data on health workers (that is,
no values since 2008), we imputed numbers of physicians and nurses/midwives based on
the median density of physicians and nurses/midwives for each of the four World Bank-
designated income groups.

The supply of physicians and nurses/midwives was projected to 2030 based on

historical data on the increase in densities of physicians and nurses/midwives in each
country. To forecast supply, a linear growth rate model was adopted, which assumes
that the historical growth rate of physicians and nurses/midwives per capita for each
country will continue into the future at the same rate each year.

Data points that represented obvious outliers due to misreporting were removed and
replaced with missing data. Missing data points for physicians and nurses/midwives
per 1000 population between any two real data points were linearly interpolated.
The following equations were then estimated for each country from time
t = {1990, … 2013}:

(Equation 1) Physicians per 1000 populationt = a0 + a1*yeart + et

(Equation 2) Nurses/midwives per 1000 populationt = b0 + b1*yeart + et

where et is the random disturbance term and a0, b0, a1 and b1 are unknown parameters,
with the last two parameters representing the linear growth rates to be estimated from
the model.

PART I: Health Workforce Dynamics | CHAPTER 1 25

 The following rules were applied to predict future (2014–2030) values of worker
densities:

• Where at least two data points were available, the estimated linear trend was
extended into the future until 2030 using the estimated coefficients for a and b.

• If the estimated linear growth was found to be too large or too small, the country’s
growth rate was replaced with aggregate medians, and then the median growth
rate was applied to the last available observation for that country (that is, most
recent year).

• For physicians: If a given country’s linear growth rate was larger or smaller than
1 standard deviation from the mean growth rate for all countries, the median
growth rate of a comparable group of countries was substituted.

• For nurses/midwives: For nurses, there was large overdispersion of the linear
growth rate distribution. Consequently, if a country’s linear growth rate was larger
than 80% or smaller than 20% of the growth rate distribution, then the median
growth rate of a comparable group of countries was substituted.

• For both physicians and nurse/midwives: If the predicted density in 2030 resulted
in a negative number, that country’s growth rate was also replaced with the
corresponding median aggregate value in a comparable group of countries.

• If there was just one point for a country (and thus linear growth rate could not be
estimated), the same median substitution for the growth rate as described above
was applied.

• When no observations were available before 2013 (that is, no empirical data at all
for both physicians and nurses/midwives), neither the supply of physicians nor
the supply of nurse/midwives was projected. Instead, the mean 2030 predicted
supply density across a comparable group of countries was substituted.

26 Health Employment and Economic Growth: An Evidence Base

CHAPTER 2

Women’s contributions to sustainable

development through work in health:
Using a gender lens to advance a transformative
2030 agenda
Veronica Magar, Megan Gerecke, Ibadat S. Dhillon, James Campbell

Abstract
This chapter explores trends in women’s work in health as related to the
achievement of the Sustainable Development Goals (SDGs), focusing on SDG
3, SDG 5 and SDG 8.1 It outlines challenges arising from gaps in the knowledge
base, gender biases in health systems, and gender biases in the institutions that
surround health systems. A qualitative literature review was supplemented with
sex-disaggregated data from several international organizations.

The health and social sector is a leading employer of women. However, significant
occupational segregation occurs by sex and institutionalized hierarchies are
prevalent within and across occupations, particularly in terms of pay rates, career
pathways and decision-making power. Gender biases create systemic inefficiencies
in health systems by limiting the productivity, distribution, motivation and
retention of female health workers.

While the health sector plays a positive role in drawing women into employment,
it could make a larger contribution to sustainable development by addressing
persistent gender biases and recognizing and valuing women’s unpaid and informal
work. The chapter calls on policy-makers to build the evidence base on women in
the health workforce; to work across sectors to recognize and reform unequal gender
laws and institutions; and to address gender biases in health systems.

1. On good health and well-being, gender equality, and decent work and economic growth, respectively.

PART I: Health Workforce Dynamics | CHAPTER 2 27

 1. Introduction and outline of methods

The health workforce, as the backbone of health systems and a key employment
sector (1), is essential to sustainable development. However, it is not a gender-neutral
terrain. Significant occupational segregation occurs by sex and institutionalized
hierarchies are prevalent within and across occupations, particularly in terms of
pay rates, career pathways and decision-making power. Many of these inequalities
stem from gender biases in health systems and in the societies and institutions that
support and surround them.

In and of themselves, gender biases undermine the achievement of many of the

Sustainable Development Goals (SDGs), including gender equality (SDG 5) and
inclusive growth, full employment and decent work (SDG 8). They also create
systemic inefficiencies in health systems by limiting the productivity, distribution,
motivation and retention of female workers, who constitute a large share of the health
workforce (2, 3). A focus on gender equality in the health sector can help countries
effectively remedy these problems and act on the mandate to increase health
financing and the recruitment, development, training and retention of the health
workforce (SDG 3.c).

Despite the importance of gender dynamics in the health workforce, gender issues
are rarely given heed in health systems design (4). This chapter draws on relational
and structural theories of gender to cast light on unaddressed issues within health
systems and the institutions that support them. While recognizing that gender is
a social process affecting both men and women, the chapter focuses primarily on
female health workers.

Gender inequalities in the health workforce are neither static nor universal (3).
They are embedded in particular contexts and shaped by health system design, the
national political economy and culture. Relational theories of gender recognize
that gender is a social process that is inextricable from “economic relations,
power relations, affective relations and symbolic relations; and [that it operates]
simultaneously at intrapersonal, interpersonal, institutional and society-wide levels”

28 Health Employment and Economic Growth: An Evidence Base

(5). Health systems, and women’s individual experiences within them, shape and
are shaped by processes operating on multiple levels. Women’s position along other
axes of inequality – such as race, ethnicity and socioeconomic class – intersect with
gender to create new hybrid identities and structures that inform their individual
(intersectional) experiences (6).

In this chapter, for a gender and human rights framing we look to the 2030 Agenda
for Sustainable Development, as adopted by 193 countries at the United Nations
General Assembly in September 2015 (7). As such, the chapter explores trends in
women’s work in health as they relate to the achievement of the SDGs, focusing on
SDG 3 (good health and well-being), SDG 5 (gender equality), and SDG 8 (decent
work and economic growth) in particular. Ending discrimination (SDG 5.1) is a
major cross-cutting theme of the chapter.

The chapter outlines challenges that arise from gaps in the knowledge base on gender,
gender biases in workforce policies and practices in health systems, and gender biases
in the institutions that support and surround health systems. After summarizing
current and previous efforts, it presents policy options for progress in these three
areas and explores challenges related to their implementation.

A desk review of literature on women’s work in health, covering more than

100 articles, chapters, books and reports, supports this analysis, which is based
on an earlier review of 175 sources (8). This qualitative literature review was
complemented by sex-disaggregated data on women in the health workforce,
gathered from several international organizations, including the World Health
Organization (WHO), International Labour Organization (ILO), Organisation for
Economic Cooperation and Development (OECD) and European Commission.
Current trends and issues were mapped onto the SDGs through a careful review
of the goals, targets and indicators. Finally, the literature was surveyed for possible
gender-transformative solutions that are in line with the SDGs.

PART I: Health Workforce Dynamics | CHAPTER 2 29

 2. Findings

Significant gaps exist in the evidence base. Gender dynamics in the health
workforce are underexplored (4). Much of women’s work in health is unpaid
or in the informal sector and, as such, is poorly covered by official statistics.
However, a review of the existing evidence does reveal important findings, as
summarized in the following subsections.

2.1 Recognizing and valuing the contribution of unpaid

and informal female health workers

SDG target 5.4 calls on countries to value unpaid care and domestic work through
the provision of public services, infrastructure and social protection policies and
the promotion of shared responsibility within the household and the family.

Health systems rely heavily on unpaid or informal work but fail to recognize or
value it. For example, in Spain, 88% of all health work is unpaid (9). A study of
volunteer caregivers in six African countries found that women made up the
majority of such workers (81%) and that only 7% of volunteers received a
stipend (10).

Shortfalls to an available, accessible, acceptable and quality health workforce

create demands for unpaid or informal health care work that disproportionately
falls on women and girls, due to the unequal division of care responsibilities at
the household and community levels. Such informal care work is typically poorly
regulated and poorly paid (or not paid at all). For example, domestic, informal
and home health workers are often excluded from protective labour regulations
(2), reducing progress on SDG 8.

Informal and unpaid care work reproduces hierarchies not only across gender
but also across class and race, with low-income, minority and immigrant women
doing the bulk of unpaid and informal care work (11). Women’s informal care
work buffers weaknesses in the health care system and may hide the extent to
which these systems are inefficient and are creating medical poverty traps (3).

30 Health Employment and Economic Growth: An Evidence Base

2.2 The health sector as a major employer of women:
supporting the goal of full, inclusive employment
SDG 8 calls for sustained, inclusive and sustainable economic growth, full and
productive employment and decent work for all. Looking at women in the health
workforce, SDG 8 overlaps with SDG 3.c, which calls for an increase in health
financing and the recruitment, development, training and retention of the health
workforce. SDG 8 also overlaps with SDG 5.1, which provides a mandate to end
all forms of discrimination against all women – in this case, discrimination against
women in the health workforce.

In terms of the quantity of employment, the health sector, as a major employer of

women, contributes to the goal of full employment and decent work for all (SDG
target 8.5). In most countries, women’s share of employment in the health and
social sector is much higher than their share of employment in the economy as
a whole (Figure 1). Across the countries shown in Figure 1, women make up an
(unweighted) average of 67% of health and social sector employment, compared
with 41% of total employment. This is true in countries and regions with both high
and low overall rates of female employment. While certain exceptions exist, for the
most part, the health sector has a disproportionate impact on increasing women’s
representation in the workforce. This in turn helps to ensure women’s full and
effective participation in political, economic and public life (SDG target 5.5); to
reduce poverty and hunger by allowing women to gain livelihoods (SDGs 1 and 2);
and to reduce inequalities by sex and improve equal opportunities (SDG 10).

PART I: Health Workforce Dynamics | CHAPTER 2 31

 Kuwait

Eastern M
Morocco

(E
Oman
Qatar
Saudi Arabia
Syrian Arab Republic
Albania
Figure 1 Armenia
Austria
Azerbaijan
Belgium
Women’s share of employment in the health and social sector versus
Bulgaria
total employment (%), by WHO region, average values for the period
Bosnia and Herzegovina
Switzerland
2005–2014 Cyprus
Czech Republic
Germany
Denmark
Women’s share of employment in the Spain economy Women’s share of employment in the health and social sector
Estonia
Finland
Europe (EURO)

Benin
France
Burkina
United Faso
Kingdom
Botswana
Georgia
Ethiopia
Greece
Ghana
Croatia
Guinea
Hungary
Africa (AFRO)

Gambia
Ireland
Liberia
Iceland
Madagascar
Israel
Mauritius
Italy
Namibia
Kazakhstan
Nigeria
Kyrgyzstan
Rwanda
Lithuania
Senegal
Luxembourg
Sao Tome and Principe
Latvia
Republic ofSeychelles
Moldova
United Republic of Tanzania
The former Yugoslav Republic of Macedonia
Uganda
Malta
South Africa
Montenegro
Zimbabwe
Netherlands
Argentina
Norway
Antigua and Barbuda
Poland
Belize
Portugal
Bolivia (Plurinational Romania
State of)
Brazil
Russian Federation
Barbados
Serbia
Chile
Slovakia
Colombia
Slovenia
Costa Rica
Americas (AMRO)

Sweden
Cuba
Tajikistan
Dominican Republic
Turkey
Ecuador
Ukraine
Guatemala
Bangladesh
Jamaica
Bhutan
theAsia

Mexico
Indonesia
(SEARO)

Nicaragua
Sri Lanka
South-East

Panama
Maldives
Peru
Nepal
Paraguay
Thailand
El Salvador
Timor-Leste
Suriname
Brunei Darussalam
Uruguay
China
Venezuela (Bolivarian Republic Japan of)
United ArabCambodia
Emirates
Bahrain
Kiribati
Mediterranean
Pacific

Egypt
Republic of Korea
(WPRO)

Iran (Islamic Republic

Mongolia of)
(EMRO)
EasternWestern

MalaysiaIraq
Kuwait
New Zealand
Morocco
Philippines
Oman
Singapore
VietQatar
Nam
Saudi Arabia
Vanuatu
Syrian Arab Republic
Samoa
Albania 0 10 20 30 40 50 60 70 80 90 100
Armenia
Austria
Source: ILOStat series: Female share of employment by economic activity (EMP_XFEM_ECO_RT)
Azerbaijan
Belgium
Bulgaria
Bosnia and Herzegovina
Switzerland
Cyprus
Czech Republic
32 Health Employment andGermany Economic Growth: An Evidence Base
Denmark
Spain
Estonia
)
 Egypt

Eastern Mediterran
Iran (Islamic Republic of)

(EMRO)
Iraq
Kuwait
Morocco
Oman
Qatar
Women’s share of employment in the economy Women’s share of employment in the health and social sector
Saudi Arabia
Syrian Arab Republic
Albania
Armenia
Austria
Azerbaijan
Belgium
Bulgaria
Bosnia and Herzegovina
Switzerland
Cyprus
Czech Republic
Germany
Denmark
Spain
Estonia
Finland
Europe (EURO)

France
United Kingdom
Georgia
Greece
Croatia
Hungary
Ireland
Iceland
Israel
Italy
Kazakhstan
Kyrgyzstan
Lithuania
Luxembourg
Latvia
Republic of Moldova
The former Yugoslav Republic of Macedonia
Malta
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
Russian Federation
Serbia
Slovakia
Slovenia
Sweden
Tajikistan
Turkey
Ukraine
Bangladesh
Bhutan
South-East Asia

Indonesia
(SEARO)

Sri Lanka
Maldives
Nepal
Thailand
Timor-Leste
Brunei Darussalam
China
Japan
Cambodia
Kiribati
Western Pacific

Republic of Korea
(WPRO)

Mongolia
Malaysia
New Zealand
Philippines
Singapore
Viet Nam
Vanuatu
Samoa
0 10 20 30 40 50 60 70 80 90 100

PART I: Health Workforce Dynamics | CHAPTER 2 33

 Over time, women’s representation in the health sector has increased. In many
countries, nursing and midwifery have long been female-dominated occupations
(3). However, over the past few decades, women have been entering medical school
in growing numbers and are making up a growing share of physicians; for example,
across OECD countries, the female share of physicians has grown from an average of
29% in 1990 to 45% in 2013 (12).

Structural and relational factors shape women’s engagement in the labour market
in general and in the health sector in particular. A variety of factors operate at
multiple levels:

• Women’s employment in general is restricted by a number of factors, including

the uneven division of care and domestic work within the household; restrictive
norms about women’s role in public life; mobility restrictions based on safety
or lack of transportation; unequal legal rights; and unequal opportunities for
education. Equitable progress in these domains can encourage greater labour force
participation. That said, high rates of female labour force participation cannot
be blindly accepted as normatively good; female labour force participation may
reflect an involuntarily decision taken in order to survive extreme poverty (13).

• Women’s employment in the health sector is restricted by the factors listed

above and factors within health systems. Biases within human resource policies
(for example, lack of appropriate work–life balance policies) limit the retention
of female workers, particularly given the psychosocial demands specific to health
care providers. The reliance of health systems on unpaid or informal work also
limits opportunities for employment.

The degree to which these factors affect individual women will depend on their
resources and capacities. The distribution of resources and capacities are in turn
shaped by where women fall on a variety of axes of inequality, such as race, ethnicity,
caste, socioeconomic status and geographical location. For example, much of unpaid
home care is concentrated among low-income women, who have fewer resources to
purchase paid care.

34 Health Employment and Economic Growth: An Evidence Base

2.3 Better-quality employment for women in the
health sector
This section looks particularly at equal pay for work of equal value (SDG target 8.5);
equal opportunities for leadership at all levels of decision-making (SDG target 5.5);
safe and secure working environments (SDG target 8.8); and the protection of labour
rights (SDG target 8.8). In all these areas, the health sector could improve the quality
of employment it offers women.

2.3.1 Closing gaps in pay across sectors and by sex

Equal pay for work of equal value means eliminating pay gaps between individuals
holding jobs that are the same or of comparable worth in terms of qualifications,
effort, responsibility and working conditions (14).

In most countries, pay for jobs in health care is lower than pay for jobs with similar
qualifications in other sectors. In fact, a pay penalty exists in general for care-related
work (including, for example, health care and child care), which remains even
after controlling for the sex composition of the workforce (15, 16). As women are
overrepresented in caring professions such as health care, they are disproportionately
affected by this pay penalty.

Looking within the health sector, gender wage gaps are common. ILO data on 33
WHO Member States show that female health professionals tend to earn less than
their male counterparts (Figure 2). Gaps among associate professionals also exist in
most cases. However, as shown in Figure 2, women earn the same or more in seven
of 33 Member States for which data exist. The data do not adjust for individual and
contextual factors that affect wages, such as seniority, education, working hours,
contract type, establishment type and size, region, and unionization.

PART I: Health Workforce Dynamics | CHAPTER 2 35

 Figure 2

Unadjusted gender wage gaps in mean monthly earnings

among health professionals and health associate professionals,
2005–2014 (latest year for which data are available)

Health professionals Health associate professionals

Argentina
Austria
Belgium
Belarus
Costa Rica
Germany
Dominican Republic
Ecuador
Spain
Ethiopia
Finland
United Kingdom
Greece
Guatemala
Indonesia
India
Israel
Sri Lanka
Madagascar
Maldives
Macedonia
Mauritius
Malaysia
Panama
Peru
Philippines
Poland
Portugal
Russian Federation
Slovakia
Thailand
Turkey
South Africa

-20 -10 0 10 20 30 40 50 60 70 80

Notes: The gender wage gap is calculated as the difference between average earnings of men and
average earnings of women expressed as a percentage of average earnings of men (using nominal
monthly earnings).
Due to concerns about the quality of data, the 2012 instead of the 2013 observation has been used for
Guatemala.
Source: Authors’ calculations based on ILOSTAT: Mean nominal monthly earnings of employees by sex
and occupation – selected International Standard Classification of Occupation (ISCO) level 2.

36 Health Employment and Economic Growth: An Evidence Base

Studies that adjust for individual and contextual factors affecting wages confirm
gender-related gaps in pay. While there are a few studies that find little or no evidence
of discrimination (17, 18), most find significant gender gaps in pay even after
adjusting for individual and contextual factors (19–24). As shown in Figure 2, gaps
tend to be larger in higher-income occupational categories (19, 21). Worryingly, gaps
may be widening over time (23). A recent study of gender pay gaps in the United
States of America found that gaps among health workers were among the highest
across different sectors and occupations (25).

Unequal division of care and domestic work within the household may lead
women to reduce their paid working hours and take career breaks. Biases in human
resourcing policies mean these choices are unfairly penalized with, for example,
unequal pay for part-time work or reduced eligibility and access to pensions and
other social benefits. Time taken off work for child care and other responsibilities
may also derail career paths, particularly if women returning to the labour market
lack opportunities to upgrade skills and access positions of power. Women from
minority and vulnerable groups may face structural obstacles on multiple levels,
exacerbating disadvantages. For example, migrants with foreign credentials have
been shown to suffer pay penalties (26).

2.3.2 Increasing women’s representation in positions of leadership

and decision-making in the health sector

A large share of the wage gaps described above reflects women’s underrepresentation
in positions of power in the health sector. In terms of political representation across
191 countries, only 51 countries had a female minister of health (27).

Data on a selection of high-income countries for 2007 show that in many countries,
women make up the majority of managers in the health and social sector but
are almost always underrepresented if one takes into account their share of total
employment in the sector (Figure 3). Underrepresentation seems to be more
prominent in countries with welfare regimes that attach social benefits to earnings

PART I: Health Workforce Dynamics | CHAPTER 2 37

 and occupation, arguably replicating market-generated inequalities (28)2 (that
is, Austria, Belgium, France, Germany and Italy; the Netherlands stands as an
exception). This may suggest that countrywide social policies are a significant factor
in determining women’s opportunities for advancement within the field of health.3

Figure 3

Women’s share of senior positions over their share of employment,

by sector and by country, 2007

FINLAND NORWAY SWEDEN BELGIUM

100

50

FRANCE NETHERLANDS AUSTRIA DEU

100

50
Female share of senior positions

AUSTRALIA CANADA IRELAND NEW ZEALAND

100

50

0 0

SPAIN GREECE ITALY PORTUGAL

100

50

0
0 50 100 0 50 100 0 50 100 0 50 100

Female share of employment

Share of management equal to share of employment Health and social work Other sectors Total

Source: Authors’ calculations based on ILO’s Labour Statistics database (LABORSTAT): Economically
active population, by industry and by occupation (thousands).

2 Examining the institutional logic of welfare states (that is, how the responsibility for welfare is divided between the
state, the market and the family), Esping-Andersen categorized countries as “social democratic” (largely Nordic),
“liberal” (largely Anglo-Saxon) and “conservative” (continental European) (28). This categorization has been critiqued
and expanded upon by several authors, but in general, revisions have produced similar country groupings.
3 That said, countries’ choice of social policies is embedded in their particular sociocultural context and political
economy.

38 Health Employment and Economic Growth: An Evidence Base

2.3.3 Violence, harassment and work-related stress as risks for all health
workers, especially women
In terms of offering safe and secure working environments, women’s work in the
health sector falls short of the objectives under SDG targets 8.8 (protect labour
rights and promote safe and secure working environments for all workers) and 5.2
(eliminate all forms of violence against all women and girls in the public and
private spheres).

Health workers, particularly nurses and community health workers, are often at risk
of violence and harassment, as understood in SDG target 5.2 (29, 30). In addition to
being problems in their own right, violence and harassment increase absenteeism
and reduce workforce retention, motivation and the quality of services provided (29).
In some countries, problems of violence and harassment are particularly rampant
in rural and remote areas, which may exacerbate uneven distribution of health
workers. Disturbingly, targeted attacks against health workers have also increased in
recent years, leading to the adoption of a United Nations Security Council resolution
strongly condemning attacks against medical personnel (31).

In addition, stress, fatigue and a high workload are common complaints in the
sector (32). Unequal division of care work within the household can exacerbate these
problems, with female health workers having the double duty of caring for patients
at work and family members at home. This contributes to the health care worker’s
poor mental and physical health. Lack of appropriate work–life balance policies and
conflicts between work and family demands have been shown to increase workers’
stress levels (33).

2.3.4 Promoting greater gender equality through strong labour rights

Freedom of association and the effective recognition of the right to collective

bargaining are internationally recognized as fundamental labour rights.4 Collective
bargaining coverage is associated with higher wages, less wage inequality, shorter
working hours and, in some cases, increased provision of training (34–37). As such,
collective bargaining has the possibility of addressing many issues that affect female

4 The ILO Declaration on Fundamental Principles and Rights at Work recognizes three other fundamental principles and
rights at work: the elimination of (a) discrimination, (b) forced or compulsory labour and (c) child labour.

PART I: Health Workforce Dynamics | CHAPTER 2 39

 health workers. In addition, agreements may explicitly target gender issues – for
example, a recent review of industrial relations in Europe found that trade unions
in several countries had successfully campaigned for policies on greater work–life
balance and reduced gender pay gaps in the health sector (32).

However, structural disadvantages may mean that vulnerable workers, such as

migrants and women, are less willing or able to exercise their voice (38). Unions and
professional associations should actively recruit women and cover a wide enough
range of interests that they are able to promote the welfare of all health workers and
their patients.

3. Discussion

3.1 Challenges

While the health sector plays a positive role in drawing women into employment,
it could make a larger contribution to sustainable development by addressing
persistent gender biases and recognizing and valuing women’s unpaid and informal
work. To achieve the targets under SDG 3, SDG 5 and SDG 8, a robust gender
(and equity) analysis and compelling response is called for. Obtaining data and
conducting analyses in underexplored areas is challenging – especially given the
likely implications for overarching policies on accountability, non-discrimination and
equality – but a gender-responsive and equity-enhancing approach is indispensable.

3.2 Action under way and previous efforts

The challenges outlined in this chapter are not new – they are recognized by the
193 countries that endorsed and adopted the SDGs. For instance, SDG target 17.18
calls on countries to build the evidence base on inequalities with disaggregated
data, and SDG targets 5.c, 10.3 and 16.b call on countries to address gender bias
and other forms of discrimination at large through laws and policies that are
non-discriminatory and gender equal. Finally, SDG targets 3.c and 5.4 recognize
deficiencies in health care and the care economy, calling for increased financing of
health systems, valuation of unpaid care work, and better recruitment, development,
training and retention of the health workforce in developing countries.

40 Health Employment and Economic Growth: An Evidence Base

3.2.1 Building the evidence base on women in the health workforce
More and more countries are collecting disaggregated data in order to monitor
health inequalities. Significant gaps, particularly in country capacity, remain in
collecting, analysing, interpreting, reporting and using data. Within the health
sector, there have been commendable efforts to explore health inequities and the
social determinants of health. Some countries (for example Mexico) have begun
monitoring and evaluating policy solutions in these areas (39). Less explored are
the gender dynamics and gender-disaggregated data across occupations, within
both the formal and informal health workforce and the broader health economy.
This requires a health labour market perspective, contextual analysis and the use of
mixed methods, with a focus on intersecting inequalities. Nonetheless, the issue is
gaining attention, with recent adoption of WHO national health workforce accounts
as a concrete step forward (2, 40, 41).

3.2.2 Working across sectors to recognize and reform unequal and

discriminatory laws and institutions

What are sometimes seen as individual choices in how men and women engage
in health work (for example, the decision of women to work fewer hours, and
different rates of volunteer work) are structured by larger social processes and biases
in institutions and laws. A 2016 survey of laws in 173 countries found that while
support for equality is written into the constitutions of most countries (91%), less
than half of the countries explicitly mandate equal pay for work of equal value (41%)
or non-discriminatory hiring based on gender (40%) (42). Progress in these areas will
assist greatly in improving equity in the health workforce.

Labour, wage and social protection policies can help narrow inequalities by gender.
For example, policies and legislation on “equal pay for work of equal value” can
address wage gaps across sectors, by sex and along other axes of inequality, such
as migrant status. They can also address less favourable treatment of part-time
workers in terms of (pro rata) pay and benefits. Such policies usually examine gaps
employer by employer. This makes them powerful tools when the health workforce
is concentrated under one large employer (for example, when health services
are publicly provided), but less effective when it is scattered across many private
employers. Other wage policies, such as minimum wages, can also help reduce

PART I: Health Workforce Dynamics | CHAPTER 2 41

 inequalities in pay. In compressing the wage structure, these policies reduce the
magnitude of pay gaps, and, as women and other vulnerable workers tend to be
overrepresented at the bottom of the wage distribution, they increase the wages of
women (43).

Social protection policies such as cash transfers can help channel resources to women
in unpaid care work. Many countries compensate time dedicated to child care in
their social security systems, for example by increasing caregivers’ eligibility for and
entitlement to pensions (44). In addition, labour laws that challenge the gendered
division of care work within the household could foster women’s integration in and
return to the labour market; for example, non-transferable parental leave for fathers
challenges the idea that women are the natural caregivers of children.

Policies that improve basic infrastructure and services can also narrow gender
inequalities. Those that improve mobility (for example, transportation services and
roads) can reduce the risks and costs associated with travel, thus increasing female
employment and educational attendance (45). Investments in housing and public
safety could also improve the retention and distribution of female health workers;
for example, one study highlights that women’s reluctance to work in rural areas has
more to do with concerns about security and inadequate housing than pay (46).

Improving women’s outcomes in the health workforce can also be supported through
designing inclusive education systems that provide, recognize, subsidize and reward
investments in vocational training and in-work training.

42 Health Employment and Economic Growth: An Evidence Base

3.2.3 Addressing gender and diversity biases in health systems
Countries have attempted to address gender biases within their health systems.
For example, Costa Rica, Turkey and the United Kingdom of Great Britain and
Northern Ireland, among others, have recognized the valuable contribution of
unpaid caregivers to health systems by introducing laws and regulations that
remunerate care work and provide job protection during leave for care (4). Norway,
in particular, has been successful in formalizing previously informal work in health
services and care for children and older people, leading to an eightfold increase in
formal employment in “care” sectors between 1970 and 2014 (47). Other countries
have introduced better work–life balance policies for female health workers; for
example, a nurses’ union in Finland increased workforce retention and improved
quality of services through better working time policies (including predictable
hours, guaranteed time off between shifts and consecutive days off) (4). Other
countries have attempted to make job evaluations gender neutral; for example, the
United Kingdom’s Agenda for Change covers 1 million workers in the national
health system (48). Gender-neutral job evaluations and more transparency in pay
structures can build towards pay equity (14).

Efforts have also been made to address problems of retention and recognition
through inclusive high-quality education and lifelong learning (SDG 4). For example,
a four-month chronic care expert training programme was established for nurses
in Thailand. This helped nurses upgrade their skills and gain recognition; after
the programme, “patients [grew] to view their nurses as their primary health-care
providers rather than doctors” (4).

The international migration of health workers is increasing rapidly. The number of

migrant doctors and nurses working in OECD countries has increased by 60% over
the last decade (49). Many are women. The WHO Global Code of Practice on the
International Recruitment of Health Personnel provides normative guidance in this
area, particularly in relation to protecting the rights of migrating health personnel.

PART I: Health Workforce Dynamics | CHAPTER 2 43

 Similarly, the Framework Guidelines for Addressing Workplace Violence in
the Health Sector, developed by WHO, ILO and two international trade union
federations, provides norms and standards for reducing and preventing violence and
harassment (50).

It should be noted that much more could be done to address gender biases in the
health system. For example, work–life balance measures remain rare, even among
developed countries (32), and policies to remunerate unpaid health care work are few
and far between.

3.3 Policy options

3.3.1 Build the evidence base on women in the health workforce

Before appropriate gender-responsive policies can be identified and adopted, the
current situation in the health workforce must be understood. To monitor progress, it
will be useful to collect, publish and analyse disaggregated data on human resources
for health (as outlined under SDG target 17.18). These data should be disaggregated
not only by sex, but also by ethnicity, age, class, migrant status and sexuality,
wherever possible, to allow for greater understanding of the intersecting effects of
social inequalities.

Simply publishing statistics is not enough. They need to be analysed, reported

and used to set the research agenda for human resources for health. Efforts
should be made to strengthen the collection and use of routine data at country
and local levels, also drawing on evidence established in qualitative studies.
Thinking about problems and constraints from a gender lens may prove to be a
cost-effective exercise for health systems; for instance, work–life balance policies
could improve retention at a relatively low cost to health systems.

44 Health Employment and Economic Growth: An Evidence Base

3.3.2 Work across sectors to recognize and reform unequal gender laws
and institutions
Health care is situated in a larger institutional framework. To address gender bias in
the health care workforce, countries need to recognize and reform unequal gender
laws and institutions. Accountable, non-discriminatory institutions, laws and policies
are important in their own right (SDG 16) and will also help achieve SDG 3, SDG 5,
SDG 8 and SDG 10.

To build supportive institutional frameworks, countries need to work across sectors

to address intersecting axes of inequality that stop health workers from reaching
their full potential. Labour market and social policies can help to reduce inequalities
and address the gendered division of care. Social protection and wage policy can
help reduce inequities in income among both paid and unpaid workers. Basic
infrastructure and services can help women access labour market opportunities, and
inclusive systems of education and lifelong learning can improve women’s career
pathways and the quality of services.

3.3.3 Address gender biases in health systems

Better policies on work–life balance (such as flexible work, regular hours and
provision for child care), remuneration and international migration can help
narrow inequalities and promote decent work (SDG 8 and SDG 10). In particular,
health systems must stop taking the male work model as the standard work model;
policies that unfairly penalize career breaks and shorter working hours constrain the
productivity, distribution and retention of female workers. Inclusive high-quality
education and lifelong learning (SDG 4) can help address problems of retention and
recognition. Violence and harassment are important issues for all health workers,
especially women.

All health care, including unpaid health care, should be formalized in the health
workforce. Outside the paid labour force, countries should take steps to recognize
and compensate women for unpaid or informal health care work. This could involve
moving women into formal work and ensuring that career pathways exist.

PART I: Health Workforce Dynamics | CHAPTER 2 45

 Countries should work to understand and meet the health and social needs
of migrant health workers working in new and potentially discriminatory or isolating
contexts.

In designing and adopting new policies, it will be important to adopt participatory

processes and good governance practices that involve and empower women in
decision-making. Women are underrepresented in positions of power and decision-
making, from the micro to macro level (that is, in households, health care settings
and higher-level policy debates). Ensuring that women’s voices are heard and that
women from diverse social and geographical contexts are involved in decision-
making is essential to remedying current problems that plague the health care
workforce. Participatory designs will help ensure that more resources are dedicated to
upgrading the health workforce and implementing gender-sensitive policies.

3.4 Implementation considerations

In addressing gender issues in the health workforce, policy-makers will face a broad
range of implementation challenges. This chapter focuses particularly on difficulties
in ensuring that enacted law is reflected in practice. As is well documented in the
growing field of leximetrics,5 this is not always the case; there are often significant
differences between de jure and de facto practice.

To ensure that laws and policies are put into practice, particular attention should
be given to process and participation, including with regard to the private sector.
Clear enforcement provisions, backed by appropriately resourced and well governed
agencies (for example, labour inspectorates, human rights commissions and
countercorruption commissions), can make a forceful contribution to ensuring
implementation.

In addition, health workers and women in particular must be empowered to defend

their rights. This requires increasing awareness of labour rights and existing gender
biases, and facilitating collective action to defend these rights.

5 A field that produces quantitative measurements of laws and subsequently analyses them against objective
outcomes.

46 Health Employment and Economic Growth: An Evidence Base

In health establishments, training on equity could bring attention to biased human
resourcing practices (though it should be noted that there are few evaluations of
the effectiveness of such awareness-building exercises). Working within social
movements and with women’s collectives can also empower women and workers to
defend their rights.

Finally, the bargaining power of women and workers can be reinforced by efforts
to guarantee substantive freedom of choice. Female health workers accept unfair
working conditions because their choice of alternatives is constrained. Thus it is
important to evaluate the range of alternatives and resources available to individuals
in order to enable them to widen their range of choices (51). Upgrading women’s
labour market opportunities and their access to resources will improve their situation
in the health sector and serve as an engine for economic growth.

PART I: Health Workforce Dynamics | CHAPTER 2 47

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50 Health Employment and Economic Growth: An Evidence Base

CHAPTER 3

Achieving sustainable and appropriately

trained health and social care workers
for ageing populations
Edward Salsberg and Leo Quigley

Abstract
Chronic illnesses increase with age, while intrinsic capability decreases. Globally,
the population aged 60 years and over is projected to grow from 901 million, 11%
of the world’s population, in 2015, to 2.1 billion, 22% of the world’s population,
by 2050. Such rapid growth of this high-need population will drive an increased
need for more and more complex services.

Following a review of 127 articles, this chapter recommends a three-pronged

strategy to ensure an adequate supply and distribution of health and social
care workers to maximize the quality of life as people live longer. The strategy
includes the following: support to countries to assess the quantitative and
qualitative gaps between services currently available and those needed over the
next 15 years, and the design of appropriate workforce strategies; ensuring that
health and social care workers have skills and competencies to provide quality
effective care to older people, including support to a cadre of health workers with
expertise in geriatrics; and organization and deployment of the workforce to
make effective and efficient use of health and social care workers (for example,
expanding scopes of practice; deploying more workers with specific roles, such as
care coordinators, to engage with needed health and social support services; and
expanded use of care teams).

PART I: Health Workforce Dynamics | CHAPTER 3 51

 1. Introduction and methods

As the World Health Organization (WHO) noted in its 2015 report on ageing and
health (1), both the proportion and absolute number of older people around the
world are increasing dramatically and will continue to do so for many years to come,
leading to the increased need for health services adapted to the needs of older people.
There is a strong rationale for believing that responding to this increased need
requires more than simply increasing the capacity of the existing health systems.
Health systems around the world are largely designed around disease-driven episodic
care using a biomedical approach that emphasizes finding a medical problem and
fixing it (1). However, the health needs of ageing populations are interlinked with
their social needs. Furthermore, these needs are typically complex and long term,
span a range of areas of functioning, wax and wane over time, and require a goal of
maintaining functional ability rather than curing disease. In addition, older people
face many barriers that limit their access to health services, particularly in low- and
middle-income countries and among disadvantaged people in higher-income
countries (1). The complex organizational and professional structures and skills
required to address these concerns suggests the need to rethink health system design.

A key component in system redesign is the workforce. The health workforce is

typically trained to identify and treat symptoms and conditions using an episodic
approach to care, deployed in a compartmentalized fashion according to clinical
role or disease specialty (1), and tied to clinical settings in ways that limit their
ability to address important social determinants of health. In part as a consequence
of the limits of current curricula, many members of the health workforce have not
achieved competency in geriatric health care or in critical non-clinical processes such
as shared decision-making, team-based care, information technology and quality
improvement (1).

Achieving our workforce goals for ageing and health requires a strategy that
includes five interconnected steps: assessment of existing workforce needs and gaps;
developing the right numbers of workers; giving them the right knowledge and skills;
deploying them in the right organizations and geographical locations; and using
them in the right roles to deliver care in a cost-effective manner that meets the needs
of a growing older population. There is not a single blueprint: how these strategies

52 Health Employment and Economic Growth: An Evidence Base

are implemented will vary from country to country depending on factors such as
national wealth, the structure and financing of health systems, geography, cultural
specificities and social structures.

This chapter on workforce strategies for ageing and health synthesizes material
from peer-reviewed research and WHO reports in three areas: demand and need
projections; workforce issues relating to supply, utilization and organization; and
tested or proposed policy solutions. The chapter draws on prior work of WHO,
including:

• World report on ageing and health (1)

• Global Strategy on Human Resources for Health: Workforce 2030 (2)

• WHO Global Strategy on People-Centred and Integrated Health Services (3)

• Multisectoral action for a life course approach to healthy ageing: draft global strategy
and plan of action on ageing and health (4)

• Health workforce: update (Progress report on implementation of three World

Health Assembly resolutions on health workforce development) (5)

• Scaling up, saving lives (Task Force for Scaling Up Education and Training for
Health Workers) (6)

• The world health report 2008 – primary health care: now more than ever (7)

• The world health report 2010 – health systems financing: the path to universal
coverage (8)

In addition, the following reports were also important sources of data:

• Reshaping the workforce to deliver the care patients need

(the Nuffield Trust) (9)

• Universal health coverage (World Bank information source) (10)

• An aging world: 2015 (United States Census Bureau) (11)

PART I: Health Workforce Dynamics | CHAPTER 3 53

 2. Findings

2.1 Implications of the demographic transition for health

workforce requirements

2.1.1 The demographic transition

In its report, An aging world: 2015, the United States Census Bureau notes:

The demographic transition is shifting population epidemiology from

primarily acute infectious disease to primarily chronic infectious and
non-infectious disease. This alone would suggest a need to reorient
health systems to ensure services meet population needs, where health
and social services are integrated, with continuity of care across different
services. Ageing populations will have different health care needs,
with more people affected by dementia, stroke, cancer, fractured hips,
osteoporosis, Parkinson’s disease, lower back pain, sleep problems, and
urinary incontinence, for example. (11)

Two trends are driving the “demographic transition”: longer lifespans, and falling
fertility rates. First, the population aged over 60 years is growing rapidly across the
globe. As of 2015, life expectancy exceeded 80 years in 24 countries (11).

In 2015, there were 106 countries where less than 10% of the population was aged 60
years and over, mostly in Africa and parts of Asia, Latin America and the Caribbean;
by 2050 only 41 countries will have less than 10% of their population aged 60 years
and over. Further, while only one country had more than 30% of its population aged
over 60 years in 2015, this will grow to 57 countries in 2050 (Figure 1).

54 Health Employment and Economic Growth: An Evidence Base

Figure 1

Percentage of population aged 60 years and over: 2015 and 2050

2015

Percentage aged
60 years or older:
30% or more
10 to <30%
<10%

2050

Percentage aged
60 years or older:
30% or more
10 to <30%
<10%

Source: World Health Organization.

PART I: Health Workforce Dynamics | CHAPTER 3 55

 The second trend is a decrease in overall fertility rates, with the result that the
percentage of the population aged under 5 years has been steadily decreasing, while
the percentage that is 60 and over has been increasing. A net result of the two trends
is that the representation of children aged under 5 years and the population aged
over 60 years as a percentage of the world’s population will nearly reverse between
1950 and 2050, as indicated in Figure 2. This means that while the need for care
of an ageing population is increasing, the younger population entering the future
workforce to supply this care is diminishing.

Figure 2

Young children and older people as a percentage

of global population, 1950 to 2050

25%
Under 5
Over 60

20%

15%

10%

5%
1950 1970 1990 2010 2030 2050

Source: United Nations, Department of Economic and Social Affairs, Population Division (12).

2.1.2 Health needs of an ageing population

Older people not only have higher medical care needs than younger populations,
they also experience decreasing intrinsic capacity and decreasing functional ability,
increasing the need for the support and social services that enable people to live
meaningful lives and have a good quality of life. All countries face a substantial
challenge in reorienting their health care services from pervasive yet relatively
inexpensive treatment for short-term conditions to the far more costly treatment of
chronic conditions such as cardiovascular disease and diabetes (13).

56 Health Employment and Economic Growth: An Evidence Base

Both the clinical and social support needs of older people are driven by the increasing
prevalence of disease as well as by chronic conditions that can include hypertension,
dementia, disabilities, frailty and loss of sensory capability, often in combination.
This creates complex health needs. Not surprisingly, loss of functional ability and
independence in older people impacts both their physical and mental health such
that, as they age, older people need help with the activities of daily living.

Many of the chronic conditions of old age can be prevented or delayed by healthy
behaviours. Indeed, even in very advanced years, physical activity and good
nutrition can have powerful benefits for health and well-being. Other health
problems and declines in capacity can be effectively managed, particularly if
detected early enough. And even for people with declines in capacity, supportive
environments can allow them to live lives of dignity and continued personal growth.
Yet the world is very far from this ideal, particularly for older people who are poor
and those from disadvantaged social groups. Comprehensive public health action is
urgently needed (4).

But even as countries are successful in improving care and the quality of life of older
people, the fact that there will be an increasing number of older people also means
that planning for and delivering end-of-life care will be needed.

2.1.3 Workforce implications

The implications for the workforce are enormous, especially if the goal is healthy
ageing with empowered and engaged seniors. Specifically, there is a need for:

• More clinical providers with relevant skills and qualifications and in the right
locations providing the needed range of services: promotion, prevention,
diagnosis, treatment, disease management, rehabilitation and palliative care. A
precondition in low-income and middle-income countries will be to increase the
general supply of health providers.

• More social service providers, assistants and other individuals to provide support
services, such as assistance with the activities of daily living and transportation.

PART I: Health Workforce Dynamics | CHAPTER 3 57

 • Greater coordination to support patient-focused care and people-centred,
integrated health services. This includes health workers functioning as care
coordinators and case managers in chronic disease management and in primary
care to fill the gaps and attend to non-clinical needs.

• Increased supply of health and social service practitioners knowledgeable and

skilled in care for individuals with terminal illness and those nearing death.

High-income countries may differ from low- and middle-income countries in

readiness or availability of resources to provide health care for an ageing population
(11). In several European countries where geriatrics is not recognized as a medical
or nursing specialty, other professionals such as dentists, pharmacists or nutritionists
will need to develop competencies responsive to older people’s needs.

In general, all countries would benefit from:

• an increased supply of non-physician clinicians such as advanced practice nurses

and physician assistants, particularly in ambulatory settings;

• greater coordination among health workers and between health and social
service sectors;

• implementation of multidisciplinary care teams with appropriate skills mix;

• increased attention to workforce maldistribution;

• attention to health and social financing streams.

Lower- and middle-income countries in particular need to focus on occupations

with education pathways of up to three years and on scaling up technical and
vocational training, while taking into consideration training in rural areas to reach
the underserved. Such occupations include physician assistants, registered nurses and
community health workers.

58 Health Employment and Economic Growth: An Evidence Base

2.2 Evidence of health systems and health workforce reforms
responding to the needs of an ageing population
While much needs to be done to reform health systems and the health workforce to
meet the needs of the world’s growing ageing population, there are some examples
to help inform planning and policies. These examples cover funding reforms,
community-level reforms, service integration reforms and wider workforce reforms,
and include both progress and lessons learned. There are also examples of good
practice from sources including experienced service provider leadership.1

A review of the reforms reveals several common features, including:

• integration or extensive coordination of services;

• use of multidisciplinary teams;

• implementation at the local, community level, sometimes with central or regional

support or guidance;

• encouragement of care in the home and community-based services, over care in

hospitals and long-term care facilities,

• support for individual involvement and empowerment in regard to their care

and lives.

The reforms also reveal the benefits of having a steady source of funds to support
services to older people (Box 1).

1 See Annex 1 for a description of the literature search process used in locating these examples.

PART I: Health Workforce Dynamics | CHAPTER 3 59

 Box 1

Examples of health system and health workforce reforms

Asia. Associations of older people represent an innovative approach to taking

community-based action, empowering people in later life by using their skills, capacities,
and willingness to actively engage with and serve their communities. For example, China
recently issued a policy promoting the improvement and expansion of their 490 000
associations to align them better with the country’s development goals. These associations
are multifunctional and conduct a wide range of activities, including improving incomes
through microcredit and income-generating activities; providing health care for older
people, including through community care programmes aimed at care-dependent older
people; providing social and cultural activities as well as disaster preparedness; and
enabling social participation. Associations in Viet Nam have demonstrated financial
sustainability through their capacity to fundraise (11).

Denmark. The success of Denmark’s community-based experimentation with new

models of home care and housing for older people, initiated in the early 1980s,
resulted in a national decision to eliminate new construction of nursing homes and
increase access to publicly funded home care. Lingering concern that the provision of
paid assistance for older people could undermine family structure was allayed by the
findings of a survey showing that three quarters of older people reported seeing their
children on a weekly or more frequent basis. Findings from the Danish experience
provide evidence that community-based services can aid family caregivers, enable frail
persons to live in the setting of their choice, and be cost-effective from a public policy
perspective (14). However, another study found that home care reforms have struggled
to reconcile the conflicting principles of standardization and the individualization of
care provision (15).

Hong Kong Special Administrative Region. Since 2008, the Hong Kong Special
Administrative Region Government has taken forward various payment initiatives
to promote primary care and encourage more use of private service. Nevertheless,
a study found that the willingness of older people in the Hong Kong Special
Administrative Region to pay for specific primary care and preventive services in the

60 Health Employment and Economic Growth: An Evidence Base

private sector fell below the current market prices, and was associated with concerns
over affordability and uncertainty (of price and quality) in the private sector. These
results suggest that most older people, who are heavy users of public health services
but with limited income, may not use more private services without seeing significant
reduction in price (16). A separate study of the introduction of vouchers in the
Region to encourage older patients to use primary health care services in the private
sector found that the voucher alone was not enough to realize the government’s
policy of greater use of private primary care services (17).

Japan. In 2000, in response to escalating demand, Japan introduced an insurance

system for long-term care to reduce the burden on family caregivers and integrate
health care and welfare services into a comprehensive plan. The system provides
community-based and residential care services as well as a choice of services and
providers. While the number of community support centres rose to 3976 in 2011,
reforms were instituted in 2012 to improve coordination of services between the
health and social services and to increase oversight of for-profit providers (18).

Netherlands. Long-term care reforms give local authorities a predominant role in

providing community-based long-term care. Outpatient personal care and nursing care
have been transferred to the health insurance system, where only the most intensive
forms of residential long-term care are covered. Meanwhile, social support, including
certain home care services and respite care, has been devolved to municipalities, which
must ensure that people can live in their own homes for as long as possible and receive
the assistance that they need to do so (1, 19).

Pakistan. Pakistan established its first day centre for people at all stages of dementia
with technical collaboration from Alzheimer’s Australia in Western Australia. Care
workers provide education, support groups and counselling for families as well as
a broad package of services, including door-to-door transportation to and from the
centre, activities such as painting, cooking, gardening, reading the newspaper and daily
exercise, and help with personal care (1).

Sweden. The Swedish Government implemented the Adel reform in the care of
older citizens in 1992, by which the communities where older people live became

(continued on page 62)

PART I: Health Workforce Dynamics | CHAPTER 3 61

 BOX 1. Examples of health system and health workforce reforms (continued)

responsible for their care and housing. An important component in the reform was
an expanded need for community nurses to refer patients for emergency treatment.
Nurses were appointed to make sure that older people were given appropriate care
and to act as supervisors for nurses’ aides (20).

United States. The Program of All-Inclusive Care for the Elderly (PACE) serves
individuals who are aged 55 years or older, certified by their state as needing nursing
home care, and able to live safely in the community at the time of enrolment and to
live in a PACE service area. Programmes under PACE deliver all needed medical and
supportive services, providing the entire continuum of care and services to seniors
with chronic care needs while maintaining their independence at home for as long as
possible. The programmes provide care and services in the home, in the community
and at PACE centres. There are now 116 programmes in the United States serving
several thousand enrollees. Comprehensiveness and coordination are key aspects of
the programme. Costs of care are covered by Medicare and Medicaid. There is some
evidence that the model reduces hospital use and reduces mortality, though it is still
unclear whether it reduces overall expenses (21–23).

United States. Although the acute hospital is the standard venue for treating acute
serious illness, it is often a difficult environment for older adults, who are highly
susceptible to functional decline and other iatrogenic consequences of hospital care.
Hospital care is also expensive. Providing acute hospital-level care at home, in lieu
of usual institutional care, is viable. As an emerging service model, the definition of
hospital at home (HaH) remains unsettled. Data favour HaH models that provide
substantial physician inputs and are geared towards substituting for hospital care,
provide services that are highly satisfying to patients and their caregivers, are
associated with less iatrogenic complications, and are less expensive. Dissemination
of HaH in integrated delivery systems is feasible. Widespread dissemination of HaH
in the United States will require payment reform that acknowledges the role of HaH
in the health care system (24).

62 Health Employment and Economic Growth: An Evidence Base

United States. The United States and other countries with poorly developed primary
care systems have promoted the “medical home” as a core method for improving the
delivery of care. Patient care in the medical home model is coordinated by a primary
care team through personalized care plans and medication reviews supported by
coaching, advice and encouragement (25). This model is particularly pertinent to
the chronic but preventable conditions that disproportionately affect older people.
Nevertheless, a review of medical home implementation for older adult patients in
primary care found that external stakeholders are less apt to recognize, encourage or
incentivize elements of medical home transformation that derive from the existing
practice social structure and everyday interactions between staff and patients.
These results suggest that there may be no standardized, one-size-fits-all approach
to making medical home implementation work, particularly for special patient
populations such as older people (26).

United States. A significant rebalancing of the long-term care system away from
nursing homes towards home- and community-based services (HCBS) has occurred
over the past two decades. In the Commonwealth Fund Long-Term Care Opinion
Leader Survey on issues related to supporting HCBS, respondents expressed strong
enthusiasm for rebalancing the long-term care system towards HCBS. In particular,
respondents supported system-based approaches for this expansion, with the
majority indicating that greater care coordination was the single most preferred
approach for rebalancing the system, helping consumers make informed long-term
care choices and supporting caregivers (27).

Zambia. In 2010, the Ministry of Health in Zambia developed the National Community
Health Assistant Strategy, aiming to integrate community health workers into national
health plans to address the human resources for health shortage and the challenges facing
the community-based health workforce in Zambia (28).

PART I: Health Workforce Dynamics | CHAPTER 3 63

 2.3 Evidence of health workforce education and training reforms
responding to the need for people-centred services for ageing
populations
While some progress has been made over the past several decades to develop
curriculum appropriate to assure that future health workers have the competencies
and skills needed to provide people-centred care to older people, far more needs
to be done. Major challenges include the large number of occupations involved in
providing services to older people, the very limited cooperation across occupations
regarding curriculum, and the large number of existing workers who do not have
the necessary competencies and skills. In addition to the consequent need to modify
existing curriculum to have greater content related to the needs of older people that
all countries face, many low- and middle-income countries also face the urgent need
to significantly increase the number of health workers being educated and trained.

In 2008, the American Geriatrics Society brought together 21 organizations to form

the Partnership for Health in Aging with the aim of ensuring that competencies
in different professional curricula are aligned. A work group from 10 disciplines
developed a set of multidisciplinary competencies in the care of older adults that can
be used to supplement existing professional competencies at entry level in all the
disciplines (Box 2) (29).

Box 2

Multidisciplinary competencies in the care of older adults at the

completion of the entry-level health professional degree

Domain #1: Health promotion and safety

1. Advocate to older adults and their caregivers interventions and behaviours

that promote physical and mental health, nutrition, function, safety, social
interactions, independence, and quality of life.

(continued on page 65)

64 Health Employment and Economic Growth: An Evidence Base

2. Identify and inform older adults and their caregivers about evidence-based
approaches to screening, immunizations, health promotion, and disease
prevention.

3. Assess specific risks and barriers to older adult safety, including falls, elder
mistreatment, and other risks in community, home, and care environments.

4. Recognize the principles and practices of safe, appropriate, and effective

medication use in older adults.

5. Apply knowledge of the indications and contraindications for, risks of, and
alternatives to the use of physical and pharmacological restraints with
older adults.

Domain #2: Evaluation and assessment

1. Define the purpose and components of an interdisciplinary, comprehensive

geriatric assessment and the roles individual disciplines play in conducting and
interpreting a comprehensive geriatric assessment.

2. Apply knowledge of the biological, physical, cognitive, psychological, and

social changes commonly associated with aging.

3. Choose, administer, and interpret a validated and reliable tool/instrument

appropriate for use with a given older adult to assess: a) cognition, b) mood, c)
physical function, d) nutrition, and e) pain.

4. Demonstrate knowledge of the signs and symptoms of delirium and whom to

notify if an older adult exhibits these signs and symptoms.

5. Develop verbal and nonverbal communication strategies to overcome potential

sensory, language, and cognitive limitations in older adults.

(continued on page 66)

PART I: Health Workforce Dynamics | CHAPTER 3 65

 BOX 2. (continued)
Multidisciplinary competencies in the care of older adults at the completion of the
entry-level health professional degree

Domain #3: Care planning and coordination across the care spectrum
(including end-of-life care)

1. Develop treatment plans based on best evidence and on person-centered

and -directed care goals.

2. Evaluate clinical situations where standard treatment recommendations, based

on best evidence, should be modified with regard to older adults’ preferences
and treatment/care goals, life expectancy, co-morbid conditions, and/or
functional status.

3. Develop advanced care plans based on older adults’ preferences and treatment/
care goals, and their physical, psychological, social, and spiritual needs.

4. Recognize the need for continuity of treatment and communication across the
spectrum of services and during transitions between care settings, utilizing
information technology where appropriate and available.

Domain #4: Interdisciplinary and team care

1. Distinguish among, refer to, and/or consult with any of the multiple health
care professionals who work with older adults, to achieve positive outcomes.

2. Communicate and collaborate with older adults, their caregivers, healthcare

professionals, and direct-care workers to incorporate discipline-specific
information into overall team care planning and implementation.

Domain #5: Caregiver support

1. Assess caregiver knowledge and expectations of the impact of advanced

age and disease on health needs, risks, and the unique manifestations and
treatment of health conditions.

(continued on page 67)

66 Health Employment and Economic Growth: An Evidence Base

 2. Assist caregivers to identify, access, and utilize specialized products,
professional services, and support groups that can assist with care-giving
responsibilities and reduce caregiver burden.

3. Know how to access and explain the availability and effectiveness of

resources for older adults and caregivers that help them meet personal
goals, maximize function, maintain independence, and live in their
preferred and/or least restrictive environment.

4. Evaluate the continued appropriateness of care plans and services based

on older adults’ and caregivers’ changes in age, health status, and function;
assist caregivers in altering plans and actions as needed.

Domain #6: Health-care systems and benefits

1. Serve as an advocate for older adults and caregivers within various health
care systems and settings.

2. Know how to access, and share with older adults and their caregivers,
information about the healthcare benefits of programs such as Medicare,
Medicaid, Veterans’ Services, Social Security, and other public programs.

3. Provide information to older adults and their caregivers about the

continuum of long-term care services and supports – such as community
resources, home care, assisted living facilities, hospitals, nursing facilities,
sub-acute care facilities, and hospice care.
Source: Partnership for Health in Aging (29). Reproduced with permission from American Geriatrics
Society; see www.americangeriatrics.org for more information.

There are also examples of educational reforms designed either to scale up provision
for or to better serve high-need populations that can serve as models to better
educate health workers on the needs of older people (Box 3). Education must
address the needs both of specialists in care of older people and of generalists who
are needed to implement service reforms – such as community-based care – that
respond to the rise in the number of older people.

PART I: Health Workforce Dynamics | CHAPTER 3 67

 Box 3

Examples of educational reform

Brazil. The Pró Saúde programme provides training institutions with financial
support, through a competitive bidding process, for projects aimed at reorienting
the health system to meet the needs of communities. In 2007, 90 medical, nursing
and dental schools received funding for curricular changes that promoted
interaction between the professions, primary care and action learning. As a
result of this training, the programme aims to expand to 40 000 the number of
community-based family health teams providing primary care (6).

United Kingdom. General practice in the United Kingdom is experiencing

difficulty with medical staff recruitment and retention. A cultural change among
medical educationalists is needed to promote general practice as a career choice
that is equally attractive as hospital practice. The introduction of pre-registration
house officer (PRHO) placements in general practice and improved flexibility
of general practitioner (GP) vocational training schemes, together with plans
to improve the quality of senior house officer (SHO) training in the future,
should address some concerns about poor quality GP training raised by survey

2.4 Strengthening collaboration between the health

and social sector actors in service provision
Many older people, especially as their intrinsic capability declines or in the face of
multiple chronic illnesses, need both clinical care and social service support if they
are to be able to live meaningful and fulfilling lives. Formal integration of health and
social sector services presents many challenges, given the need to replace traditional
hierarchical coordination with more or less voluntary cooperation or collaboration
among organizations (32), rendering this high-level approach problematic, time
consuming and costly (33). Furthermore, the evidence suggests that most financial
and organizational system-level reforms have had either inconclusive or negative
effects (34).

68 Health Employment and Economic Growth: An Evidence Base

respondents. The reluctance of newly qualified GPs to enter principalships, and
the increasing demand from experienced GPs for less-than-full-time work,
indicate a need for a greater variety of contractual arrangements to reflect
doctors’ desires for more flexible patterns of working in general practice (30).

United Kingdom. Recently, NHS England decided to create a new cadre of

“nursing associates” to enable nurses to concentrate on more complex tasks (31).
The United Kingdom is also experimenting with nurse-led practices.2

Other countries. In South Africa, Walter Sisulu University’s Faculty of Health

Sciences was created in 1990 with the specific goal of producing health
professionals for underserved areas. The Barrio Adentro “micro-school” project
in Venezuela carries out all education and training in supervised community
settings, responding directly to patients’ needs. The University of the Philippines
collaborates extensively with government health services in decentralized clinical
settings to help students better understand and improve local health systems (6).

2 For example, see http://cuckoolanesurgery.co.uk/.

As an alternative to large-scale organizational restructuring, an emerging tactic for

improving collaboration across health and social sector services is the introduction
of the new workforce role of care coordinator or case manager (35). While the
professional background of care coordinators can vary, the core competencies for the
role typically include advocacy, teamwork, cross-setting communication, and patient
education and support. At least some of the care coordination function can be carried
out by entry-level workers, such as community health workers, if they operate in a
supportive and systematic service delivery system (36). Care coordination programmes
require careful design but they are most likely to be successful when tailored to meet
the needs of particular populations, such as older people (37).

PART I: Health Workforce Dynamics | CHAPTER 3 69

 3. Discussion

3.1 Challenges
There are three major challenges to ensuring an effective workforce for achieving the
healthy ageing goals of maximizing quality of life in old age and giving older people
a say in how that is achieved through action to combat ageism in policy-making and
service delivery.

3.1.1 Organization of work

The first component is the deployment of the workforce needed to support healthy
ageing. The lack of effective links between professions and sectors – despite the fact all
may be essential for healthy ageing for many seniors – includes major gaps between
health professions within the health sector and gaps between the health and social
services workforce. These gaps have led to an increased need for care coordination.
However, the reality is that, given the complexity of illnesses of older people and
the number of clinical and non-clinical services needed, care coordination can be
extremely challenging, involving use of IT, multiple referrals, self-care by the patient
and a role for volunteers and relatives. Figure 3, for example, shows some of the
workers typically involved in the care of an Alzheimer’s patient.

Another component of the organization of work concerns unnecessary limitations in

most countries on the permissible scope of practice of many health professions, preventing
them from working to the full extent of their education, training and capacity.
Examples include allowing pharmacists to address drug interactions in polypharmacy;
and allowing nurse practitioners, physician assistants, community health workers and
home health aides to use their training and expertise to the full. Unnecessary scope of
practice limitations not only weaken the effectiveness of the workforce, they are also
costly. While there may be resistance from professional associations to expanding the
scope of existing occupations and recognizing new types of workers, much may be
achieved simply by maximizing the extent to which each professional operates at the
top of their license to practise (38). There may also be legal and regulatory issues that
need to be addressed.

70 Health Employment and Economic Growth: An Evidence Base

Figure 3

People-centred integrated health services delivery:

the example of Alzheimer’s

Out-of-hours Consultant Continence adviser

doctors
Speech &
District language adviser
Dementia GP nurses
advisory nurse
Dietician

PATIENT & Community dentist

Live-in carers
FAMILY
Occupational
therapist
Social worker

Equipment service
Alzheimer’s social Oxygen Wheelchair
outreach worker service service Physiotherapist

Source: Adapted from WHO Global Strategy on People-Centred and Integrated Health Services (3).

Another key component to the organization of work is the development of people-

centred and integrated health services. WHO has documented the evidence showing
the benefits of this approach to care (39). It is within this framework that a wide
variety of health and social service providers can be effectively employed and work to
the full extent of their education and capabilities.

3.1.2 Lack of adequate preparation of health workers on the clinical

and social service needs of older people
This includes inadequate curriculum related to ageing in the training of physicians,
nurses and other health workers. Most countries have few experts in geriatrics, which
hinders both care and education of other health professionals.

PART I: Health Workforce Dynamics | CHAPTER 3 71

 3.1.3 A basic shortage of practitioners to care for older people
Care for older people is often regarded as a low-status, low-wage, and physically
and mentally challenging occupational sector, which may contribute to shortages of
carers. Home health aides in the United States, for example, earned 51% of the average
wage in 2007 (40). Working hours are often long and irregular (Canadian long-term
care workers, for instance, are sometimes required to be on site for 12 to 14 hours to
accumulate 6 to 8 hours of paid work), and career progression is largely absent in most
countries (40).

There is great variation in the reported number of long-term care workers per 1000
population aged over 65 years, ranging from 16 in France to 213 in the Netherlands
(40). While some of this variation may reflect differences in job categorization and in
the prevalence of part-time arrangements – which can have an impact on the difference
between numbers of long-term care workers (measured as headcounts) and full-time
equivalent workers – the variation is still significant.

Even in higher-income countries that have an adequate total supply, practitioner

distribution is often not well aligned with high-need populations, including older
people. Geriatric care management programmes aiming at improving the skills
of personal care aides are found to have a strong influence on retention and job
satisfaction (40).

3.2 Environmental and structural changes to support

policy options

“Healthy ageing is the process of developing and maintaining the functional ability
that enables well-being in older age”(1). Health and social care workers work in health
systems and structures that operate within the values and beliefs of the community at
large. There are four environmental and structural changes that are needed to support
the policy options related to human resources for health of an ageing population.
These changes will greatly magnify the impact and effectiveness of a well prepared
workforce.

• Combating ageism. Societal attitudes – including attitudes within the health

system – have to recognize the dignity of each individual regardless of age or

72 Health Employment and Economic Growth: An Evidence Base

 physical or mental capacity if the goals of empowerment and engagement of older
people are to be attained.

• Reframing sickness care to health care. The health care system, in collaboration
with the social services sector, needs to reframe its role from care of the sick to
preservation of health and the quality of life.

• Assuring a robust primary health care system. The health care system and its
workers will be more effective and productive if they can work in a health care
system with a well designed system for primary health care.

• Modifying health care financing systems. The workforce needed for healthy and
meaningful ageing extends across many services and also includes caregivers not
usually considered as part of health care delivery and not provided for in health
services funding. Health organizations and funders must recognize the contribution
of social and community-based services, supports, and workers, such as social
workers and community health workers, to the health and well-being of older people,
along with the very real difficulties associated with coordinating those services in
practice. Without expanded financing and reimbursement, these needed services are
not likely to be covered or provided.

3.3 Workforce policy options to support healthy ageing

The following policy options are proposed to assist the health workforce in supporting
healthy ageing:

A. Organize and deploy the workforce to make effective and efficient use
of health and social service workers to meet the needs of older people:

• Support countries to assess the quantitative and qualitative gaps between

services currently available and those needed over the next 15 years, to inform
policies and programmes for older people.

• Promote the widespread adoption of teams with a wide range of skills and
competencies to meet the needs of old people. The teams should include both

PART I: Health Workforce Dynamics | CHAPTER 3 73

 health and social service workers and have the capability to reach out to the
community to provide more accessible health care to older people and to take
advantage of community-based non-health services that may help promote
independence and autonomy.

• Extend the roles of existing health workers – role enhancement – by removing

unnecessary barriers to their scope of practice.

• Expand the use of technology across the continuum of care for older people
and extend team membership to isolated, rural workers.

• Promote the development and expanded use of workers such as community health
workers, care coordinators, case managers, registered nurses and others who
can be part of teams, function as connectors between health and social services,
and promote steps to improve the quality of life of older people. There are many
examples of the effective use of community health workers (41).

• Promote programmes and policies that empower and assist individuals to

make care decisions and to care for themselves. Also, encourage and provide
support for volunteers.

B. Ensure that health and social care workers have the skills and competencies
needed to provide high-quality and effective care to older people:

• Ensure competencies related to healthy ageing are included in the curriculum

of all health professions students. This includes – in addition to an
understanding of symptoms and care of chronic and multisystem disease –
competencies around communication and empowerment, interprofessional
practice, cultural competence, and knowledge of measures that can slow loss of
functional capacity.

• Ensure that credentialing organizations include skills and competencies

related to ageing and health of older people in certification and recertification
examinations.

74 Health Employment and Economic Growth: An Evidence Base

 • Educate and train all health workers to practise collaboratively in teams of
health professionals and others, and increase exposure and cross-fertilization
during the educational process (both during entry into the field and in
continuing professional education) of health and social service providers.

• Support the education and training of a small number of specialists in

geriatrics to provide clinical, educational, and policy guidance to primary care
practitioners and other health workers.

• Support the education and training of a small number of specialists in

palliative care for the terminally ill and those near death.

• Ensure affordable and accessible continuing professional education in ageing and

health care for existing health workers, including training in teams.

C. Ensure an adequate supply and distribution of appropriately skilled health and

social care workers to meet the needs of the older population:

• Assess at the country level the supply of, demand for, need for and distribution
of health and social care workers who serve older people.

• Countries should give priority to workers who can be educated and trained
quickly and at a modest cost but can provide a wide range of services needed
by an ageing population. This includes medical assistants, health officers,
dental assistants, community health workers, nurse assistants and others. In
addition, priority should also be given to non-physician clinicians and other
advanced practitioners such as nurses, advanced practice registered nurses
(nurse practitioners, nurse midwives and clinical nurse specialists), physician
assistants, pharmacists and social workers.

• Support programmes and policies that encourage practitioners to practise in

areas with shortages in their occupation. This could include scholarships or
loan repayment for service, dissemination of information on areas of need,
promotion of educational opportunities to those most likely to make careers
in shortage areas, and reimbursement incentives for practice in underserved

PART I: Health Workforce Dynamics | CHAPTER 3 75

 areas. Priority should also be given to supporting students from underserved
areas, and to education programmes in those areas, as recommended by WHO
in 2010 (42).

• As noted above, there is a need to modify reimbursement and financing

policies to cover both clinical and social services to older people. Clinical staff
alone cannot be expected to take responsibility for reform and redesign of
health systems.

• Lower-income countries in particular will need to consider how to educate

and train the administrators who will share responsibility with clinicians for
ensuring that health care delivery meets high-level goals such as efficiency,
equity and effectiveness.

76 Health Employment and Economic Growth: An Evidence Base

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PART I: Health Workforce Dynamics | CHAPTER 3 79

 ANNEX 1: Ovid database search process
Search terms
(‘older people’ OR ‘older adult$’ OR ‘elderly’ OR ‘senior$’ OR ‘later life’ OR ‘long-
term care’) AND

(‘workforce’ OR ‘physician$’ OR ‘doctor$’ OR ‘nurs$’ OR ‘pharmac$’ OR ‘primary

care$’ OR ‘dentist$’ OR ‘dental’ OR ‘care coordinat$’ OR ‘case manag$’ OR ‘care
manag$’ OR ‘community health worker’ OR CHW) AND

(‘federal’ OR ‘government’ OR ‘state’ OR ‘nation$’) AND

‘reform’

Filters
English language

2006 or later

Databases searched
Ovid: Global Health and all available Medline databases

Search results
The search was run in May 2016 and yielded 184 results. Removal of duplicates,
non-English language articles that had not been filtered out, and articles that
were clearly not relevant left 127 articles which were reviewed and classified for
subject relevance.

A full listing of the 127 articles is available on request from [email protected]

or [email protected].

80 Health Employment and Economic Growth: An Evidence Base

CHAPTER 4

International migration of doctors

and nurses to OECD countries:
Recent trends and policy implications
Jean-Christophe Dumont, Gaétan Lafortune

Abstract
This chapter examines trends in the international migration of health workers to
Organisation for Economic Co-operation and Development (OECD) countries
since 2000. In total, the number of migrant doctors and nurses working in
OECD countries increased by 60% between 2000 and 2010. This rate is higher
for those who migrated to OECD countries from countries with severe health
workforce shortages, with an 84% increase during this time period. Immigrant
doctors and nurses account for growing shares of health professionals working
in OECD countries. Foreign-born doctors accounted for 22% of active doctors
in OECD countries in 2010/2011 (up from 20% in 2000/2001), whereas foreign-
born nurses represented 14% of all nurses (up from 11% in 2000/2001).

The chapter calls for movement towards greater self-sufficiency in OECD countries
through increased domestic education and training capacity, as required to
respond to current and future projected demand; implementation of retention
measures (for example, better working conditions and pay rates) in lower-income
countries, which itself will require good governance of the health systems and
may require international support as called for by the World Health Organization
(WHO) Global Code of Practice on the International Recruitment of Health
Personnel; and better management of health workforce migration through
negotiation of mutually beneficial agreements, as well as consideration of more
ambitious approaches to global governance.

PART I: Health Workforce Dynamics | CHAPTER 4 81

 1. Introduction

The international migration of doctors, nurses and other health workers is not a new
phenomenon, but it has drawn a lot of attention in recent years because of concerns that
it exacerbates shortages of skilled health workers in some countries, particularly in those
that are already experiencing critical shortages. The WHO Global Code of Practice on
the International Recruitment of Health Personnel was adopted by the World Health
Assembly in 2010 to support improved management of international health personnel
migration according to globally accepted ethical norms and standards. It encourages
greater international cooperation and support in the area and encourages countries to
achieve greater “self-sufficiency” in the training of health workers, while also recognizing
the workers’ basic human right of freedom of movement (Box 1).

The 2007 Organisation for Economic Co-operation and Development (OECD) study
on “Immigrant health workers in OECD countries in the broader context of highly
skilled migration”, published in International migration outlook, presented for the first
time a complete picture of the migration flows of health personnel to OECD countries
by country of origin and destination (3). This work was recently updated in a chapter on
“Changing patterns in international migration of doctors and nurses to OECD countries”,
published in the 2015 edition of International migration outlook (4). This policy chapter
presents some of the main results from these chapters and additional information on
health workforce policies from the 2016 publication Health workforce policies in OECD
countries: right jobs, right skills, right places (5), and the 2008 publication The looming crisis
in the health workforce: how can OECD countries respond? (6). This chapter addresses the
following questions:

• What is the scale of the international migration of doctors and nurses to OECD
countries, and who heads where?

• What is the contribution of migrant health workers to their destination countries

and what are the consequences for their countries of origin?

• How much do immigration and health policies affect migration growth and
what is the scope of bilateral agreements and new possible global governance
arrangements to better manage health workforce migration?

82 Health Employment and Economic Growth: An Evidence Base

Box 1

Highlights from the WHO Global Code of Practice on the International

Recruitment of Health Personnel

Ethical international recruitment

The Code discourages the active recruitment of health workers from developing
countries with critical workforce shortages.

Equal treatment of migrant health care workers

The Code highlights the importance of equal treatment of foreign-trained health
workers and their locally trained counterparts. All health care workers should
have the opportunity to assess the benefits and risks associated with employment
positions, and to make informed decisions about vacancies.

Health workforce development and sustainable health systems

Member States should develop strategies for workforce planning, training and
retention, adapted to the specific circumstances of each country, so that there is
less need to recruit migrant health workers.

International cooperation
The Code encourages collaboration between health workers’ countries of origin
and countries of destination, so that both benefit from the migration of health
professionals.

Technical collaboration and financial support

Developed countries should provide technical and financial assistance to
developing countries experiencing a shortage of health workers.

Data gathering
Member States are encouraged to strengthen or establish health personnel
information systems, including information on health personnel migration, in
order to collect, analyse and translate data into effective health workforce policies
and plans.
Sources: WHO Global Code of Practice, and user’s guide to the Code (1, 2).

PART I: Health Workforce Dynamics | CHAPTER 4 83

 2. Findings: perspective of destination countries

Immigration patterns can be measured based on nationality, place of birth or

place of education/training. The first approach, based on nationality, faces several
shortcomings, the main one being that foreign-born citizens disappear from the
statistics when they are naturalized. The second approach, based on place of birth,
is more meaningful because when the country of birth differs from the country
of residence, it implies that the person did cross the border at some point in time.
However, the main question that arises in evaluating the impact of highly skilled
migration on origin countries is where the education took place. Some of those
who were foreign born arrived at younger ages, most probably accompanying their
family, while others came to the country to pursue tertiary education and stayed
after completion of their study. In those circumstances, most of the cost of education
will have been supported by the destination country, or by the migrants themselves,
not by the country of origin. The third approach, based on the place of education/
training, is probably the most relevant from a policy perspective, although it does
raise several measurement issues related to the fact that medical and nursing
education and training can be very long and go through different stages that may
occur in both origin and destination countries (7).

This section uses two different data sets to monitor trends in the number of foreign-
born doctors and nurses working in OECD countries (based mainly on population
census data available in many countries at 10-year intervals) and the number of
foreign-trained doctors and nurses working in OECD countries (based mainly on
data from professional registries available each year). It focuses only on the migration
of doctors and nurses, given the preeminent role that these have traditionally played
in health service delivery in OECD countries.

2.1 Foreign-born health workers in OECD countries

Foreign-born doctors and nurses account for a significant and growing share of
health professionals in OECD countries. The share of foreign-born doctors increased
in most countries between 2000/2001 and 2010/2011, with the total number
increasing from 19.5% to 22% across 23 OECD countries, while the share of foreign-
born nurses rose from 11% to 14.5% across 22 OECD countries. In total, the number

84 Health Employment and Economic Growth: An Evidence Base

of migrant doctors and nurses working in OECD countries increased by 60% over
that decade. To a certain degree, the share of migrants among health professionals
mirrors that of highly skilled immigrants in the workforce as a whole. However,
the percentage of foreign-born doctors tends to be greater than the percentage of
immigrants among highly educated workers, whereas the share of foreign-born
nurses is similar or lower.

Although the United States of America receives the highest number of migrant
doctors and nurses in absolute terms, the steepest rises in foreign-born doctors
between 2000/2001 and 2010/2011 were in Germany and the United Kingdom.
There were also significant increases in Australia, Ireland, New Zealand and
Switzerland, while the shares continued at their relatively high levels in Canada
and the United States.

There were important variations across OECD countries in the proportion of health
personnel born abroad in 2010/2011. For doctors, the share ranges from less than
3% in Poland and Turkey to over 50% in Australia and New Zealand. The share of
foreign-born nurses is insignificant in Poland and the Slovak Republic, but over
30% in Australia, Israel, Luxembourg, New Zealand and Switzerland. In almost all
countries, with the exception of Estonia, Israel, Italy and Turkey, immigrants make
up a higher proportion of doctors than of nurses. This is particularly the case in
Australia, Ireland and New Zealand.

Not surprisingly, the proportions of foreign-born doctors and nurses are highest
in the main settlement countries (for example, Australia, Canada, Israel and New
Zealand) and European countries such as Luxembourg and Switzerland. Other
countries, including Belgium and the United Kingdom, are also near the top of the
list in terms of the share of foreign-born health professionals, as are some Nordic
countries when it comes to doctors and Ireland in regard to both doctors and nurses
(Tables 1 and 2).

PART I: Health Workforce Dynamics | CHAPTER 4 85

 Table 1

Practising doctors by place of birth in 30 OECD countries,

2000/01 and 2010/11
Doctors
2000/01
Country of residence Year Total Foreign born % foreign born
Australia (2001) 48 211 20 452 42.9
Austria (2001) 30 068 4 400 14.6
Belgium1 (1998-02) 39 133 4 629 11.8
Canada (2001) 65 110 22 860 35.1
Czech Republic* … … … 39 562
Denmark2 (2002) 14 977 1 629 10.9
Estonia* … … …
Finland (2000) 14 560 575 4.0
France (1999) 200 358 33 879 16.9
Germany (1998-02) 282 124 28 494 11.1
Greece3 (2001) 13 744 1 181 8.6
Hungary (2001) 24 671 2 724 11.0
Ireland (2002) 8 208 2 895 35.3
Israel* … … …
Italy* … … …
Luxembourg (2001) 882 266 30.2 1 347
Mexico* (2000) 205 571 3 005 1.5
Netherlands (1998-02) 42 313 7 032 16.7
New-Zealand (2001) 9 009 4 215 46.9
Norway (1998-02) 12 761 2 117 16.6
Poland (2002) 99 687 3 144 3.2
Portugal (2001) 23 131 4 552 19.7
Slovak Republic* … … … 21 552
Slovenia* … … …
Spain (2001) 126 248 9 433 7.5
Sweden4 (2003) 26 983 6 148 22.9
Switzerland5 (2000) 23 039 6 431 28.1
Turkey (2000) 82 221 5 090 6.2
United Kingdom (2001) 147 677 49 780 33.7
United States (2000) 807 844 196 815 24.4
OECD Total (23 countries) 2 142 959 418 741 19.5

1 Other sources indicate a slightly higher increase in the number of doctors in Belgium during this period.
2 Some doctors undergoing specialty training may not be counted in 2011.
3 In 2001, doctors are only partially covered.
4 Other sources indicate a slightly lower increase in the number of doctors in Sweden during this period.
5 Some doctors undergoing specialty training may not be counted in 2000.
Sources: OECD, 2007 (3) for 2000/2001 data; database on immigrants in OECD countries1 2010/2011
and labour force surveys 2009–2012 for 2010/2011 data.

1 http://www.oecd.org/els/mig/databaseonimmigrantsinoecdcountriesdioc.htm.

86 Health Employment and Economic Growth: An Evidence Base

Table 1 (continued)
Practising doctors by place of birth in 30 OECD countries, 2000/01 and 2010/11

Doctors
2010/11
Country of residence Year Total Foreign born % foreign born
Australia (2011) 68 795 36 076 52.8
Austria (2011/12) 40 559 6 844 16.9
Belgium1 (2011/12) 40 148 10 202 25.4
Canada (2011) 79 585 27 780 34.9
Czech Republic* 3 468 8.8 (2011)
Denmark2 (2011) 15 403 2 935 19.1
Estonia* (2011) 4 145 747 18.0
Finland (2011) 18 937 1 454 7.7
France (2011) 224 998 43 955 19.5
Germany (2011/12) 366 700 57 210 15.7
Greece3 (2011/12) 49 577 3 624 7.3
Hungary (2011) 28 522 3 790 13.3
Ireland (2011/12) 12 832 5 973 46.6
Israel* (2011) 23 398 11 519 49.2
Italy* (2011/12) 234 323 11 822 5.0
Luxembourg 536 40.0 (2011)
Mexico* … … …
Netherlands (2011) 57 976 8 429 14.6
New Zealand (2011) 12 708 6 897 54.3
Norway (2011) 19 624 4 460 22.7
Poland (2011) 109 652 2 935 2.7
Portugal (2011) 36 831 6 040 16.4
Slovak Republic* 823 3.8 (2011)
Slovenia* 2011) 5 556 1 006 18.1
Spain (2011) 210 500 21 005 10.3
Sweden4 (2011/12) 47 778 14 173 29.8
Switzerland5 (2011/12) 43 416 18 082 41.6
Turkey (2011/12) 104 950 3 003 2.9
United Kingdom (2011/12) 236 862 83 951 35.4
United States (2007-11) 838 933 221 393 26.4
OECD Total (23 countries) 2 666 632 590 748

Notes: Countries for which data for 2000/2001 are derived from a census: Australia, Austria, Canada, Finland,
France, Hungary, Ireland, Luxembourg, Mexico, New Zealand, Poland, Spain, Switzerland, Turkey, United
Kingdom, United States; countries for which data for 2000/2001 are derived from labour force surveys:
Belgium, Germany, Netherlands, Norway. Countries for which data for 2010/2011 are derived from a
census: Australia, Canada, Czech Republic, Denmark, Estonia, Finland, France, Hungary, Israel, Luxembourg,
Netherlands, New Zealand, Norway, Poland, Portugal, Slovak Republic, Slovenia, Spain, United States; countries
for which data for 2010/2011 are derived from labour force surveys: Austria, Belgium, Czech Republic,
Germany, Greece, Hungary, Ireland, Italy, Sweden, Switzerland, Turkey, United Kingdom. Foreign-born doctors
whose place of birth is unknown are excluded from the calculation of the percentage of foreign-born doctors.
Countries marked with an asterisk (*) are not counted in the total (OECD 23) due to data gaps for at least
one year.

PART I: Health Workforce Dynamics | CHAPTER 4 87

 Table 2

Practising nurses by place of birth in 30 OECD countries,

2000/01 and 2010/11

Nurses
2000/01
Country of residence Year Total Foreign born % foreign born
Australia (2001) 191 105 46 750 24.8
Austria (2001) 56 797 8 217 14.5
Belgium (1998-02) 127 384 8 409 6.6
Canada (2001) 284 945 48 880 17.2
Czech Republic* … … …
Denmark1 (2002) 57 047 2 320 4.1
Estonia* … … …
Finland (2000) 56 365 470 0.8
France (1999) 421 602 23 308 5.5
Germany (1998-02) 781 300 74 990 10.4
Greece (2001) 39 952 3 883 9.7
Hungary (2001) 49 738 1 538 3.1
Ireland 2002) 43 320 6 204 14.3
Israel* … … …
Italy* … … …
Luxembourg (2001) 2 551 658 25.8
Mexico* (2000) 267 537 550 0.2
Netherlands (1998-02) 259 569 17 780 6.9
New Zealand (2001) 33 261 7 698 23.2
Norway (1998-02) 70 698 4 281 6.1
Poland (2002) 243 225 1 074 0.4
Portugal (2001) 36 595 5 077 13.9
Slovak Republic* … … … 52 773
Slovenia* … … … 17 124
Spain (2001) 167 498 5 638 3.4
Sweden (2003) 98 505 8 710 8.9
Switzerland2 (2000) 62 194 17 636 28.6
Turkey* (2000) … … …
United Kingdom (2001) 538 647 81 623 15.2
United States (2000) 2 818 735 336 183 11.9
OECD Total (22 countries) 6 441 033 711 327 11.0

1 Other sources indicate that the number of nurses in Denmark may be about 25% higher in 2002 and in 2012.
Some associate professional nurses may not be counted.
2 Other sources indicate that the number of nurses in Switzerland may be about 50% higher in 2000 and 20%
higher in 2010.
Sources: OECD, 2007 (3) for 2000/2001 data; database on immigrants in OECD countries2 2010/2011 and
labour force surveys 2009–2012 for 2010/2011 data.
Notes: Countries for which data for 2000/2001 are derived from a census: Australia, Austria, Canada, Finland,
France, Hungary, Ireland, Luxembourg, Mexico, New Zealand, Poland, Portugal, Spain, Switzerland, Turkey,

2 http://www.oecd.org/els/mig/databaseonimmigrantsinoecdcountriesdioc.htm.

88 Health Employment and Economic Growth: An Evidence Base

Table 2 (continued)
Practising nurses by place of birth in 30 OECD countries, 2000/01 and 2010/11

Nurses
2010/11
Year Total Foreign born % foreign born
Australia (2011) 238 935 78 508 33.2
Austria (2009-10) 70 147 10 265 14.6
Belgium (2011-12) 140 054 23 575 16.8
Canada (2011) 326 700 73 425 22.5
Czech Republic* (2011-12) 89 301 1 462 1.6
Denmark1 (2011-12) 61 082 6 301 10.3
Estonia* (2011-12) 8 302 2 162 26.0
Finland (2011-12) 72 836 1 732 2.4
France (2009-10) 550 163 32 345 5.9
Germany (2009-12) 1 074 523 150 060 14.0
Greece (2011-12) 55 364 1 919 3.5
Hungary (2011-12) 59 300 1 218 2.1
Ireland (2011-12) 58 092 15 606 26.9
Israel* (2011) 31 708 16 043 50.6
Italy* (2011-12) 399 777 39 231 9.8
Luxembourg (2011-12 4 372) 1 347 30.8
Mexico* … … …
Netherlands (2009-10) 323 420 30 909 9.6
New Zealand (2011) 40 002 13 884 35.0
Norway (2009-10) 97 725 8 795 9.0
Poland (2009-10) 245 667 595 0.2
Portugal (2011-12) 53 491 4 643 8.7
Slovak Republic* (2011-12) 303 0.6
Slovenia* (2011-12) 1 483 8.7
Spain (2011-12) 252 804 14 400 5.7
Sweden (2011-12) 113 956 15 834 13.9
Switzerland2 (2011-12) 110 069 36 531 33.3
Turkey* (2009-10) 147 611 4 484 3.1
United Kingdom (2011-12) 618 659 134 075 21.7
United States (2007-11) 3 847 068 561 232 14.6
OECD Total (22 countries) 8 414 429 1 217 200 14.5

United Kingdom, United States; countries for which data for 2000/2001 are derived from labour force surveys:
Belgium, Germany, Netherlands, Norway; country for which data for 2000/2001 are derived from a register:
Denmark. Countries for which data for 2010/2011 are derived from a census: Australia, Canada, Israel, New
Zealand, United States; countries for which data for 2010/2011 are derived from labour force surveys: Austria,
Belgium, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Italy,
Luxembourg, Netherlands, Norway, Poland, Portugal, Slovak Republic, Slovenia, Spain, Sweden, Switzerland,
Turkey, United Kingdom. Foreign-born nurses whose place of birth is unknown are excluded from the
calculation of the percentage of foreign-born nurses. Countries marked with an asterisk (*) are not counted in
the total (OECD 23) due to data gaps for at least one year.

PART I: Health Workforce Dynamics | CHAPTER 4 89

 2.2 Foreign-trained health workers in OECD countries
In most OECD countries, the proportion of health workers trained abroad is
lower than that of health workers born abroad, indicating that host countries
provide part of migrants’ education and training. In 2012–2014, foreign-trained
doctors accounted for 17% of all doctors across 26 OECD countries and foreign-
trained nurses for 6% of all nurses across 25 countries. While the number of
foreign-trained health workers is usually lower than those that are foreign born,
in some countries (for example, Israel), the share of foreign-trained health
workers is higher, reflecting the fact that many people born in those countries
went to study abroad before returning back to practise in their home countries.

Australia, Ireland, New Zealand and Norway have the highest share of foreign-
trained doctors, with more than 30% of doctors trained abroad. Following these
countries are Canada, Sweden, Switzerland, the United Kingdom and the United
States, with rates between 24% and 30%. The very high proportion of foreign-
trained doctors in Israel reflects not only the importance of immigration in this
country, but also the fact that an increasing number of new licences are issued to
people born in Israel but trained abroad (about one third in 2014). Similarly, in
the case of Norway, large numbers of Norwegians study medicine abroad, with
most of them returning to practise in Norway.

In absolute numbers, the United States has by far the highest number
of foreign-trained health workers, with more than 200 000 doctors and
almost 250 000 nurses trained abroad in 2013. Following the United States
are the United Kingdom (with more than 48 000 foreign-trained doctors
and 86 000 foreign-trained nurses in 2014) and Germany (with nearly
29 000 foreign-trained doctors in 2014 and 70 000 foreign-trained nurses
in 2010, the latest year available).

90 Health Employment and Economic Growth: An Evidence Base

In most OECD countries, the proportion of nurses trained abroad tends to
be much lower than that of doctors. Only Australia, Israel, New Zealand and
Switzerland report figures higher than 10% in 2012–2014. Recent trends in the
migration of foreign-trained nurses also vary across countries. There has been
a strong rise in the immigration of foreign-trained nurses in Italy, primarily
driven by the arrival of nurses trained in Romania. However, in some other
countries (for example, the Netherlands, Portugal and the United Kingdom),
there was a reduction in the number and proportion of foreign-trained nurses
between 2006 and 2012–2014.

Most OECD countries have stepped up their education and training efforts for
doctors and nurses since 2000 in response to expected shortages arising from
general population ageing (which is expected to increase the demand for health
services) and the ageing of the medical and nursing workforce (which is expected
to reduce their supply). These efforts have partly slowed down the increase in
international recruitment (see section 4.1 on the impact of domestic education
and training policies on international migration flows) (Tables 3 and 4).

PART I: Health Workforce Dynamics | CHAPTER 4 91

 Table 3

Foreign-trained doctors working in 26 OECD countries, 2000, 2006 and

2012–2014
Doctors
2000
Foreign-
Country of residence Year Total trained % of total
Australia 2000 ... ... ...
Austria 2000 25 611e 461 1.8%
Belgium 2000 44 380 1 934 4.4%
Canada 2000 64 462 13 701 21.3%
Chile 2000 ... ... ...
Czech Republic 2000 43 765 579 1.3%
Denmark 2000 15 551 681 4.4%
Estonia 2002 2 259 0 0.0%
Finland 2000 ... ... ...
France 2000 199 445 7 795 3.9%
Germany1 2000 267 965 9 971 3.7%
Hungary 2000 ... ... ...
Ireland 2000 12 243e 1 359 11.1%
Israel 2000 21 869 14 080 64.4%
Netherlands 2001 39 772 706 1.8%
New Zealand 2000 9 890 3 756 38.0%
Norw ay 2000 ... ... ...
Poland 2000 ... ... ...
Slovak Republic 2000 18 571e 130 0.7%
Slovenia 2000 ... ... ...
Spain 2000 ... ... ...
Sweden 2000 27 502 3 827 13.9%
Switzerland 2000 25 272 e
2 982 11.8%
Turkey 2000 85 242 55 0.1%
United Kingdom2 2000 ... ... ...
United States3 2000 ... ... 25.5%
OECD Total (26 countries)
1 The data refer to foreign citizens (not necessarily foreign trained).
2 Data cover England, Wales and Scotland (but not Northern Ireland).
3 The percentage in 2000 is calculated based on all doctors registered to practise. Data for 2006 and 2013
refer to doctors who are professionally active.
e: estimation.

92 Health Employment and Economic Growth: An Evidence Base

Table 3 (continued)
Foreign-trained doctors working in 26 OECD countries, 2000, 2006 and 2012–2014

Doctors
2006 2012–2014
Foreign- Foreign-
Year Total trained % of total Year Total trained % of total
2005 ... ... 25.0% 2013 82 498 25 153 30.5%
2006 30 236 888 2.9% 2014 35 844 1 640 4.6%
2006 49 695 2 636 5.3% 2014 59 070 6 732 11.4%
2006 70 870 15 237 21.5% 2013 90 205 21 225 23.5%
2006 ... ... ... 2014 36 013 5 489 15.2%
2006 44 064 1 744 4.0% 2014 41 671 1 135 2.7%
2006 18 403 1 145 6.2% 2012 20 250 1 127 5.6%
2006 5 336 30 0.6% 2014 6 294 166 2.6%
2005 ... ... ... 2012 20 866 4 154 19.9%
2006 212 711 12 261 5.8% 2013 219 833 20 275 9.2%
2006 284 427 14 703 5.2% 2013 326 945 28 901 8.8%
2006 37 908 2 917 7.7% 2013 32 668 2 470 7.6%
2006 15 512e 4 663 30.1% 2014 19 066 6 877 36.1%
2006 23 890 14 746 61.7% 2014 25 570 14 839 58.0%
2006 45 051 941 2.1% 2011 51 939 1 352 2.6%
2006 11 889 4 833 40.7% 2014 14 786 6 298 42.6%
2008 18 557 5 996 32.3% 2014 22 659 8 447 37.3%
2008 119 604 2 529 2.1% 2012 125 073 2 203 1.8%
2004 17 375e 139 0.8% 2011 16 899 506 3.0%
2006 ... ... ... 2013 5 416 781 14.4%
2006 ... ... ... 2011 207 042 19 462 9.4%
2006 32 802 6 321 19.3% 2012 38 144 9 283 24.3%
2008 29 653 6 479 21.8% 2012 31 858 8 617 27.0%
2006 104 475 240 0.2% 2013 133 775 261 0.2%
2008 146 834 43 885 29.9% 2014 172 561 48 766 28.3%
2006 664 814 166 810 25.1% 2013 859 470 214 438 25.0%
OECD Total (26 countries) 2 696 415 460 597 17.1%

Note: Doctors whose place of training is unknown have been excluded from the calculation of the percentage
of foreign-trained doctors (Netherlands, Slovak Republic, Slovenia and United Kingdom).
Source: Annex 4.A1 in chapter 4 of OECD, Health workforce policies in OECD countries: right jobs, right skills,
right places (5).

PART I: Health Workforce Dynamics | CHAPTER 4 93

 Table 4

Foreign-trained nurses working in 25 OECD countries,

2000, 2006 and 2012-14

Nurses
2000
Foreign-
Country of residence Year Total trained % of total
Australia 2000 ... ... ...
Belgium 2000 130 560 679 0.5%
Canada 2000 232 566 14 187 6.1%
Chile 2000 ... ... ...
Denmark1 2000 49 694 889 1.8%
Estonia 2000 ... ... ...
Finland2 2000 ... ... 0.2%
France 2000 404 564 7 016 1.7%
Germany3 2000 ... ... ...
Hungary 2000 ... ... ...
Ireland 2000 … ... ...
Israel 2000 39 064 7 277 18.6%
Italy 2000 304 159 1 825 0.6%
Netherlands 2001 169 580 1 495 0.9%
New Zealand 2002 33 027 4 860 14.7%
Norway 2000 ... ... ...
Poland 2000 ... ... ...
Portugal 2002 41 902 1 954 4.7%
Slovenia 2000 ... ... ...
Spain 2000 ... ... ...
Sweden 2000 88 302 2 358 2.7%
Switzerland 2000 ... ... ...
Turkey 2000 69 550 11 0.0%
United Kingdom4 2001 632 050e 50 564 8.0%
United States 5
2000 ... ... ...
OECD Total (25 countries)

1 The data only include professional nurses (and exclude associate professional nurses).
2 The data refer only to general nurses.
3 The data refer to citizens born abroad, not German by birth (except ethnic German repatriates),
and the highest degree in nursing acquired in a foreign country.
4 Different source in 2001 (8).
5 Data refer to all nurses registered to practise.

94 Health Employment and Economic Growth: An Evidence Base

Table 4 (continued)
Foreign-trained nurses working in 25 OECD countries, 2000, 2006 and 2012–2014

Nurses
2006 2012–2014
Foreign- Foreign-
Year Total trained % of total Year Total trained % of total
2007 263 332 38 108 14.5% 2013 296 029 47 507 16.0%
2006 150 817 1 290 0.9% 2014 186 278 5 411 2.9%
2006 326 170 21 445 6.6% 2013 375 768 28 330 7.5%
2006 ... ... ... 2014 34 674 702 2.0%
2006 51 840 818 1.6% 2012 55 037 724 1.3%
2006 10 264 ... ... 2014 12 519 4 0.0%
2005 ... ... 0.3% 2012 72 471 1 293 1.8%
2006 493 503 11 712 2.4% 2014 622 052 17 692 2.8%
2006 ... ... ... 2010 1 211 000 70 000 5.8%
2006 ... ... ... 2013 53 323 650 1.2%
2004 60 819e 8 758 14.4% 2013 ... ... ...
2006 43 481 6 077 14.0% 2014 45 982 4 528 9.8%
2006 358 746 15 108 4.2% 2014 424 813 20 072 4.7%
2006 186 990 2 149 1.1% 2011 198 694 1 358 0.7%
2008 39 247 8 931 22.8% 2014 45 572 11 170 24.5%
2008 70 575 5 022 7.1% 2014 83 647 7 640 9.1%
2008 268 015 5 0.0% 2012 278 496 7 0.0%
2006 51 095 2 285 4.5% 2013 65 868 1 947 3.0%
2006 ... ... ... 2013 4 797 20 0.4%
2006 ... ... . .. 2011 250 277 5 247 2.1%
2006 98 905 2 789 2.8% 2012 106 176 2 882 2.7%
2006 ... ... ... 2012 61 609 11 536 18.7%
2006 82 626 79 0.1% 2013 139 544 239 0.2%
2006 659 470 88 609 13.4% 2014 683 625 86 668 12.7%
2006 ... ... ... 2012 4 104 854e 246 291e 6.0%
9 413 105 571 918 6.1%

e: estimation.
Note: Nurses whose place of training is unknown are excluded from the calculation of the percentage of
foreign-trained nurses (for example, Switzerland).
Source: Annex 4.A1 in chapter 4 of OECD, Health workforce policies in OECD countries: right jobs, right skills,
right places (5).

PART I: Health Workforce Dynamics | CHAPTER 4 95

 3. Findings: experiences of sending countries

3.1 Countries of origin of migrant health workers in OECD

countries

The emigration of health workers from their country of origin can be reconstructed
through the use of data collected in OECD destination countries.3 Figure 1 presents
the distribution by region of origin of foreign-born doctors and nurses who were
working in OECD countries in 2000/2001 and 2010/2011.

In 2010/2011, 26% of doctors and 29% of nurses working in OECD countries

came from other OECD countries. These figures reflect both the scale of historical
migration – particularly of Europeans to the main settlement countries – and the
vitality of intra-European Economic Area, trans-Tasman and North American
flows. Beyond movements between countries within the OECD, the region from
which most doctors originated was South-East Asia, while most nurses came from
the Western Pacific Region. Growth in the number of expatriate doctors between
2000/2001 and 2010/2011 was distributed fairly evenly among these different regions.
For nurses, it was more uneven, depending on the region of origin.

Figure 2 shows the top 25 countries of origin of foreign-born doctors and nurses
working in OECD countries in 2010/2011 and the increase since 2000/2001. In
the South-East Asia Region, the increase came mainly from doctors born in India.
Germany and the United Kingdom were the main countries of origin among OECD
countries. In non-OECD European countries, Romania also stands out for its high
volume of emigration. In the Eastern Mediterranean and Western Pacific Regions,
Pakistan and China accounted for the highest shares of foreign-born doctors
working in OECD countries, while the Philippines sent the largest proportion of
nurses. In the African Region, immigrant doctors in OECD countries came primarily
from Nigeria and South Africa, and in the Region of the Americas, from Colombia
and Peru, while the Caribbean supplied the most nurses.

India and the Philippines account for the largest shares of migrant doctors and
nurses in OECD countries. They were already the two main sending countries in

3 These data provide a lower-bound estimate, as they do not include migration to other non-OECD countries.

96 Health Employment and Economic Growth: An Evidence Base

2000/2001, but their outflows grew further over the following decade. The first
seven countries of origin accounted for nearly half of the increase in the number
of foreign-born doctors. For nurses, nearly half of those emigrating came from
the first four countries of origin. The tendency of some countries to train health
professionals who intend to migrate is an important factor in the international
mobility of health workers.
Figure 1

Number of foreign-born doctors and nurses in 30 OECD countries by

main region of origin, 2000/2001 and 2010/2011

Doctors 2000/01 2010/11

350 000
300 000
250 000
200 000
150 000 136 344
103 290
100 000 76 800 66 168 55 541 50 092 44 384
50 000
0
OECD South-East Eastern Western Africa Americas Europe
Asia Mediterranean Pacific

Nurses 2000/01 2010/11

350 000
309 028
300 000 281 296
250 000
200 000
155 430
150 000 135 970

100 000 88 599

58 657
50 000 35 023

0
OECD South-East Eastern Western Africa Americas Europe
Asia Mediterranean Pacific

Note: The regional groupings correspond to the six WHO regions (for country details, see http://www.who.int/
about/regions), except the OECD countries.
Source: OECD, Changing patterns in the international migration of doctors and nurses to OECD countries,
Figure 3.15, p. 129 (4).

PART I: Health Workforce Dynamics | CHAPTER 4 97

 Figure 2

Number of foreign-born doctors and nurses in OECD countries by

25 main countries of origin, 2000/2001 and 2010/2011

Doctors 2010/11 2000/01

India
China
Germany
United Kingdom
Pakistan
Philippines
Iran
Algeria
Romania
Canada
South Africa
Viet Nam
Korea
Egypt
Poland
Nigeria
Malaysia
Colombia
Syria
United States
Morocco
Lebanon
Russian Federation
Cuba
Italy

0 5 000 10 000 15 000 20 000 25 000 30 000

Source: OECD, Changing patterns in the international migration of doctors and nurses to OECD countries,
Figure 3.16, p. 129 (4).

98 Health Employment and Economic Growth: An Evidence Base

FIGURE 2 (continued)
Number of foreign-born doctors and nurses in OECD countries by 25 main coun-
tries of origin, 2000/2001 and 2010/2011

Nurses 2010/11 2000/01

Philippines
India
United Kingdom
Germany
Jamaica
Canada
Nigeria
Haiti
China
Mexico
Korea
Poland
Ireland
France
Zimbabwe
Vietnam
Ghana
South Africa
Romania
New Zealand
Guyana
Trinidad and Tobago
Cuba
Kenya
Iran

0 10 000 20 000 30 000 40 000 50 000 60 000 70 000 80 000

PART I: Health Workforce Dynamics | CHAPTER 4 99

 3.2 Expatriation rates from countries of origin
Table 5 summarizes the broad trends in expatriation rates over the past decade.4
Between 2000/2001 and 2010/2011, emigration rates have risen for both doctors and
nurses. In 2010/2011, about 6% of doctors and nurses in the world had migrated to
an OECD country.

In Africa, the expatriation rate for nurses in South Africa rose from 12.6% in
2000/2001 to 16.5% in 2010/2011, in Nigeria from 10% to 17%, and in Zimbabwe
from 28% to 43%. For the two main origin countries of doctors in Africa

Table 5

Trends in the expatriation rates of doctors and nurses to OECD

countries, 2000/2001 and 2010/2011

Doctors Nurses
2000/01 2010/11 2000/01 2010/11
Overall expatriation rate 5.3 5.9 4.5 5.7
Average expatriation rate 19.5 21.8 16.6 21.8
Median expatriation rate 13.0 13.6 6.4 10.4

Notes: The average expatriation rate corresponds to the unweighted average of each country’s expatriation
rate (and therefore does not take into account the demographic weight of each country), whereas the
overall expatriation rate indicates the share of expatriates in OECD countries in the total number of doctors
and nurses of the countries examined. The average expatriation rate is higher than the global rate, because
countries with the lowest populations and those that are islands show the highest rates of emigration.
Countries for which expatriation rates are under 10 for nurses (5 for doctors) or resident rates in the origin
country are below 50 for nurses (10 for doctors) are not included in the calculations. Expatriation rates are
only calculated for countries for which data back to 2005 at the latest are available. Therefore, 149 countries
of origin are included for doctors and 141 for nurses. Data on the expatriation rates in 2000/2001 of nurses
born in Brazil, India and South Africa have been updated on the basis of new data on the number of nurses
working in these countries in 2000/2001. The revised expatriation rates in 2000/2001 are: Brazil 1.5%; India
2.9%; and South Africa 12.6%.
Sources: OECD (3); database on immigrants in OECD countries 2010/2011;5 labour force surveys 2009–2012;
Global Health Observatory (WHO).

4 Table 3.A1.1 in the International migration outlook 2015 (4) presents expatriation rates by country of origin.
5 http://www.oecd.org/els/mig/databaseonimmigrantsinoecdcountriesdioc.htm.

100 Health Employment and Economic Growth: An Evidence Base

who have migrated to an OECD country (Nigeria and South Africa), expatriation
rates have also risen: in South Africa from 17% to 22%, and a lower rise in Nigeria
from 11.7% to 12.3%. In some cases, the changes observed in the expatriation rates
are not so much related to an increase or a decrease in migration flows, but rather to
a change in the national stock of health workers. For example, the expatriation rate
for doctors in Angola dropped from 63% to 34%, while the number of expatriate
doctors remained stable. This reflects a sharp increase in the number of doctors
registered by WHO as working in Angola over the last decade. In Nigeria, the
number of expatriate doctors nearly doubled in 10 years (from around 4600 to 8200),
whereas the expatriation rate remained stable at around 12%. This again reflects the
growth in the number of doctors working in the country. On the other hand, the
increase in the expatriation rate of doctors in Zimbabwe (from 28% to 56%) is in
large part attributable to the fact that the number of doctors practising in the country
fell by more than half.

Despite the sharp increase in the number of health professionals emigrating from
India and the Philippines, their expatriation rates remained relatively constant. For
example, the number of expatriate Indian doctors jumped from 56 000 in 2000/2001
to around 87 000 in 2010/2011, but the corresponding expatriation rates rose only
by one half of a percentage point to 8.6%. In China, the number of expatriate nurses
doubled in 10 years (from around 12 200 to 24 400), but the expatriation rate
remained at only 1%.

3.3 Impact of emigration on health systems in countries

of origin

In its 2006 World health report, WHO estimated that 2.4 million health workers
were needed in the 57 countries considered to have critical shortages (9).6 In
2010/2011, WHO estimated that 54 countries were still facing critical shortages
of about 2 million health workers. Most of these countries (31 countries) were in
Africa. Progress made in India to close the gap between health worker supply and
demand accounted for much of the reduced shortage in 2010/2011. In Africa and

6 Countries with critical shortages were defined in the 2006 World health report as those with less than 22.8 health
professionals (doctors, nurses and midwives) per 10 000 people and where less than 80% of childbirths were deliv-
ered by skilled birth attendants.

PART I: Health Workforce Dynamics | CHAPTER 4 101

 the Americas, however, the gap widened (10). It should be noted that WHO no
longer uses the categorization of countries with critical shortages.

The slightly smaller group of countries having critical shortages saw their health
workers continue to emigrate in growing numbers between 2000/2001 and
2010/2011. Emigration therefore appears to have contributed to these critical
shortages over the decade. It accounted for 20% of estimated critical shortages in
2010/2011, compared with 9% in 2000/2001. In the decade preceding the adoption
of the WHO Global Code, the number of doctors and nurses originating from
countries with severe shortages who migrated to OECD countries grew by 84%,
while the total number of migrant health workers increased by 60%.

In African countries assessed as facing critical shortages, the number of health

professionals born in these countries and working in OECD countries doubled
between 2000/2001 and 2010/2011. At the same time, the critical shortages in their
origin countries grew, so the migration’s share of the estimated shortage rose from
7% in 2000/2001 to 13% in 2010/2011. However, the picture varies from one country
to another. Ethiopia was the African country with the most severe critical shortage.
There was an estimated shortfall of 175 000 health workers in 2010/2011, but only
6000 doctors and nurses had emigrated. In Nigeria, by contrast, emigrant workers
accounted for over 40% of the critical shortage, with 36 000 expatriates for a shortfall
estimated at 81 000 health workers.

In the Americas, the high share of the estimated shortage attributed to migrant
health personnel is due mainly to the high emigration of nurses from the Caribbean.
In absolute terms, the greatest shortage is in the South-East Asia Region. Shortages
are particularly acute in Bangladesh and Indonesia, with health worker shortfalls
estimated at 260 000 and 240 000 respectively. In the Eastern Mediterranean Region,
the increase in emigration – particularly of Pakistan-born doctors – to the OECD
area accounted for 17% of the region’s estimated critical shortage in 2010/2011, up
from 10% in 2000/2001. Cambodia, Lao People’s Democratic Republic and Papua
New Guinea were the countries where the shortfalls in health personnel were the
greatest in the Western Pacific Region. In this region, migration also accounted
for a higher share of the shortage in 2010/2011 compared with 2000/2001. Table 6
assesses the relative contribution of emigration for those countries where the density

102 Health Employment and Economic Growth: An Evidence Base

of health workers was considered too low, and the extent to which such emigration
contributed to these critical shortages. The table presents data at a broad WHO
regional level; it is important to keep in mind that the actual impact in different
countries can vary significantly.

Table 6

Estimated critical shortages of doctors, nurses and midwives,

by WHO region, 2000/01 & 2010/11

foreign-born doctors and

Number of in countries with nurses in OECD countries
countries critical shortages by region of origin
% of the
estimated
With critical Estimated critical critical
Total shortages Total stock shortage Number shortage
2000/ 2010/ 2000/ 2010/ 2000/01 2000/01 2000/ 2010/ 2000/ 2010/
2001 2011 2001 2011 2010/11 2010/11 2001 2011 2001 2011

Africa WHO Region

46 36 31 464 865 579 748 817 992 941 505 61 212 124 824 7% 13%
Americas Region
35 5 5 82 647 59 695 37 886 49 376 26 917 36 689 71% 74%
South-East Asia Region
11 6 7 1 763 637 2 318 101 1 164 001 661 267 90 216 177 018 8% 27%
Europe WHO Region
52 0 0
Eastern Mediterranean WHO Region
21 7 6 278 412 344 050 306 031 263 394 29 926 45 703 10% 17%
Western Pacific WHO Region
27 3 5 20 991 26 443 32 560 38 269 3 577 5 732 11% 15%
Total number of countries with critical shortages
57 54 2 610 552 3 328 037 2 358 470 1 953 810 211 848 389 966 9% 20%

Sources: OECD (3); database on immigrants in OECD countries 2010/2011;7 labour force surveys
2009–2012; Global Health Observatory (WHO).

7 http://www.oecd.org/els/mig/databaseonimmigrantsinoecdcountriesdioc.htm.

PART I: Health Workforce Dynamics | CHAPTER 4 103

 There are many possible causes behind the international migration of health
workers and consequences for the health systems of origin countries. On the one
hand, this migration may be interpreted as a symptom rather than a determinant
of the problems facing these health systems. The fact that there is a shortage
does not necessarily mean that there is a lack of health workers with the required
qualifications and skills: it may also reflect the reluctance of these individuals to work
under existing conditions (11). On the other hand, the emigration of health workers
can indeed be a problem when the volume of outflows is significant, particularly
when it concerns skills that are in short supply or when migrants come from regions
that are already undersupplied (12). The emigration of even a limited number of
specialists can have an important impact on the delivery of health care, especially in
rural areas where there is a dearth of health workers (13, 14).

4. Impact of health and immigration policies

on international mobility of health workers
The growing international mobility of health professionals must be viewed in relation
to other elements that also affect the supply of health workers, primarily the entry to
the labour market of new graduates on the inflow side, and the retirement or exit of
workers on the outflow side. The main factors influencing inflows and outflows are
education and training policies, immigration policies, and changes in economic and
institutional circumstances.

4.1 Impact of domestic education and training policies

on international migration flows

Policies relating to the education and training of doctors, nurses and other health
professionals are among the most powerful tools that countries can use to adjust the
supply to projected needs. Training sufficiently large numbers of health workers to
curb any dependence on immigration is in fact one of the key principles of the WHO
Global Code of Practice. Most OECD countries control in some ways the number of
students admitted to medical and nursing schools, mainly through numerus clausus
policies, and several countries have raised admission levels in these programmes
since 2000, either to meet expected growing needs for health services or to reduce
their dependence on foreign-trained doctors or nurses.

104 Health Employment and Economic Growth: An Evidence Base

The efforts to train new doctors have intensified in most OECD countries since 2000,
including in Australia, Canada and the United Kingdom, and to a lesser extent in
the United States. The number of students admitted to and graduating from nursing
programmes also rose sharply in many countries after 2000 (4, 15).8

The United States provides a striking example of how a substantial increase in

domestic training efforts for nurses has reduced the need to recruit foreign-trained
nurses. Between 2001 and 2012, the number of domestically trained nurses passing
the certification exam more than doubled, rising from less than 70 000 in 2001 to
nearly 150 000 in 2012 (Figure 3, right panel). This was accompanied by a sharp drop
in the number of foreign-trained nurses who passed that exam, coming down from a
peak of around 23 000 in 2007 to only about 5000 in 2012. Until recently, the number
of newly registered doctors who obtained their initial degree in another country has
remained more stable, but if the number of domestically trained doctors continues
to rise, it is possible that fewer foreign-trained doctors will become registered in the
United States in coming years (Figure 3, left panel).

In the United Kingdom, the steady rise in the number of domestic medical graduates
since 2002 has also reduced the need to recruit abroad (Figure 4), although the annual
inflow of foreign-trained doctors seems to have stabilized in recent years. But the
countries of origin of foreign-trained doctors in the United Kingdom have changed
considerably over the past decade, with a growing proportion of doctors trained in
other European Union countries. Regarding nurses, the inflow of foreign-trained
nurses fell sharply between 2004 and 2009, but it has gone up since then, driven
mainly by the migration of nurses trained in other European Union countries (for
example, Portugal and Spain), to meet growing demands for nurses that are not fully
met by the growing supply of domestically trained nurses. It is important to keep in
mind that there are also large outflows of nurses trained in the United Kingdom who
are emigrating to other English-speaking countries, such as Australia, Canada, New
Zealand and the United States (16).

8 See, for example, Figures 3.18 and 3.19 in the International migration outlook 2015 (4) and Figures 5.7 and 5.16
in Health at a glance 2015 (15).

PART I: Health Workforce Dynamics | CHAPTER 4 105

 Figure 3

Changes in the number of domestic graduates and inflow of

foreign-trained health workers, United States, 2001–2014

Domestic graduates Foreign-trained

Number
24 000

20 000

16 000

12 000
NEED DATA
8 000

4 000

0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Domestic graduates Foreign-trained

Number
160 000

140 000

120 000

100 000

80 000

60 000

40 000

20 000

0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Source: OECD, Health workforce policies in OECD countries: right jobs, right skills,
right places, Figure 8, p. 7 (5).

106 Health Employment and Economic Growth: An Evidence Base

Figure 4

Changes in the numbers of domestic graduates and inflow of foreign-

trained health workers, United Kingdom, 2000–2014

Domestic graduates Foreign-trained

Number
16 000

14 000

12 000

10 000

8 000

6 000

4 000

2 000

0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Domestic graduates Foreign-trained

Number
30 000

25 000

20 000

15 000

10 000

5 000

0
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Note: Between 2005 and 2008, data on staff trained abroad correspond to the administrative period ending
31 March of the year indicated. There is a break in 2008 for the graduate series. Data from 2008 onwards
are estimated.
Source: OECD, Health workforce policies in OECD countries: right jobs, right skills, right places, Figure 9, p. 7 (5).

PART I: Health Workforce Dynamics | CHAPTER 4 107

 In most OECD countries, the number of medical and nursing graduates is expected
to continue to rise in the coming years, possibly further reducing the need to recruit
foreign-trained doctors and nurses, unless the demand for their services exceeds the
growth in domestic supply.

4.2 Impact of European Union enlargement on international

mobility of health workers

The free movement of people and workers has been a cornerstone of efforts to
build the European Union since the Treaty of Rome was signed in 1957. Prior to
the accession of the 10 new member countries in 2004, there were concerns about a
possible massive inflow of health workers from these countries. These concerns were
based primarily on the results of surveys of health workers’ intentions to migrate,
conducted before 2004. For example, more than a third of Polish health workers and
more than half of Estonian health workers expressed their intention to emigrate to
find work (17). Yet migration flows have been more modest, all things considered.

Following accession, a substantial number of Polish doctors obtained a registration

in another European Union country in 2004, particularly in Germany (Figure 5).
However, this number (fewer than 200) still remained very low in comparison to
the total number of doctors practising in Poland then (over 80 000). Furthermore,
admissions plummeted after 2005 and have remained very low, despite a slight
increase in recent years. Since 2010, Polish doctors have been returning home in
sizeable numbers. This trend may reflect the substantial increase in doctors’ incomes
in Poland following the strikes in 2006/2007, and the increase in financing of the
health system.

The available information indicates that there was no sudden inflow of Polish nurses
in western European countries in 2004. In Ireland and the United Kingdom, the
flows appear to have been affected more by labour market demand, which grew up to
2007 before falling from 2008 onwards.

108 Health Employment and Economic Growth: An Evidence Base

Romania is a country that joined the European Union in 2007, and from which
there are large outflows of health workers. In Italy and to a lesser extent France, there
have been steep increases in the recruitment of Romanian health workers over the
last 10 years. France has seen a steady inflow of Romanian-trained doctors since
2007, when recognition of their professional qualifications became easier following
European Union accession. In Italy, the migration of nurses trained in Romania started
to grow around 2002 before European Union accession, and reached its peak in 2007
at the time of accession (Figure 6). While Italy limited access to its labour market to
Romanian and Bulgarian citizens, these restrictions did not include nurses; since 2002,
nurses who trained outside Italy have been exempted from annual quotas in response
to shortages.

Figure 5

Changes in numbers of new registrations of doctors trained in Poland in

three OECD countries, 2001–2012

Germany Denmark Norway

200
180
160
140
120
100
80
60
40
20
0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Source: OECD, International migration outlook, Figure 3.27, p. 145 (4).

PART I: Health Workforce Dynamics | CHAPTER 4 109

 Figure 6

Changes in numbers of new registrations in Italy and France of nurses

trained in Romania, 2000–2012 and 2006–2012

Nurses registered in Nurses registered in

Italy trained in Romania France trained in Romania
2 500

2 000

1 500

1 000

500

0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Source: OECD, International migration outlook, Figure 3.29, p. 146 (4).

4.3 Impact of the economic crisis and health spending reductions

on international migration of health workers in Europe

The economic crisis, which started in 2008 in many OECD countries, had varying
effects on international flows of migrant health workers. Some countries recruited
fewer international health professionals as they cut health expenditure growth,
and some domestic-born health workers came back on the job market. Some
countries hardest hit by the crisis, mainly in southern, central and eastern Europe,
experienced considerable outflows of health workers after 2008, with most of them
going to Germany and the United Kingdom. In some European Union countries,
this international mobility helped to achieve a better balance on labour markets and
reduced the risks of unemployment and underemployment among health workers.
Greece and Italy, two countries particularly hard hit by the crisis, have since 2008 seen
a significant increase in the numbers of doctors moving to other European countries,
notably Germany and the United Kingdom.

In recent years, Germany seems to be the favoured country of destination for doctors
born in Greece and Italy. The number of doctors of Greek nationality in Germany

110 Health Employment and Economic Growth: An Evidence Base

rose by 50% between 2008 and 2012, from slightly more than 1700 to nearly 2600.
Doctors trained in Italy also headed for France, Switzerland and the United Kingdom.
At the same time, many German doctors emigrated to other countries. In Switzerland,
for instance, nearly 1500 German-trained doctors were added to the professional
register between 2008 and 2012. The emigration of doctors from crisis-hit countries to
Germany might thus have served to offset the emigration of some German doctors.

As for nurses, there has been a steep rise in emigration from Italy, Portugal, Romania
and Spain, with the United Kingdom being the main destination country. Since 2009,
nurses trained in these four countries have represented most of new internationally
registered nurses in the United Kingdom.

4.4 Impact of bilateral agreements on the training and employment

of health workers

The WHO Global Code of Practice encourages Member States to put in place bilateral,
regional or multilateral arrangements to promote cooperation and coordination
in the area of international recruitment (1). The Code specifies, in particular, that
these arrangements should take into account the needs of developing countries and
countries with economies in transition. In recent years, several OECD countries
have implemented such bilateral agreements for the international recruitment of
health personnel.

For example, Germany concluded a bilateral agreement with Viet Nam in 2012,
covering pilot projects for the training and recruitment of geriatric care nurses in
Vietnam, a country identified on the basis of its strategy of training nurses for the
global market. The project was commissioned by the German Federal Ministry
for Economics and Technology (BMWi) and is being implemented by German
Development Cooperation (Deutsche Gesellschaft für Internationale Zusammenarbeit,
GIZ), in collaboration with the Vietnamese Ministry of Labour, Invalids and Social
Affairs. Some 100 Vietnamese nursing graduates were selected initially to take six
months of training in the German language and culture. Participants then travelled to
Germany at the end of 2013 to begin two years of professional training, accompanied
by a programme of integration and language courses. This pilot project seeks to
establish a baseline for future recruitment of skilled foreign personnel to provide care

PART I: Health Workforce Dynamics | CHAPTER 4 111

 in Germany (18). At the same time, a pilot project for recruiting nurses in China was
launched by the Caregiving Employers’ Association (Arbeitgeberverband Pflege). A
bachelor’s degree, one year of professional experience and eight months of language
and cultural training are the conditions for participation in the programme. While
they await recognition of their credentials, these Chinese nurses work as nursing
assistants. The Caregiving Employers’ Association created 150 places for Chinese
nurses to participate in this programme in 2014.

The German authorities have also sought to ensure that, consistent with the principles
of the WHO Global Code of Practice, its international recruitment activities do not
come at the expense of countries of origin. During the July 2013 review of the list of
professions in short supply in Germany, the government prohibited the recruitment
of health workers in the 57 countries identified by WHO in 2006 as facing a critical
shortage. This decision was subsequently reconsidered, as it not only banned active
recruitment by an employer or private agency but also prevented health workers
from seeking employment in Germany at their own initiative (so-called passive
recruitment). This provision was finally eliminated with the revision in October 2013
of the Employment Ordinance, which prohibits active recruitment and the private
placement of health workers from the 57 countries mentioned.

In Finland, the Mediko programme (which stands for Recruitment of Foreign Health
and Social Care Professionals to Finland) was launched in 2008 and is still in place.
Initially coordinated by the municipality of Kotka, the Mediko project was then
expanded to cover all of Finland. Since its creation, Mediko has provided counselling
to some 80 doctors, mainly Russian, wishing to practise in Finland. Mediko has also
begun to recruit nurses in Spain. Following an exploratory visit in 2012 by Mediko to
Spain, 2000 Spanish nurses expressed an interest in moving to Finland. Finnish language
courses have been organized in various Spanish cities, and since 2012, nearly 150 persons
have been recruited via this programme. With a view to longer-term recruitment,
intensive language courses before departure are planned as a way of bolstering the
motivation to move. Mediko also promotes cooperation between Finnish training
institutions and Estonian, Russian and Spanish institutions.

These examples illustrate the proliferation of international recruitment initiatives in

the health field within the context of bilateral agreements. For the time being, the

112 Health Employment and Economic Growth: An Evidence Base

number of people involved in these projects is still limited and represents only a
very small proportion of doctors and nurses. They may however play an important
role if they are steered towards positions that are particularly difficult to fill. Some
stakeholders also believe that a recruitment campaign, once launched, may well grow
over time to reach a substantial number of candidates for immigration.

Another feature of several of the recruitment initiatives discussed here is the absence
of historical, colonial and linguistic ties that previously prevailed between countries
of origin and countries of destination. Countries are being increasingly targeted for
recruitment in light of their strategy of training health workers for the international
market. Learning the language of the destination country then becomes a central
condition of success of such recruitment programmes.

There may also be a need to think about more ambitious approaches to bilateral and
multilateral agreements building on the recent example of the Paris Agreement on
Climate Change (Box 2).

5. Conclusions
Migrant health workers represent a significant share of doctors and nurses working
in OECD countries. The share of foreign-born doctors and nurses increased in most
OECD countries between 2000/2001 and 2010/2011, as did the share of foreign-
trained doctors and nurses between 2000 and 2012–2014, although it is worth noting
that the share of foreign-trained doctors in the two main destination countries – the
United Kingdom and the United States – has decreased slightly in recent years, which
is also probably the case for foreign-trained nurses, mainly due to greater domestic
education and training efforts.

A large proportion of these foreign-born and foreign-trained doctors and nurses

were born and trained in other OECD countries (between one fourth and
one third in 2010/2011). Two Asian countries are also important places of
origin – India for doctors and the Philippines for nurses – although the annual
migration flows from these countries to OECD countries has decreased sharply in
recent years.

PART I: Health Workforce Dynamics | CHAPTER 4 113

 Box 2

Learning from new models of global governance in the area of

climate change

The Paris Agreement has been hailed by many as the new model for global
governance (20, 21). It aims to address an issue of global concern, with
clear recognition of countries that are most vulnerable. It also identifies
ethical principles and standards associated with national, international
and global efforts. The Paris Agreement does not strictly represent binding
international law with strict obligations. Instead, it substitutes a strong focus
on “compliance”, determination of legality or illegality, with an “enhanced
transparency framework”.

The Paris Agreement also incorporates intended nationally determined

contributions (INDCs). Here, monitoring and accountability are linked to
voluntary nationally determined commitments, which are to be progressively
raised. This voluntary individualized bottom-up approach to changing
behaviour, as exemplified in the Paris Agreement, is one that holds significant
promise and can lead to deeper action than would otherwise be possible.

A final, important, lesson from the Paris Agreement is a clear rejection of

the idea of compensation. While the Paris Agreement speaks to providing
support to offset loss and damage in countries threatened by climate change,
the associated Paris Decision explicitly states that “Article 8 of the agreement
does not involve or provide any basis for liability or compensation”.

The Paris Agreement might provide some useful lessons for formalizing
similar dialogue structures through bilateral agreement between key source
and destination countries for migrant health personnel.

114 Health Employment and Economic Growth: An Evidence Base

The group of 57 countries identified in 2006 as having critical shortages saw their
health workers continue to emigrate in growing numbers between 2000/2001
and 2010/2011. Emigration therefore appears to have contributed to the critical
shortages in these countries over the past decade. It accounted for 20% of estimated
critical shortages in 2010/2011, compared with 9% in 2000/2001. In the decade
preceding the adoption of the WHO Global Code, the number of doctors and nurses
originating from countries with severe shortages who emigrated to OECD countries
grew by 84%, while the total number of migrant health workers increased by 60%.

By adopting the WHO Global Code of Practice in 2010, all countries have committed
to improving their health workforce planning and to responding to their future
needs without relying unduly on the training efforts of other countries, in particular
those already having critical workforce shortages. The goal must not necessarily be to
achieve self-sufficiency, but to reduce the magnitude of reliance on other countries to
fill domestic needs.

Three possible areas for action in both destination and origin countries are proposed:

• OECD countries should adjust their domestic education and training capacity
to respond to current and future projected demand where necessary, based on
more robust health workforce planning, and promote greater retention rates of
currently active health professionals, to reduce their demand for foreign-trained
doctors and nurses.

• Lower-income countries that are losing many of their skilled health workers need
to address some of the “push” factors by increasing their efforts to retain these
scarce resources through improving their working conditions and pay rates.
These retention measures will require good governance of the health system and
long-term financial commitment, which in many cases may require the support of
the international community (22–24), as called for by the WHO Global Code of
Practice.

• As called for by the WHO Global Code of Practice, both destination and origin
countries should also seek to better manage health workforce migration by
negotiating mutually beneficial bilateral agreements, including by possibly

PART I: Health Workforce Dynamics | CHAPTER 4 115

 instituting a process of formalized dialogue between key source and destination
countries. Until now, most bilateral or multilateral agreements have involved a
fairly limited number of doctors or nurses. However, if these agreements provide
benefits for both origin and destination countries, there is a potential to increase
their scope in the years ahead.

The opinions expressed and arguments employed herein are solely those of the author(s)
and do not necessarily reflect the official views of the OECD or of its member countries.

Acknowledgements

The authors would like to thank Professor James Buchan (School of Health Sciences,
Queen Margaret University) and Ibadat S. Dhillon (Department for Health
Workforce, World Health Organization) for their useful comments and suggestions
on a draft version.

Note on data for Israel

The statistical data for Israel are supplied by and under the responsibility of the
relevant Israeli authorities. The use of such data by the OECD is without prejudice
to the status of the Golan Heights, East Jerusalem and Israeli settlements in the West
Bank under the terms of international law.

116 Health Employment and Economic Growth: An Evidence Base

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118 Health Employment and Economic Growth: An Evidence Base

CHAPTER 5

Human resources for health care in

the Nordic welfare economies:
Successful today, but sustainable tomorrow?
Tyra Merker, Ivar Sønbø Kristiansen, Erik Magnus Sæther

Abstract
The Nordic countries are “welfare superstars” with high-income economies, no
extreme inequality, high life expectancies and well functioning care services.
Their health care model is characterized by high proportions of public funding
through taxes, providers that are mostly publicly owned and modest co-
payments with universal access to care. This chapter presents forecasts that
evidence the need to reform these successful health care sectors, even in the
wealthiest of Nordic countries, in order to achieve their sustainability.

In Norway, due to income from the country’s pension fund, the current health
care model appears to be financially viable towards 2030. But extending the
projections makes clear that the current model is financially unsustainable.
Projections estimate a shortage of 76 200 FTEs (full-time equivalents) in the
Norwegian health care sector, including 28 200 FTE nurses and 1400 FTE
doctors by 2035. The numbers are expected to increase further towards
060. Estimates by Statistics Norway suggest that a staggering 38% of
Norway’s workforce will need to work within the health sector if the
system is not reformed.

This chapter calls for increasing efficiency and patient focus in the sector;
introduction of mechanisms to curb demand and reduce the tax burden; and
leadership to create a more optimal personnel mix, respecting the WHO Global
Code of Practice on the International Recruitment of Health Personnel.

PART I: Health Workforce Dynamics | CHAPTER 5 119

 1. Introducing the issue of replicability and
sustainability of the Nordic model

The so-called Nordic model aims at equal and universal access to health care.
Given that it delivers high-quality services while limiting the financial burden on
individuals, the model can be considered a success (1).

In this chapter, we provide a short introduction to the essential aspects of the Nordic
model. Subsequently, we discuss the potential of the model, focusing on its sustainability
and replicability in oil-rich Norway. We assert that the model is dependent on the
financial, demographic and cultural context. We present forecasts of demographic
developments, the prevalence of diseases and the extent of care episodes for Norway.
Together, these factors will largely influence future demand for health care. Based on the
publications of Statistics Norway, we assert that an increase in supply of health care, if it
is to keep up with increasing demand from demographic changes and new technologies,
will not be financially sustainable – even in a wealthy country such as Norway.

Consequently, the Nordic model is in need of adaptation to a changing demographic

and financial environment. This, in turn, raises questions regarding the model’s
replicability in other countries. We focus on contextual factors needed for the Nordic
model to be well functioning, as well as specific policy options in order to ensure its
sustainability.

This chapter is based on forecasts of labour demand, presented in a series of articles

by Statistics Norway. We use Norway as an example, as it is hard to argue for the
Nordic model’s sustainability if forecasts show that it is unsustainable even in the
wealthiest of the Nordic countries. The model for the estimations, HELSEMOD,
utilizes gender-specific demographic projections combined with data on full-time
equivalent health personnel (FTEs) per population subgroup. This methodology is
described in more detail in the section on forecasting demand below.

The estimation entails assumptions about future demand for health care services and
the quality thereof. By relaxing some of the simplifying assumptions of the model, we
are able to determine the effects that different factors, such as delayed morbidity and
informal care, have on demand.

120 Health Employment and Economic Growth: An Evidence Base

2. The Nordic welfare state and the context of the
Nordic model

2.1 Premises for the welfare state

The four largest Nordic countries – Denmark, Finland, Norway and Sweden –
are welfare “superstars” with high-income economies, high life expectancies and
well functioning care services. The Nordic model refers to the economic and social
policies common to the Nordic countries. This includes a combination of free market
capitalism with a comprehensive welfare state. The Nordic countries have a universal,
tax-funded, single-payer health care system. All citizens and residents are insured,
and the level of co-payment has been relatively low. As a supplement, an increasing
share of the population pays out of pocket for private care.

Although there are significant differences among the Nordic countries, they all share
some common traits. These include support for a “universalist” welfare state, aimed
specifically at enhancing individual autonomy and promoting social mobility. There
is a commitment to widespread private ownership, free markets and free trade (2, 3).

Key premises for the Nordic model are transparent societies, democracy, high
social capital and low acceptance of corruption. The political model evolved in
similar countries with small and at the time homogeneous populations. There is
a check and balance between the key stakeholders within a corporatist system
involving a tripartite arrangement. The representatives of the labour force and
employers negotiate wages, and labour market policy is mediated and supported by
the government. The model has been adapted with the globalization of the Nordic
countries, but its financial sustainability is threatened by the ageing population,
through a relative reduction in the labour force, an increase in the share of recipients
and a costly public service production.

The journal The Economist (4) discusses the Nordic model with a practical approach
focusing on what works and what changes and adaptations have been implemented
thus far, dubbing the new, leaner Nordic model “the next supermodel”. The article
asserts that “A Swede pays tax more willingly than a Californian because he gets
decent schools and free health care.” Despite the model being in need of changes, the

PART I: Health Workforce Dynamics | CHAPTER 5 121

 Nordic countries have already pushed far-reaching reforms and proven that market
mechanisms can be injected into the welfare state to sharpen its performance. Hence,
it is possible for the model to adapt to new circumstances, yet maintain many of its
positive traits. However, a premise for the model is high social capital in the country
of implementation, defined as a large degree of trust between actors (for example, no
significant corruption or vested interests).

3. Health care and human resources

In the Nordic countries, the responsibility for health care lies with the state, but the
administration of primary care services is delegated to municipalities, and of secondary
and tertiary care services to regions. Some services, such as dental care for adults and
optometry, are not a part of the universal package. Long waiting times for elective care
continue to be a problem and are the cause of dissatisfaction among patients. All the
Nordic countries have introduced reforms or centralization initiatives to increase the
quality of care, reduce waiting lists and control the cost growth. The reforms include
“patient focus”1 and various schemes of patient choice, lean production and increased
use of private providers.

As a share of their gross domestic product (GDP) (excluding investments), Finland

spent 8.6%, Norway spent 8.9%, Denmark spent 10.4% and Sweden spent 11.0% on
health care in 2013 (5). Given the Nordic countries’, and especially Norway’s, very
high GDP per capita, their health expenditure per capita is higher than that of most
countries. The share of private funding is slightly higher in Finland, approximately
25%, versus 15% in Norway. See Nordic Medico-Statistical Committee (Nomesco) (6)
and European Observatory for Health Systems and Policies (7) for further details of
the health services in the Nordic countries.

1 In markets in general, customers’ preferences have a large impact on the products and services that are delivered.
However, when health care is paid for by a third party, the views and needs of patients can be neglected. In this
article, the term “patient focus” therefore refers to a political shift towards attention on patients’ needs, for example,
through valuing patients’ time when considering queues for treatments. A recent Norwegian reform is termed
“patient first”.

122 Health Employment and Economic Growth: An Evidence Base

Since the 1980s, health economics and institutions for medical priority setting have
been part of policy development, especially in the field of financing mechanisms and
priority setting for pharmaceuticals.

The Nordic governments introduced a common labour market in the 1950s and a
common accreditation for health personnel in 1982. The flow of health personnel
between the Nordic countries has varied with the relative attractiveness of the national
labour markets. The countries are also members of the joint European labour market,
as members of the European Union or the European Economic Area. The high wages
in Norway have resulted in a net influx of nurses and physicians from the other Nordic
and northern European countries.

There is ongoing immigration from other non-European countries, and many of

these immigrants find employment in the health sector. However, there is no large-
scale active recruitment of foreign-trained health personnel.

The number of practitioners in most health personnel groups, including physicians

and nurses, has been increasing during the last few decades. Consequently, the
number of health care personnel per 100 000 inhabitants is high compared to
other European Union countries, as illustrated in Figure 1.2 In 2014, immigrants
constituted 11.8% of all employed, qualified health care workers in Norway.
Of immigrants, 59% were from Europe and 24% originated from other Nordic
countries (8).

2 It is noteworthy that the share of workers with part-time positions in the Norwegian health care sector is relatively
low. This may reflect good pay rates combined with a backward-bending supply curve, reducing demand for labour
as wages increase past a certain threshold.

PART I: Health Workforce Dynamics | CHAPTER 5 123

 Figure 1

Density of physicians and nurses in the Nordic countries

Practising physicians per 1 000 population

5.0

4.0

3.0

2.0

1.0

0.0
1995 2000 2005 2010 2013

Practising nurses per 1 000 population

18

12

0
1995 2000 2005 2010 2013

Norway Denmark Sweden Finland OECD

Note: The figure for physicians has a smaller scale, in order to better display the differences between countries.
However, the difference between the Nordic countries and OECD average is much larger for nurses.
Source: OECD health statistics (http://www.oecd.org/els/health-systems/health-data.htm).

124 Health Employment and Economic Growth: An Evidence Base

4. Forecasting the prevalence of diseases and
technological advancements

Among all factors that influence health care demand, health itself is critical.
Cardiovascular disease (CVD), cancer and respiratory disease are the three main
killers in Norway. Cancer, CVD, mental disease and diseases of the musculoskeletal
system are the diseases with the highest health care costs in Norway.

The incidence of CVD is declining, and so is the number of deaths, but no

predictions for the future are available. A range of other diseases could also change in
terms of incidence or prevalence, and consequently influence the demand for health
care. However, no scientific projections are available. The increase in body mass
index will probably augment the number of patients with diabetes.

In 2013, 16 482 males and 13 919 females in Norway were diagnosed with cancer (9).
NORDCAN, a project that collects incidence, mortality, prevalence and survival
statistics from 50 major cancers in the Nordic countries, predicts that by 2033 the
crude rate of cancer will have increased by 39.5% among men and 17.1% among
women (10). The increase in crude rates is likely to be greater during the period
2034–2060, due to the rapid growth in the number of elderly people during this
period. Because innovative cancer therapies will be available over the coming
decades, patients will live longer with their disease, and the prevalence of cancer
will increase more than the increasing incidence would predict.

The introduction of new medical technologies contributes substantially to the cost of

health care. A Hastings report suggests that 40–50% of the increase in United States
health care expenditure can be explained by new technologies or increased use of
older ones (11). Predicting innovations is inherently impossible. However, cancer
treatment is an area where cost increases are likely. During the period 2012–2014,
cancer drug expenditure increased by 34.3% in Norway, while total health care
expenditure increased by 11.5%. The increased use of cancer drugs requires
surveillance with computed tomography (CT), magnetic resonance imaging (MRI)

PART I: Health Workforce Dynamics | CHAPTER 5 125

 and laboratory tests. Taking into account that there are at least 34 “promising late
stage cancer drugs” that may head for approval by the United States Food and
Drug Administration (FDA) or European Medicines Agency (EMA) in the near
future (12) and 700 more in the pipeline, we expect a 285% increase in cancer
drugs during the period 2016–2019 (13).

The pharmaceutical industry and research institutions focus on treatments for

prevalent diseases such as type 2 diabetes, dementia, infections that are resistant to
antibiotics, obesity and chronic obstructive pulmonary disease. A breakthrough in
any of these areas could increase total health care expenditure by 1–10%.

In addition to new pharmaceuticals, a range of new medical devices and

diagnostic and therapeutic technologies – including CT, MRI, positron emission
tomography (PET) and robot surgery – have entered the market. The prices of
these technologies tend to decline over time, as do drug prices, with generic
competition, and the development of more advanced technologies may free labour
from certain tasks, but new technologies may simultaneously create new labour
tasks. New technologies may furthermore shift demand towards new health care
services (diagnostic and therapeutic), resulting in an increase in the total labour
demand (14).

5. Forecasting demand: Norway as a case

5.1 Forecasting demand through demographic projections

As life expectancy rises, the demographic age profile of Norway is changing. The
increase in the share of retirees and the reduction in the share of the tax-paying
labour force will cause the dependency ratio to rise, despite an expected decline
in the share of the population aged 0–19 years. Figure 2 depicts the expected
demographic development for Norway.

126 Health Employment and Economic Growth: An Evidence Base

Figure 2

Demographic development and projection for Norway

100%

80%

60%

40%

20%

0%
1950 1970 1990 2010 2030 2050

0-19 years 20-66 years 67 years or older

Source: Figure 2 is based on two tables from Statistics Norway: Table 10211 (demography until 2015)
(https://www.ssb.no/statistikkbanken/selectvarval/Define.asp?subjectcode=&ProductId=&MainTable=Folkem
EttAarig&nvl=&PLanguage=1&nyTmpVar=true&CMSSubjectArea=befolkning&KortNavnWeb=folkemengde&
StatVariant=&checked=true, accessed 6 November 2016); and Table 10212. The latter is no longer available
on the Statistics Norway website, and the demographic projections from 2016 onwards have been replaced
by Table 11167 (https://www.ssb.no/statistikkbanken/selectvarval/Define.asp?subjectcode=&ProductId=&Main
Table=Framskr2016T1&nvl=&PLanguage=0&nyTmpVar=true&CMSSubjectArea=&KortNavnWeb=folkfram&
StatVariant=&checked=true, accessed 6 November 2016). The projections may differ from those in Table 10212.

The number of health personnel that countries will need in order to satisfy the
population’s future demand for health care is dependent on several factors, especially
demographic development and changes in morbidity and mortality.

We can forecast how large the supply of health care personnel would have to be
to satisfy future demand by dividing the population into subgroups, each group

PART I: Health Workforce Dynamics | CHAPTER 5 127

 consisting of individuals with the same age and sex. For each subgroup, the following
variables are calculated:

• the number of individuals in the subgroup

• the number of users per individual in the subgroup

• FTEs per user of a specific health care service.

The data are then combined with demographic projections to estimate future
personnel needs. Figure 3 illustrates this forecasting process for one subgroup.

Figure 3

Forecasting health care demand

Today Estimated future

Person-years needed for subgroup X

Person-years per user

Number of users in subgroup X

Number of users per individual

Demographic projection
Number of individuals
in subgroup X
Age= y
Gender= z

Source: Oslo Economics.

128 Health Employment and Economic Growth: An Evidence Base

The example in Figure 3 illustrates that the forecast with the ratios of users per
individual and FTEs per user are both equal to 1 : 2. As an example, assume that
there are 4000 individuals in the subgroup today, 2000 of these individuals are users
and they require 1000 FTEs in health care. A demographic projection forecasts that
the population of the subgroup will double in the future. Assuming that the two
ratios remain constant at 1 : 2, this implies that the future demand for health care will
be 2000 FTEs.

As illustrated in Figure 3, such estimation assumes that the ratio of users per
individual in each subgroup remains unchanged. For example, we assume that
informal care (family members taking care of sick or disabled relatives) will increase
at the same rate as the expansion of the health care system. However, if informal
care should remain at today’s level, the number of users per individual for older age
groups would increase. Consequently, the supply of health care personnel would have
to increase even further.

6. Important factors influencing future demand

Some of the factors that can affect the ratio of users per subgroup are:

• Delayed morbidity. A recent study indicates that mortality among older people
will continue to decline. This will probably delay morbidity to later stages in life,
but it is still uncertain whether this means a shorter morbidity period before death
(“compression of disease” and lower costs), or the opposite (15).

• Increase in standard or “quality of care”. The quality of health care has been
increasing with economic growth. If quality continues to increase over time, more
personnel will be needed in the future. This can be modelled as a proportional
increase in the number of users per individual in each subgroup or, perhaps
preferably, as a proportional increase in FTEs per user.

PART I: Health Workforce Dynamics | CHAPTER 5 129

 • Informal care. If informal care remains at today’s level (in terms of FTEs),
a larger share of the ageing population will require health care services. This
would increase the number of users per individual, especially for the older
subgroups.

Thus, the model for estimating future health care demand is able to relax basic
assumptions and include several factors that may influence demand in the future.
By testing different sets (or combinations) of these assumptions we are able to
estimate different trajectories for future health care personnel demand.

Table 1 shows the results of the forecast of demand in 2060 for health care
personnel in Norway. The table provides an overview of the differing results for
several combinations of assumptions. For example, the reference case assumes no
growth in the quality of health care and no delayed morbidity. These assumptions
entail that 17% of all Norwegian FTEs would have to be in health care in order to
satisfy the 2060 demand. In comparison, there were 246 000 FTEs in health care
in 2010, constituting 11% of total FTEs in Norway (16).

However, if quality were to grow at an annual rate of 1% (which is less than

previous growth), the demand for health care would require approximately 28% of
total FTEs to be in the health care sector. If people live longer and healthier lives,
growing older and getting sick later, this would reduce demand to approximately
15%. Compared to the 17% reference, delayed morbidity thus has a smaller effect
on demand than quality growth.

The extent of informal care will also have a large impact on the demand for
health care. The bottom rows of Table 1 show the predicted demand given
that informal care stagnates at a level of approximately 100 000 FTEs per year.
This scenario will occur if, for example, the number of people caring for their
parents at home would remain constant, despite the increasing number of
elderly persons. Given the ageing demographic composition, a constant share
of informal care implies that informal care per dependent has to increase.
Furthermore, it is reasonable to assume that there is a connection between

130 Health Employment and Economic Growth: An Evidence Base

expecting an increase in quality and expecting public services to care for the older
generations. The combination of both improved quality and a constant level of
informal care would require a staggering 38% of the 2060 population to work within
the health sector, almost quadrupling the share from 2010.

Table 1

Projections for health care personnel demand in Norway in 2060 (in

thousand FTEs)

Reference excl. Reduced Quality growth Delayed

informal care mortality (1% annually) morbidity
Proportional informal care
FTEs 485 549 797 428
Share of total FTEs 17% 19% 28% 15%
Constant informal care (100 000 FTEs)
FTEs 615 723 1077 514
Share of total FTEs 22% 26% 38% 18%
Source: Holmøy, Kjelvik and Strøm (16).

7. Educational capacity:
possibilities for health care supply
In order to meet future demand for health care services, it is imperative to train
sufficient and correct types of health care personnel. Forecasts for Norway indicate
that there already will be a deficit of approximately 76 000 health care workers in
2035 (17).

PART I: Health Workforce Dynamics | CHAPTER 5 131

 Figure 4 illustrates the projected surplus or deficit of different types of health care
personnel in 2035. The grey pillars represent summarized projections for three
educational levels: high school, college and university. University-educated personnel
include doctors and psychologists; college-educated personnel include nurses, dental
workers and bioengineers; and high school-educated personnel include nurses’ aides
and general health care educated workers.

While there will be an expected surplus of psychologists and general high school-
educated personnel, there is a large deficit of nurses and specialized high school-
educated health care personnel, such as nurses’ aides.

Figure 4

Projected balance between supply and demand of health care personnel

in Norway in 2035

SUM university-educated
Psychologists
Doctors
SUM college-educated
Nurses
Physiotherapists
SUM high school-educated
Other high school health/social education
Nurses aides, carers, health workers
-60 -50 -40 -30 -20 -10 0 10

Balance supply-demand in 1000 FTEs

Source: Statistics Norway (SSB) (8).

132 Health Employment and Economic Growth: An Evidence Base

As demand for health care increases further towards 2060, the gap between supply of
and demand for health care personnel will only widen. Consequently, recruitment of
health care personnel will become increasingly challenging.

8. Long-term public finances

In Norway, public financing constitutes 85% of total health care funding.
Consequently, the future demand for national health care services will have a large
impact on the country’s public spending. Increased wages for additional FTEs is
not the only public expense caused by increased demand. Assuming that the shift
towards a larger health care sector does not affect the total level of employment, an
expanding health care sector will “steal” labour from other sectors. A reduction in
the production of the private sector will cause a loss in tax income from labour and
business taxes.3 This additional loss of public income amounts to approximately 25%
of the reduction in public surplus (16).

Despite increasing expenses, unfunded public spending currently constitutes a

decreasing part of Norwegian public finances. This is largely due to income from
the Norwegian Government Pension Fund. However, with economic growth, this
income will represent a decreasing share of total GDP. Consequently, unfunded
public spending is expected to increase in the near future (18). Figure 5 illustrates
how predicted unfunded public spending depends on the assumptions we make
about developments in the health care sector. The large effect of standard or quality
again becomes evident. More importantly, the figure illustrates the importance of
a long-term perspective. In 2030, unfunded public spending is negative. However,
forecasts until 2060 reveal that a policy change is needed in order for the health care
system to be sustainable.

3 In a macro context, labour taxes from public sector employees equal a transfer from one public institution to another.
However, labour taxes from private sector employees constitute an income for the government, alongside direct
business taxes (16).

PART I: Health Workforce Dynamics | CHAPTER 5 133

 Figure 5

Predicted unfunded public spending as percentage

of Norway’s mainland GDP
20 Reference
Reduced immigration
15 Quality-growth
Delayed morbidity
10

-5
2010 2020 2030 2040 2050 2060

Sources: Norwegian Ministry of Finance (18) and Holmøy (19).

9. A sustainable model?

The main challenge concerning the Nordic model is the difficulty of meeting
future health care demand, due to a changing epidemiological, technological and
demographic context. Thus, adapting the model is essential to ensure sustainable and
equitable health care in the future.

9.1 Challenges: adapting the model to ensure sustainability

and equity

The Norwegian health care system is relatively well funded, and most new
pharmaceuticals, devices and other technologies are adopted early. Still, there are
challenges such as unmet needs, queuing, and not least discontent among health
personnel because of “too small budgets”. One current challenge in the health
services lies in funding the great number of cancer treatments.

The short-term challenges lie in developing the optimal personnel mix, as

well as adopting new technologies and, importantly, costly innovative drugs.

134 Health Employment and Economic Growth: An Evidence Base

It is also important to avoid care models that are personnel intensive, as the boom of
elderly patients will peak after 2030.

With reduced oil prices and the economic downturn, health care budgets in the Nordic
countries could grow more slowly or even experience cuts. In the years towards 2030,
the situation seems manageable from a financial standpoint. However, the long-term
(2030–2060) projections indicate an increasing gap between supply of and demand
for health care personnel in terms of funding. This gap is so large that relatively drastic
measures need to be taken, unless some unexpected innovation in technology or
productivity is developed.

The example of Finland shows that the situation may become dramatic even in the
short run. The current economic recession has forced the Finnish parliament to agree
on a 1.9% real reduction in public expenditure on health care and social benefits during
the period 2016–2019 (20). While private financing currently lies at 25%, it is expected
that this share will increase and that private providers (a range of clinics and smaller
hospitals) will expand their capacity. The Finnish Government is now developing a
package of basic, necessary health care that all citizens will have access to, while other
services will be left to private providers and private funding. The content of the package
has not yet been agreed upon.

10. Lessons learned

The Nordic health care model has thus far functioned exceptionally well and has
provided, at least in principle, equal access for all. However, the combination
of increasing standards (more personnel, increasing types of care included and
adoption of newest technologies) and an ageing population will probably make it
impossible to raise the necessary funding and number of personnel with current
levels of productivity.

The projections presented earlier indicate that health services require production
with less use of resources per unit output. Furthermore, a greater share of the
funding needs to be from private sources, in order to reduce demand and limit the
strain on public finances.

PART I: Health Workforce Dynamics | CHAPTER 5 135

 9.3 Policy options

Even though it is difficult to see how it will be possible to keep future supply
of health care at a level that is financially sustainable, we see three areas of
possible action.

Increasing the efficiency and customer service of health care production represents
one policy avenue. Lessons from the airline industry show that increased competition
has improved efficiency such that the costs have greatly diminished, the service level is
only moderately lower and safety is maintained. The key to higher efficiency in health
care may be through education of personnel, technology (including information and
communication technology), economic incentives, evidence-based medicine that
avoids ineffective care, and competition. Perhaps an increased use of privately owned
providers with public funding may create more competition and improve efficiency,
but there is still a need for better empirical evidence. It should be noted that hospital
efficiency has been a research area for decades, while we know even less about
efficiency in primary care, not least in the nursing services. Even though there has been
a more than 60% increase in registered nurses per 1000 population over the past 20
years, the discontent among nurses about the “staff shortage” is palpable. This may in
part be due to a change in health care services, characterized by shorter patient lengths
of stay in hospital, causing increased dependency and a higher workload.

Mechanisms to curb demand and reduce the tax burden, such as gatekeeping, cost
sharing and removing services from today’s high-cost universal health care coverage,
are another policy option. A greater share of funding needs to be private and some
co-payments for almost all types of care will be necessary, with few exemptions.
Some types of health care will also need to be left completely for private funding.
Surgery for varicose veins and screening procedures are examples of care that could
be excluded from the public health care package. Cost-effectiveness analysis is a
good tool, for example, to decide which services should fall outside public funding.

The third policy option is to focus on leadership in order to create a more optimal
and cost-efficient personnel mix; combining staff with different education and
educational levels; allowing for a wider range of tasks per educational group;
and increasing retention by limiting shifts towards administrative positions and
increasing the share of workers with full-time positions. The Nordic countries should

136 Health Employment and Economic Growth: An Evidence Base

avoid systematic recruitment of health personnel from low-cost countries as a quick
fix, respecting the WHO Global Code of Practice on International Recruitment of
Health Personnel.

A leaner Nordic model will be more able to provide sustainable universal coverage of
critical health services as well as long-term job security for those considering a career
in the health services.

9.4 Implementation considerations

The main implication of our findings is that the context is crucial in order for a
health care model to function well. Even with a well-functioning model such as
the Nordic model, the circumstances and socioeconomic context are imperative
for its success.

Factors such as a homogeneous population, financial capacities of the state, low

tolerance for corruption and sufficient, suitable personnel are factors that have
been present in the Nordic countries. Changing any of these factors could lead to a
situation where the model is no longer sustainable. The fact that the Nordic model
may not even be sustainable in the Nordic countries in the future warrants serious
consideration of its implementation elsewhere. At the very least, modification and
adaptation are needed.

Nevertheless, the policy options presented in this chapter may be part of the solution,
allowing the Nordic model to set an example for good health care in the future as
well. Perhaps it can even become more valuable, hopefully by demonstrating its
adaptability to changing and differing circumstances.

PART I: Health Workforce Dynamics | CHAPTER 5 137

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reviews-hits/full-list-of-country-hits). Presentation at Conference for Health Economics
(Helseøkonomikonferansen), 2014.
8. Helse- og sosialpersonell, 2014, 4. kvartal. Statistics
Norway (SSB); 2014 (http://ssb.no/hesospers, 20. Economic Policy Council report 2015. Helsinki: VATT
accessed 31 October 2016) (in Norwegian). Institute for Economic Research; 2016 (https://www.
eduskunta.fi/FI/vaski/JulkaisuMetatieto/Documents/
9. Cancer in Norway 2013: cancer incidence, mortality, EDK-2016-AK-39122.pdf, accessed 31 October 2016).
survival and prevalence in Norway. Oslo: Cancer
Registry of Norway; 2015.

10. Engholm G, Ferlay J, Christensen N, Kejs A,

Johannesen T, Khan S et al. NORDCAN: cancer
incidence, mortality, prevalence and survival in the
Nordic countries, version 7.2. Association of the
Nordic Cancer Registries. Danish Cancer Society;
2015 (http://www-dep.iarc.fr/NORDCAN/english/
frame.asp, accessed 31 October 2016).

138 Health Employment and Economic Growth: An Evidence Base

CHAPTER 6

Global estimates of the size of the

health workforce contributing to
the health economy:
The potential for creating decent work in achieving
universal health coverage
Xenia Scheil-Adlung, Andrea Nove

Abstract
Acknowledging the fact that the health sector is strongly linked to the wider
economy, this chapter takes a broad health economy perspective and presents
new exploratory evidence on the size and scope of the workforce working
towards the achievement of health objectives such as universal health coverage.

It provides evidence that progress towards the health-related Sustainable

Development Goals (SDGs) requires the input of both workers in health
occupations (HO workers), for example doctors and nurses, and a substantial
number of workers in non-health occupations (NHO workers), producing
necessary goods and services to support HO workers, for example production of
pharmaceuticals and maintenance of facilities. In the latter category, a considerable
contribution is also made by workers without payment, particularly women who
provide care informally to family members.

We estimate the size of the HO and NHO workforces contributing to economic

growth and health goals in the global health economy to show the impact of

(continued on page 140)

PART I: Health Workforce Dynamics | CHAPTER 6 139

 ABSTRACT (continued)
investments in employment, particularly the multiplier employment effects on jobs
for NHO workers arising from investment in HO workers.

It is estimated that NHO workers, including unpaid NHO workers, currently

constitute around 70% of global health employment. Throughout the world each
HO worker is supported by 2.3 NHO workers. In low-income countries that
ratio is 3.4 – thus, each investment in one HO worker will generate 3.4 jobs for
NHO workers in the wider health economy. Population growth by 2030 indicates
that globally as many as 57 million jobs for NHO workers would be needed to
achieve universal health coverage and create inclusive growth through health
employment.

These findings highlight that policies for strengthening the health economy
workforce must take into account both HO and NHO workers. The chapter
specifically calls on policy-makers to address shortages of decent jobs for health
economy workers through enabling macroeconomic and labour market policies;
to invest in new and better jobs to enhance economic growth by extending
health protection towards universal health coverage; and to transform unpaid
work into decent paid jobs in order to create inclusive and sustainable growth.

1. The role of workers in non-health occupations

in achieving health objectives and contributing to
inclusive economic growth
In many countries, the health workforce accounts for a large share of total
employment – for example, 11% of total employment in Organisation for Economic
Co-operation and Development (OECD) countries (1) – and globally this share
is expected to grow significantly over the coming years due to population growth

140 Health Employment and Economic Growth: An Evidence Base

and ageing (2). At the same time, investing in the health workforce has significant
potential to boost economic growth. This will mainly be due to the creation of
necessary jobs for the delivery of health care and the increased productivity of a
healthier labour force. The related implementation of social protection policies in
addressing the lack of access to health care also contributes to attaining Sustainable
Development Goal (SDG) 3 in the context of SDG 1 (target 1.3) on national social
protection floors, as outlined in the International Labour Organization (ILO) Social
Protection Floors Recommendation, 2012 (No. 202) (3) and SDG 8 on economic
growth and decent work.

The health economy requires workers with a broad range of skills, including workers
in health occupations (HO workers), such as doctors and nurses, but also those in
non-health occupations (NHO workers), who provide necessary goods and services
to support the work of HO workers. Achieving health objectives and realizing the
related potential for economic growth is not possible without the contribution of
NHO workers: their work is essential, for example in administration to register
patients, the provision of social and long-term care services (including from family
members as outlined in Box 1), ensuring clean and sanitized laboratory coats,
producing and packaging medicines, operating computers, delivering financial
and legal advice, moving goods such as food in the production line, and producing
finished products for use in the health sector.1 Without diminishing the importance
of health occupations, the roles of other workers contributing to the health economy
seem to be equally crucial for achieving health objectives. Thus, for this study we take
a broad approach to identifying workers in the health economy, including workers
providing unpaid long-term care, and we thereby cover a larger group than is usually
included in the health sector alone.

Projected increases in the number of HO workers due to demographic changes are

likely to generate substantial numbers of NHO workers as well, both within and
beyond the health sector. Thus, significant returns of investments can be expected,
given improved health coverage, creation of jobs and associated economic growth.

1 A detailed definition of NHO workers is provided in the next section of this paper.

PART I: Health Workforce Dynamics | CHAPTER 6 141

 Box 1

The forgotten workforce: female family members filling in for

shortages of long-term care workers

Given critical shortages of long-term care workers – estimated by ILO at

13.6 million globally (4) – large numbers of family members are providing
long-term care to their older relatives to fill the gap. In fact, family members
provide up to 90% of care work in Europe, where their numbers exceed by far
the number of skilled long-term care workers. In low- and middle-income
countries, these numbers are estimated to be even higher due to the nearly
complete absence of long-term care workers.

Shortages of skilled long-term care workers often result from the assumption
that “family care” is a “free” service without a cost to the economy. The
situation is worsened by age and gender discrimination, which manifests
itself in neglect of the need for paid long-term care workers and the
perception of such work as a financial burden.

However, many family workers are giving up formal employment, reducing

working hours or retiring early to provide care, and thus are not available
to contribute to the economy. The work provided is unpaid, physically and
mentally demanding and carried out irrespective of national regulations on
working time, vacation, occupational safety and health. Even if compensated
by minor in-kind or cash benefits, family workers risk poverty and ill health at
later stages of their lives, thereby increasing the economic costs of family care.

Finally, accepting the lack of formal long-term care workers as normal fails to
recognize the potential for physical and mental improvements made possible
by the services of skilled workers and foregoes the potential for economic
growth through creating a sufficient number of long-term care jobs.
Source: Scheil-Adlung (4).

142 Health Employment and Economic Growth: An Evidence Base

Despite NHO workers being an indispensable part of the health workforce, the
debates and strategies about health workforce shortages generally do not take them
into account. Similarly, the need for decent working conditions of NHO workers, as
highlighted in SDG 8 on the promotion of economic growth and decent work, has
not been central to the debate. This may be due to the fact that hardly any national or
global statistics exist to quantify the current number of NHO workers contributing
to achievement of the SDGs.

This lack of data has a strong impact on countries’ ability to allocate resources
efficiently and devise evidence-based employment policies. Against this background,
this paper assesses the employment and multiplier effects of investments in health
economy employment, focusing on the following questions:

a. Globally, how many NHO workers are supporting HO workers to achieve health
objectives?

b. How many decent jobs for NHO workers should be created by 2030 to achieve
universal health coverage in the context of SDGs 1, 3 and 8?

c. What ratio of NHO workers to HO workers is required today and by 2030

to attain the SDGs?

2. Methodology
Few data at global and national level are available on the number of NHO workers,
and current data do not permit country-level comparisons to be made, due to
differing definitions and categories of workers. We have therefore developed a new
methodology to estimate the current ratio of HO workers to NHO workers. From
this we can extrapolate the number of NHO workers and the number of NHO jobs
that would need to be created in the health economy to achieve universal health
coverage by 2030, assuming that the current ratio does not change. The methodology

PART I: Health Workforce Dynamics | CHAPTER 6 143

 is based on a broad view of the health workforce taking into account health
economy workers, that is, all workers in the health sector as well as in other sectors
that contribute to the health sector. For the purpose of this study, health economy
workers consist of two groups of workers: HO workers and NHO workers. We
identify both groups working within or beyond the health sector to provide goods
and services financed through health expenditure or delivered unpaid, for example
by family members. For the purposes of this study we define:

• HO workers as workers in occupations that require higher or vocational

education in a health field based on the International Standard Classification
of Occupations (ISCO) (5), specifically workers in paid employment or self-
employment in the public or private health sectors or in the broader health
economy working as health professionals, health associate professionals and
personal care workers (ISCO codes 22, 32 and 532).

• NHO workers as paid or unpaid workers not in heath occupations within the
health sector or in other sectors contributing through the delivery of goods and
services to the work of HO workers. They include long-term care workers such as
family members, friends or neighbours who provide unpaid services informally to
persons needing long-term care.

We estimate the number of workers in each of these categories for 185 countries
using the ILOSTAT database (6), World Health Organization (WHO) Global Health
Observatory database (7) and national databases, with data taken for the most
recent available year for each country. First, we calculate the number of HO workers
based on ISCO codes2 and the WHO Global Health Observatory data and apply
an upward adjustment to balance the data of countries where the WHO Global
Health Observatory data are likely to undercount certain professional categories,
such as associate health professionals.3 Then we calculate the number of workers in
all service industries4 and estimate the proportion of these who are formal NHO
workers based on a proxy: total health expenditure as a percentage of GDP.

2 This refers to ISCO codes 22 (health professionals), 32 (health associate professionals) and 532
(personal care workers).
3 Further details are available in the methodological annex (Annex 1).
4 The calculations are based on ISIC Rev.4 categories G–U. For details see Annex 1.

144 Health Employment and Economic Growth: An Evidence Base

Numbers of informal NHO workers are estimated based on long-term care
requirements of the population aged 65 and over and recent ILO estimates (4).
We assume that the majority of unpaid informal caregiving is carried out by
family members and that such work should be converted into formal jobs if
paid employment has been given up, working hours have been reduced or early
retirement has been taken to provide long-term care in the absence of paid formal
long-term care workers. The reference country considered is the United Kingdom
(8). We assume we are underestimating the situation in low- and middle-income
countries, where family members are more likely to provide long-term care than in
OECD countries.

Using the total number of HO workers and both formal and informal NHO workers
working across all sectors we compute the current global ratio of NHO workers to
HO workers based on workforce-weighted data for each country.

For estimates of the number of HO workers and NHO workers needed to achieve
universal health coverage in the context of the SDGs by 2030 we follow earlier
methodologies (9) applied to estimate health workforce deficits by setting a threshold
based on workforce–population ratios in low-vulnerability countries and comparing
the situation in each individual country against this threshold.

Incomplete data necessitated the application of a methodology based on the use

of assumptions derived from the limited evidence available. Besides the necessary
use of a proxy variable to estimate the number of HO workers beyond the health
sector (such as excluding workers in the manufacture of pharmaceutical products
and construction workers), both numbers are probably relatively small. Further, we
assume that the ratio of workers’ wages to material costs would be similar for all
service industry sectors; and we also assume that informal NHO workers providing
care consist largely of family members. Finally, we base our estimates on a limited
number of countries and apply workforce-weighted average ratios to others. This
probably introduces some inaccuracies at individual country level, but should not
greatly affect the global total.

PART I: Health Workforce Dynamics | CHAPTER 6 145

 3. Global estimates of the relative sizes of the
HO and NHO workforces

The global estimates provide information on the number of NHO workers working
inside or outside the health sector in activities including (but not
limited to):

• administration

• social services, including delivery of long-term care

• insurance

• finance

• information technology

• transportation

• education.

Our analyses indicate that, globally, NHO workers account for 60% of all health
economy employment and 70% of all paid and unpaid workers, including informal
long-term care workers in the health economy (Figure 1).

Figure 1

Composition of workers in
the global health economy
(thousands), 2015
Unpaid NHO HOs:
workers: 70 631
56 665

Paid NHO
workers:
106 042
Source: ILO calculations, 2016 (10).

146 Health Employment and Economic Growth: An Evidence Base

In more detail, worldwide we find:

• 71 million HO workers;5

• 106 million paid, mostly formal, NHO workers;

• 57 million unpaid, mostly female, NHO workers, providing care to older relatives.

The global ratio of NHO workers to HO workers is 2.3, with each HO worker
supported by 2.3 (paid or unpaid, formal or informal) NHO workers to achieve
overall health objectives. Excluding unpaid NHO workers (mostly female family
members), and the necessary transformation of the work into paid employment in
formal jobs for long-term care workers, brings the ratio to 1.5, meaning that each
HO worker is supported by 1.5 paid NHO workers.

Figure 2 shows how the ratio of NHO workers to HO workers varies by income
group. If we consider just paid NHO workers, high-income countries have an NHO–
HO ratio of 1.7, compared with 1.4 for middle-income countries and
1.3 for low-income countries.

Taking paid and unpaid, formal and informal workers into account, however, we
see a much higher ratio in low-income countries, because these countries tend to
have smaller numbers of HO workers relative to the size of their populations. The
relatively high ratio in high-income countries, on the other hand, is probably a
reflection of the higher proportion of older persons among the populations and
therefore greater numbers of long-term care workers.

5 Our estimates of 70.6 million HO workers are different from and larger than earlier estimates from WHO as a result
of different approaches, definitions, and data sources, for example including or excluding private health sector em-
ployment. Global estimation of HO workers is also a challenging task, as data from various sources differ in terms of
the definitions used, and the scope and completeness of the data. The differences show the range of the size of the
total health workforce depending on choices about which groups to include.

PART I: Health Workforce Dynamics | CHAPTER 6 147

 Figure 2

Ratio of NHO workers to HO workers, by income

group, 2015

4.0
3.4
NHO workers per HO workers

3.5
3.0
2.5 2.3 2.4 2.3
(current)

2.1
2.0 1.7
1.5 1.4 1.4
1.5 1.3

1.0
0.5
0.0
All High Upper Lower Low
(n=185) (n=57) middle middle (n=27)
(n=50) (n=49)
Income group

Including unpaid Excluding paid

NHO workers NHO workers

Source: ILO calculations, 2016 (10).

Figure 3 provides estimates that suggest the world is currently short of about 18 million
HO workers and 32 million NHO workers to achieve universal health coverage.
However, the shortages of workers are not equitably distributed. While some countries
have a surplus of HO workers and NHO workers – particularly high-income countries
– others show gaps: 89 countries are observed with a shortage of HO workers and 95
countries with a shortage of formal NHO workers.

Adding unpaid workers to the calculations, we find that currently 123 countries have a
shortage of 38 million formal and informal NHO workers.

Figure 4 shows that the shortages of HO workers and NHO workers predominantly
affect Asia and the Pacific, which reflects the fact that this region contains the most
populous countries in the world, with Africa the next most affected. Relative to the
population size, however, Africa has the most severe shortages.

148 Health Employment and Economic Growth: An Evidence Base

Figure 3

Numbers of formal HO workers and NHO workers currently

available and missing, 2015

120
106 042
100
Number of workers

80 70 631
(thousands)

60

40 31 761
18 340
20

0
HO workers Paid NHO workers
Available Missing

Source: ILO calculations, 2016 (10).

Figure 4

Numbers of formal HO workers and NHO workers missing in public and

private employment, by region, 2015

20 18 575
18
16
Number of workers

14
(thousands)

12
10 347 10 494
10
8
6 368
6
4
2 966 1 510
499 829 353
160
0
HO workers Paid NHO workers
Asia & Pacific Africa Americas
Arab States Europe & Central Asia

Source: ILO calculations, 2016 (10).

PART I: Health Workforce Dynamics | CHAPTER 6 149

 By 2030, population growth means that the world will have to create jobs for an
estimated additional 27 million HO workers and 57 million NHO workers in order
to achieve universal health coverage. Most of the additional jobs for HO workers
and formal NHO workers will be in lower middle-income and low-income countries
(Figure 5), and in the regions of Asia and the Pacific and Africa.

Figure 5

Additional HO and NHO jobs to be created by 2030 in public and private

employment, by income group

45
40 38 144
Number of additional workers
required by 2013 (thousands)

35
30 856
30
25
20 17 982

15 12 921
9 945
10
6 173 4 971
5 3 917
2 201
437 784 1 099
0
HO jobs Paid NHO jobs Paid and unpaid
NHO workers
High Upper middle Lower middle Low
income income income income

Source: ILO calculations, 2016 (10).

150 Health Employment and Economic Growth: An Evidence Base

4. Assessment of economic effects from investments
in health economy employment

The evidence provided leads to some key observations.

• By applying a health economy perspective, evidence is provided that the global

number of NHO jobs required to achieve health objectives such as universal
health coverage exceeds the number of HO jobs. This suggests that the size of the
health workforce is underestimated, and the contribution of NHOs to economic
growth and meeting health needs is overlooked.

This also holds true for the provision of decent working conditions for NHO
workers, who often work for low wages. Working conditions that do not respect
human rights, including labour rights, social protection coverage, occupational safety
and participatory processes through social dialogue, will not address challenges to
economic growth such as poverty and inequality. Based on this analysis, investments
in decent jobs for NHO workers should be considered alongside investments in
HO workers.

• In all countries, investments in HO workers have significant economic multiplier

effects resulting, among other things, in the creation of new jobs for NHO
workers both within and beyond the health sector.

The data suggest that the economic return on investments in HO workers – or more
generally in universal health coverage – has a positive impact on job creation for
NHO workers. Globally, the ratio of NHO workers to HO workers is estimated at
2.3. If this ratio were to be maintained, the creation of one HO job has the potential
to result in 2.3 jobs for NHO workers. If only paid NHO work is considered the ratio
is still 1.5, meaning that each HO job could result in the creation of 1.5 NHO jobs.
Thus, a direct effect of additional HO jobs is the generation of NHO employment,
from which the resultant incomes are used and reused to contribute to the broader
economy, leading to further employment and economic growth.

PART I: Health Workforce Dynamics | CHAPTER 6 151

 • High deficits in the number of NHO workers are observed globally, especially
in lower-income countries, and demand for NHO workers will increase
significantly by 2030.

Despite their importance, evidence suggests that the world is short of 32 million
NHO workers, with larger shortages in lower middle-income and low-income
countries. The demand for NHO workers will grow significantly by 2030, when
170 million NHO workers are likely to be required to provide goods and services
to achieve universal health coverage.

These results suggest that much potential economic growth is foregone due to the
gaps in employment. Further, NHO shortages reduce the accessibility of health
services, thus creating (a) negative health and economic impacts as the unserved
population cannot fully contribute to economic growth due to absenteeism,
disability and reduced life expectancy; and (b) increased public expenditure due to
higher morbidity.

• The creation of NHO jobs can benefit workers with all levels of qualifications
and in areas with limited employment opportunities and thus has the potential
to reduce un(der)employment and poverty.

The many occupations included in NHO work provide a wide range of job
opportunities for workers at all skill levels. Thus, the creation of decent jobs
in non-health occupations can play an important role in areas with high
unemployment of low-skilled workers. It can also provide learning and career
development opportunities to workers who have missed out on primary or
secondary education.

Further, NHO employment effects are likely to occur not only in affluent areas
but also in poor and rural areas if investments in decent jobs are made in the
context of universal health coverage policies based on equitable access to services,
as implied in SDGs 1, 3 and 8. Thus, the multiplier effects of investments in
health economy employment might include poverty alleviation and reduced
unemployment in such areas.

152 Health Employment and Economic Growth: An Evidence Base

• Large numbers of unpaid workers providing informal care are filling in for the
lack of jobs in formal employment, often without decent working conditions and
by reducing or withdrawing their own formal employment.

Shortages of formal jobs for health workers result in informal work, particularly for
the provision of long-term care services. These estimates indicate that, globally, there
are nearly as many unpaid NHO workers providing informal care as HO workers.
Often, these unpaid services are provided without decent working conditions,
defined working hours, rights to breaks, holidays, or social protection coverage for
sickness, unemployment and old age. This may result in negative health impacts such
as burnout and old age poverty among care workers.

Against this background, it is crucial to ensure adequate staffing for long-term

care services, which has been estimated at 4.2 full-time equivalent long-term care
workers per 100 persons aged 65 years and over (4). Further, it is essential to provide
adequate cash benefits and social protection coverage to informal care workers such
as family members to alleviate their burden.

5. Policy considerations: achieving inclusive

growth by creating decent jobs for HO and
NHO workers
Closing the identified gap of HO and NHO workers will be essential for attaining
the SDGs. It will help to address the large deficits in decent jobs in countries of
all income levels. This should be considered as an asset for the economy through
contributing to improved health, economic growth and development, and decreasing
inequality.

Closing the gaps requires a rethinking of current health employment policies, which
often focus on HO workers in the health sector only rather than considering the
macroeconomic dimension of employment effects for all workers contributing to the
health economy. Thus, it is important to evaluate where investments are best placed
to achieve optimal health, social and economic returns on investment. Evidence
from prior studies (11) indicates that investments in medically underserved rural

PART I: Health Workforce Dynamics | CHAPTER 6 153

 areas in low-income countries have the greatest impact in terms of improving health
coverage and creating jobs.

Policies should not be limited to solely achieving higher numbers of HO jobs, but
should also consider decent work for NHO workers as an integral part of health
employment. Only if decent working conditions for the entire health economy
workforce are considered can sustainable progress be achieved (12).

Addressing these issues and achieving inclusive growth requires strengthened

policies that focus on:

• integrating macroeconomic, employment and labour market policies with the

potential to realize inclusive and sustainable economic growth due to investments
in decent health economy employment for NHO workers based on progress
towards SDGs 1, 3 and 8;

• ensuring that sufficient funds for attaining universal health coverage are made
available for the workforce, requiring fair social protection financing mechanisms
aimed at financial, fiscal and economic sustainability with due regard to social justice
and equity, as highlighted in ILO Recommendation No. 202;

• guaranteeing the delivery of services to the population by providing equitable

access in the context of social protection floors and universal health coverage
policies;

• transforming the informal provision of long-term care (obligated by the absence

of formal long-term care workers) into formal jobs.

154 Health Employment and Economic Growth: An Evidence Base

Policy option 1
Address shortages of decent jobs for NHO workers through enabling
macroeconomic and labour market policies
Macroeconomic policies are often detached from employment and labour market
policies and the need for decent working conditions, particularly in the health sector.
No less important than fiscal and monetary policies are macroeconomic policies
that enable raising labour productivity or investments in decent jobs because of their
important employment effects. Jobs providing decent working conditions, such as social
protection and decent incomes, have immediate beneficial effects for the economy as
a result of improved health of the workers and the related increase in their productive
potential, and stabilized consumption in the longer term based on regular income.

An essential foundation for policies to ensure that the health economy contributes fully
to and benefits from progress towards decent work for all is improved national data on
the size and composition of NHO workers.

Against this background, it is important to unlock the positive effects of health economy
employment and realize inclusive and sustainable growth based on investments in
decent jobs for NHO workers. Labour market and employment policies should be
closely linked to employment-friendly macroeconomic policies. Such enabling policies
reverse the prioritization of fiscal policies aimed at reducing debts and financial deficits
only. By using macroeconomic frameworks allowing for higher budget deficits and
inflation, policies have the potential to reduce unemployment, provide for education,
training, and skills development, alleviate poverty, and promote investments in social
protection in health (13). This can be achieved without jeopardizing macroeconomic
stability as the policies are thereby linked to employment-generating growth.

Labour market policies such as public investments in employment or subsidized

employment are needed to trigger economic growth through the health economy and
to provide incentives for private sector investments. Decent working conditions should
be established that include full and rights-based health economy employment, social
protection coverage, freedom of association and collective bargaining, resulting in
equitable income distribution and thus inclusive growth (3). The exclusion of groups
such as women, migrant workers or youths is often rooted in the absence of such
enabling policies.

PART I: Health Workforce Dynamics | CHAPTER 6 155

 Thus, major efforts are needed to mainstream labour market and employment
policies based on decent work into macroeconomic policies aimed at stimulating
inclusive and sustainable economic growth.

Policy option 2
Invest in new and better jobs to enhance economic growth by extending
health protection towards universal health coverage

It will be important to ensure sufficient investments for increasing the quality and
quantity of health employment for workers in health and other occupations in both
the public and private sectors. The generation of public funds requires fiscal space
that needs to be created based on fair financing mechanisms, including taxes and
shared contributions to health protection systems providing for universal health
coverage. Resultant funds should be equitably distributed in terms of geography, age
and gender, to avoid access deficits. Thus, increased health economy employment
will be linked to the needs and demands of the population, who can then access
affordable services and will in return be enabled to contribute to economic growth.

Some prerequisites and principles should be met to enable the population to utilize
services. These include the establishment of rights and legislation guaranteeing
access to health care for the whole population, rather than an approach based on
charity. Such legislation should be based on the principles of universality, equity,
social inclusion and non-discrimination. Further, it is essential to ensure that quality
services are affordable and financially protected, for example by minimizing out-of-
pocket payments.

An enabling framework for related policies is provided in ILO Recommendation No.

202, which also provides guidance on achieving coherence with social, economic and
labour market policies and highlights the need to coordinate related policies with
development policies, such as rural development plans.

156 Health Employment and Economic Growth: An Evidence Base

Policy option 3
Transform informal work into formal jobs to create inclusive and sustainable
growth
Currently, many policy-makers and decision-makers do not anticipate the need to
transform informal long-term care work into formal jobs due to the expectation
of “free” services – mainly from female family members. Reliance on the informal
provision of long-term care is unsustainable in the context of global ageing,
particularly given that many informal workers are not trained for caregiving, yet
the work can be very demanding, for example when caring for persons with mental
disorders. Further, informal caregiving has the potential to aggravate gender
inequality as it is often provided without any remuneration or social protection
coverage.

It is therefore crucial to transform informal work that is undertaken as a consequence

of the absence of formal care workers into formal jobs with decent working conditions.
This will allow for acceptable living conditions for those who currently provide
informal care, as well as helping to alleviate poverty and promote gender equality. Most
efficient and effective measures for formalizing long-term care relate to the creation of
decent jobs that provide adequate wages, as well as skills development for the provision
of quality care (14).

Acknowledgements

The authors would like to thank ILO colleagues for their contributions: Amber
Barth, Thorsten Behrendt, Ekkehard Ernst, David Hunter, Stephen Pursey, Dorothea
Schmidt-Klau and Christiane Wiskow.

PART I: Health Workforce Dynamics | CHAPTER 6 157

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International Labour Office; 2016 [unpublished: 10. Scheil-Adlung X. Health workforce: a global supply
available upon request from the author]. chain approach – new data on the employment
effects of health economies in 185 countries. Geneva:
3. R202 – Social Protection Floors Recommendation, International Labour Office; 2016.
2012 (No. 202) [Internet]. Geneva: International
Labour Office; 2012 (http://www.ilo.org/dyn/normlex/ 11. Scheil-Adlung X. Global evidence on inequities in rural
en/f?p=NORMLEXPUB:12100:0::NO::P12100_ health protection: new data on rural deficits in health
INSTRUMENT_ID:3065524, accessed coverage for 174 countries. Geneva: International
6 November 2016). Labour Office; 2015 (http://www.social-protection.
org/gimi/gess/ShowRessource.action?ressource.
4. Scheil-Adlung X. Long-term care (LTC) protection ressourceId=51297, accessed
for older persons: a review of coverage deficits in 7 November 2016).
46 countries. Geneva: International Labour Office;
2015 (http://www.ilo.org/secsoc/information- 12. Wiskow C. The role of decent work in the health
resources/publications-and-tools/Workingpapers/ sector. In: Buchan J, Dhillon I, Campbell J, editors.
WCMS_407620/lang--en/index.htm, accessed Health employment and economic growth: an
7 November 2016). evidence base. Geneva: World Health Organization;
2016 [forthcoming].
5. ISCO: International Standard Classification of
Occupations [Internet]. Geneva: International Labour 13. World social protection report 2014–15: building
Office; 2010 (http://www.ilo.org/public/english/bureau/ economic recovery, inclusive development and social
stat/isco/, accessed 7 November 2016). justice. Geneva: International Labour Office; 2014
(http://www.ilo.org/global/research/global-reports/
6. ILOSTAT database [Internet]. Geneva: International world-social-security-report/2014/WCMS_245201/
Labour Office; 2016 (http://www.ilo.org/global/ lang--en/index.htm, accessed
statistics-and-databases/lang--en/index.htm, accessed 16 November 2016).
7 November 2016).
14. R204 – Transition from the Informal to the Formal
7. Global Health Observatory data repository: 2014 Economy Recommendation, 2015 (No. 204)
update, Global Health Workforce Statistics [Internet]. [Internet]. Geneva: International Labour Office; 2015
Geneva: World Health Organization; 2016 (http:// (http://www.ilo.org/dyn/normlex/en/f?p=NORMLE
apps.who.int/gho/data/node.main?showonly=HWF, XPUB:12100:0::NO:12100:P12100_INSTRUMENT_
accessed 7 November 2016). ID:3243110:NO, accessed 7 November 2016).

158 Health Employment and Economic Growth: An Evidence Base

ANNEX 1: Methodology

The analyses are based on the conceptual framework illustrated in Table A1.1.
Within the framework, the workers of interest fall into five groups.

Table 1

Conceptual framework

Workers in health Workers in non-

occupations health occupations Health economy
(HO workers) (NHO workers) workers
Employed in the health
A C A+C
sector
Employed outside the
B D B+D
health sector
Unpaid informal
– E E
workers
Total A+B C+D+E A+B+C+D+E

The terms used in Table 1 are defined as follows:

• Workers in health occupations (HO workers) (groups A and B) = workers in

occupations that require post-secondary education in a health field.

• Workers in non-health occupations (NHO workers) (groups C, D and

E) = workers providing goods or services that support the work of HO workers.

• Health economy workers (groups A, B, C, D and E) = all HO workers and NHO

workers contributing with or without pay to the provision of health services,
whether within or outside the health sector.

• Employed in the health sector (groups A and C) = employed by an organization

whose primary purpose is to deliver preventive, promotive or curative health
services, or self-employed in a job with this primary purpose.

PART I: Health Workforce Dynamics | CHAPTER 6 159

 • Employed outside the health sector (groups B and D) = employed by
an organization that provides goods or services to the health sector,
or self-employed workers, in a job with this primary purpose.

• Workers engaged in any activity to produce goods or provide services

for pay or profit (groups A, B, C and D).

• Unpaid informal workers (group E) = persons who worked without pay to

provide health and long-term care or to provide support to HO workers. In this
study we specifically focus on unpaid informal caregiving of family members
providing long-term care.

Throughout, we used data based on headcounts rather than numbers of

full-time equivalent workers.

Three data sources were used:

• ILO’s central statistics database: ILOSTAT (www.ilo.org/global/

statistics-and-databases);

• WHO Global Health Observatory workforce statistics (http://apps.who.int/gho/

data/node.main?showonly=HWF);

• National sources of data.

The steps followed were as follows.

1. Estimate the size of the entire formal health economy

workforce (A + B + C + D) for ILOSTAT countries

At present, there is no global data source that will allow the number of NHO
workers outside the health sector (group D) to be counted. Only NHO workers
within the health sector (group C) usually appear in global estimates, which is a
major limitation because NHO workers can and do work in non-health sectors,

160 Health Employment and Economic Growth: An Evidence Base

and without them the health sector would not be able to operate to its full scope.
Therefore, rather than ignoring this important group of workers and their
contribution to the health economy, it was judged to be important to attempt to
estimate their numbers, as follows:

For the 68 countries in the ILOSTAT database, the number of workers in service
industries (ISIC Rev.4 categories G–U or ISIC Rev.3 G–Q) was extracted for the
most recent available year. This number includes most types of formal HO workers
and NHO workers (groups A–D), as well as people working in other service
industries. Five countries were excluded at this stage because their ILOSTAT data
were not disaggregated by industry sector (Algeria, Japan, Madagascar, Maldives
and Ukraine).

For the remaining 63 countries, workers in ISIC Rev.4 category Q (or ISIC Rev.3
category N) were assumed to represent workers employed in the health sector
(groups A + C). Five countries were excluded at this stage because their data
showed zero employees in the health sector (Albania, Belarus, Dominican Republic,
Indonesia and South Africa).

For the remaining 58 countries, to estimate the number of workers in ISIC Rev.4
categories G–P and R–U (or ISIC Rev.3 categories G–M and O–Q) who are health
workers outside the health sector (groups B + D), we used “total health expenditure
(THE) as a % of gross domestic product (GDP) 2014” (1) as a proxy variable. Thus,
the % of service workers in non-health sectors who provide health services was
assumed to be the same as the % of GDP that is the total health expenditure.

Limitations

• It was assumed that the numbers of workers recorded in the most recent year in
ILOSTAT still applied. Although the data were fairly recent for most countries (49
out of 63 countries had data for 2014, four for 2013, three for 2012), the data for a
few countries were slightly out of date (2009 or 2010).

PART I: Health Workforce Dynamics | CHAPTER 6 161

 • People working in the manufacture of pharmaceutical products were not
counted (they are categorized under ISIC Rev.4 category C or ISIC Rev.3
category D). However, those involved in research and development and retail of
pharmaceutical products were counted.

• People working in construction were not counted (they are categorized

under ISIC Rev.4 category F or ISIC Rev.3 category F), so workers involved in
construction of health facilities were not included in the counts of NHO workers.

• The lack of empirical data means that the assumption that THE/GDP is equal to
NHO workers/all service workers cannot be verified and it should therefore be
treated with an appropriate degree of caution.

• It is highly unlikely that the percentage of service industry workers who provide
services to the health sector is constant across all service industry sectors G–P
and R–U. The proxy variable assumes that, on average, the percentage who do is
equal to the percentage of GDP that is THE.

• The use of THE/GDP as a proxy variable for estimating B + D means that we

assume that the ratio of worker costs to goods/materials costs is similar for all
service industry sectors, which may not be the case.

2. Estimate the number of formal HO workers

(A + B) for ILOSTAT countries

For the 58 remaining ILOSTAT countries, the number of workers with ISCO-08
code 22 or 32 (or ISCO-88 222, 223, 322, 323 or 324) was extracted for the most
recent available year. However, these ISCO codes do not include personal care
workers (ISCO-08 code 532). ILOSTAT does not disaggregate ISCO codes to the
three-digit level, so it was not possible to identify numbers of personal care workers.
Because personal care workers are HO workers as defined in this study, and in many
countries represent a significant proportion of HO workers, it was necessary to
estimate their numbers. This was done using OECD data (2), which showed that,
for the 17 OECD countries with data from 2012, 2013 or 2014 about both total
employment in health and social care and the number of personal care workers,

162 Health Employment and Economic Growth: An Evidence Base

on average 10% of all those employed in the health sector (groups A + C) are
personal care workers.

The size of the formal HO workforce (groups A + B) was therefore estimated by

taking 10% of the number of workers in ISIC Rev.4 category Q (or ISIC Rev.3
category N) and adding this to the number of workers with ISCO-08 code 22 or 32
(or ISCO-88 222, 223, 322, 323 or 324).

Four countries (Azerbaijan, Bhutan, Botswana and Brazil) were excluded at the stage
because they had no data for the relevant ISCO codes, and two more (the Russian
Federation and Sri Lanka) were excluded because the number of workers with these
ISCO codes was larger than the number of service industry workers counted in step
1. These two situations were taken as indicators of poor-quality data.

This left a total of 52 countries with sufficient data in ILOSTAT to estimate the size of
both the total number of health economy workers (groups A–D in Table A1.1) and
the number of HO workers (Groups A + B).

Limitations

• The proportion of workers employed in the health sector who are personal care
workers varies even within OECD countries, so the estimate of 10% on average
may not be representative of all countries.6

• The ISCO codes used to identify HO workers probably includes veterinary

workers and some other categories that are not relevant for our study for at least
some countries. Their numbers are much smaller than numbers of human health
workers, so this is not thought to be a major limitation.

6 We tried to work out a method of adjusting for this by referring to the WHO Global Health Observatory database,
which includes personal care workers within its counts of “other health workers”, but also provides separate counts
of personal care workers as well as other health workers. However, only 15 countries had disaggregated data on
personal care workers for a comparable year to the data on “other health workers”, of which five recorded more
personal care workers than “other health workers”, which caused us to doubt the quality of the data.

PART I: Health Workforce Dynamics | CHAPTER 6 163

 3. Estimate the number of formal NHO workers
(C + D) for ILOSTAT countries
For the 52 remaining ILOSTAT countries, the size of the paid NHO workforce
(Groups C + D) was estimated by subtracting the number of HO workers (see step 2)
from the number of service industry workers (see step 1).

4 Calculate the ratio of HO workers to NHO workers

((A + B):(C + D)) for ILOSTAT countries

The ratio of HO workers to NHO workers in each country was calculated by dividing
the number of NHO workers (see step 3) by the number of HO workers (see step 2).

Across all 52 countries, the median ratio was 1.62, that is, for every HO worker
in these countries, on average there were 1.62 NHO workers. The ratio was
disaggregated by World Bank income group, as shown in Table A1.2.

Table 2

Median ratio of NHO workers to HO workers in

52 ILOSTAT countries

Median number of NHO

Income group No. of countries workers per HO workers
High 33 1.72
Low and middlea 19 1.38
All 52 1.62

a The low- and middle-income categories were combined because there were very few low-income countries
in ILOSTAT, and the medians for the low-income, lower middle-income and upper middle-income countries
were very similar.

164 Health Employment and Economic Growth: An Evidence Base

5. Estimate the number of HO workers (A+B)
in countries with other data sources
ILOSTAT does not include data for enough countries to permit global and regional
estimates of the number of HO workers. The WHO Global Health Observatory
database contained data on health worker numbers for 182 countries, of which 133
were not included in ILOSTAT. The WHO database uses cadre definitions that do
not directly match the ISCO codes used for the ILOSTAT countries, so we made
assumptions as presented in Table A1.3.

Table 3

WHO database categories and their ISCO code equivalents

WHO category ISCO-08 equivalent Our classification

Physician 221 HO
Nursing & midwifery 222, 322 HO
Dentistry 226 HO
Pharmaceutical 226 HO
Laboratory 321 HO
Environmental & public health 226 HO
Community & traditional health 223 HO
Other health workers (which 532 + 226 not mentioned above HO
includes personal care workers)
Management & support various NHO

As with ILOSTAT, data were taken from the WHO database for the most recent
available year. For one of the WHO database countries (United Republic of
Tanzania), the data showed zero physicians, which was taken as an indicator of poor-
quality data. An alternative data source was therefore used for the United Republic
of Tanzania (3), which used the same health worker categories as the WHO database
(see Table A1.3).

Thus, estimates of the number of HO workers were made for 185 countries
(52 from ILOSTAT, 132 from WHO and one from a national data source).

PART I: Health Workforce Dynamics | CHAPTER 6 165

 The numbers of HO workers in the WHO database were systematically lower
than the numbers in the ILOSTAT database. It seems likely that this was due
to undercounting of certain categories of worker, most notably associate health
professionals (our analyses indicated that the numbers of health professionals were
similar across the two databases, whereas ILOSTAT tended to include many more
associate health professionals). It is also possible that, for some countries with data
provided by national governments (4), private sector workers are undercounted (5)
due to public data systems focusing on the public sector. For this reason, an upward
adjustment was made to the WHO numbers to make them more comparable with
the ILOSTAT numbers. This was done by examining the 49 countries that had data
on the number of HO workers in both ILOSTAT and the WHO database. For these
countries, the median ratio of WHO to ILOSTAT estimates was 0.59 (that is, on
average, the number of HO workers in the WHO database was 0.59 the number in
ILOSTAT). For each of the 133 non-ILOSTAT countries, therefore, the number of
HO workers in the database was divided by 0.59 to give an estimate of the actual
number of HO workers.

Limitations

• The upward adjustment of HO numbers in the WHO database is based on an

average, which is unlikely to apply to all individual countries. For this and other
reasons, it is not appropriate to present individual country estimates. In all
outputs relating to this study, aggregate estimates and regional and global levels
only should be presented.

6. Estimate the number of formal NHO workers

in countries with other data sources

The median ratio of HO to NHO workers in high-income ILOSTAT countries (1.72)

was applied to high-income countries in the WHO database, and the median ratio in
low- and middle-income ILOSTAT countries (1.38) was applied to low- and middle-
income countries in the WHO database. These ratios were applied to the number of
HO workers (see step 5) to give an estimate of the number of formal NHO workers
(groups C + D).

166 Health Employment and Economic Growth: An Evidence Base

7. Estimate the number of unpaid care workers (E)
Estimates of total numbers of unpaid workers for 21 OECD countries were taken
from a recent ILO paper (6). For these 21 countries, we calculated the median
“informal workers to population over 65” ratio7 (on the assumption that most of
those in need of informal care workers are people in this age bracket), and applied
this ratio to all 185 countries included in the above calculations. This yielded an
estimate of the number of informal workers in all 185 countries.

This was almost certainly an overestimate of the number of unpaid workers according
to our definition, because not all unpaid work can or should be transformed into
formal jobs. To estimate the numbers who fit our definition of unpaid workers, we
first assumed that most were family members, then used data from a 2015 United
Kingdom survey of family members providing care (7) to estimate the proportion
of unpaid work that could be converted to formal jobs. That survey found that 51%
of carers had given up work to provide long-term care for a family or household
member, 12% had taken early retirement and 21% had reduced their working hours.
Of those who gave up work, retired early or took reduced working hours, 30% said
it was because there were no suitable care services and 22% because they could not
afford to pay for the available services. This indicates that 44% of all informal unpaid
workers should be counted as part of the NHO workforce because the work that they
do should be transformed into formal jobs ((51 + 12 + 21) * (0.3 + 0.22) = 44)).

Limitations

• Most of the 21 countries in the ILO paper are in Europe and all are high-income
countries, so the applicability of their data to other countries is questionable. It
seems likely that the number of informal long-term carers is strongly negatively
correlated with the number of paid long-term carers, but very few data were
available on the number of paid long-term carers either. It is plausible that
in low- and middle-income countries with less developed health and social
care systems, a higher proportion of the population is performing long-term
care roles, in which case our estimates will be conservative rather than an
overexaggeration.

7 Estimates of the population aged over 65 years for 2015 were taken from United Nations Population Division
(http://esa.un.org/unpd/wpp/).

PART I: Health Workforce Dynamics | CHAPTER 6 167

 • The situation in the United Kingdom regarding the proportion of unpaid care
work that could be transformed into formal employment is unlikely to be typical
of all countries, but comparable data from other countries were not located in the
time available.

8. Estimate the global number of HO workers to NHO

workers and thus the global ratio of NHO workers to
HO workers

For all 185 countries, the number of HO workers (A + B) and formal NHO workers
(C + D) were summed to give a global total. The ratio of the global number of formal
NHO workers to the global number of HO workers was 1.5. In other words, for every
HO worker in the world, we estimate that there are 1.5 paid NHO workers.

Likewise, the numbers of paid + unpaid NHO workers (C + D + E) were summed

across all 185 countries to give a global total. The ratio of the global number of paid +
unpaid NHO workers to the global number of HO workers was 2.3. In other words,
for every HO in the world, we estimate that there are 2.3 NHO workers (formal +
informal).

Effectively, these global ratios give the weighted mean of the individual country
ratios (weighted by workforce size). We can also calculate the unweighted means: 1.5
excluding informal workers and 3.0 including informal workers. In other words, in
the average country, there are 1.5 paid NHO workers for every HO worker, and there
are 3 formal + informal NHO workers for every HO worker.

9. Disaggregate the global estimates by ILO region and

income group

Estimated numbers of HO workers and NHO workers were summed for all countries
in each ILO region and each income group. Within each region and each income
group, the total number of NHO workers was divided by the total number of HO
workers to yield a weighted average ratio for that region or income group.

168 Health Employment and Economic Growth: An Evidence Base

10. Estimate the number of NHO workers missing
For all low-vulnerability countries (n = 24) – countries with low poverty levels
and small informal economies (8) – the median number of HO workers per 1000
population8 was calculated. This calculation was also done for paid NHO workers
and for paid + unpaid NHO workers, and the results are shown in Table A1.4.

Table 4

Median number of workers per 1000 population in

low-vulnerability countries

HO workers Paid NHO workers Paid + unpaid NHO workers

(groups A+B) (groups C+D) (groups C+D+E)
9.2 14.5 20.6

The above numbers were applied to the 2015 population in each of the 185 countries to
estimate the number of each type of worker currently missing, and also applied to the
United Nations Population Division’s medium variant population projections for 2030
to estimate the related level of missing workers in 2030.

The gap for informal NHO workers was estimated by subtracting the gap of paid
NHO workers from the gap of paid + unpaid NHO workers.

For each country, the shortage of workers of each type was estimated by
subtracting the number currently in the workforce from the number needed. If
the result was a negative number (that is, availability was higher than need), the
shortage was set at zero.

The individual country shortages were then summed to give global and
regional totals.

8 Using United Nations Population Division population estimates for 2015.

PART I: Health Workforce Dynamics | CHAPTER 6 169

 Limitations
Changing age structures and changes in epidemiology are likely between now and
2030, which will affect the number of workers necessary per 1000 population. In
estimating the gap for workers in 2030 we have assumed that the worker–population
ratio thresholds will be the same in 2030 as in 2015.

Annex references

1. Health expenditure, total (% of GSP) [Internet]. 6. Scheil-Adlung X. Long-term care (LTC) protection
Washington (DC): World Bank; 2016 (http://data. for older persons: a review of coverage deficits in
worldbank.org/indicator/SH.XPD.TOTL.ZS, accessed 46 countries. Geneva: International Labour Office;
7 November 2016). 2015 (http://www.ilo.org/secsoc/information-
resources/publications-and-tools/Workingpapers/
2. ECD health statistics 2016 [Internet]. Paris: OECD; WCMS_407620/lang--en/index.htm, accessed
2016 (http://www.oecd.org/els/health-systems/ 7 November 2016).
health-data.htm, accessed 7 November 2016).
7. State of Caring 2015. Carers UK [Internet]. London:
3. Tanzania: HRH fact sheet [Internet]. Brazzaville Carers UK; 2014 (https://www.carersuk.org/for-
(Republic of Congo): African Health Workforce professionals/policy/policy-library/state-of-caring-2015,
Observatory; 2010 (http://www.hrh-observatory. accessed 7 November 2016).
afro.who.int/en/country-monitoring/89-tanzania.html,
accessed 7 November 2016). 8. Scheil-Adlung X. Health workforce benchmarks
for universal health coverage and sustainable
4. Technical notes: global health workforce statistics development. Bulletin of the World Health
database [Internet]. Geneva: World Health Organization. 2013;91:888–9. doi:10.2471/
Organization; n.d. (http://www.who.int/hrh/statistics/ BLT.13.126953.
TechnicalNotes.pdf, accessed 7 November 2016).

5. Health workers count, but are we counting them?

[Internet]. London: Save the Children; 2013 (http://
healthworkers.savethechildren.net/issues/health-
workers-count-but-are-we-counting-them/, accessed
7 November 2016).

170 Health Employment and Economic Growth: An Evidence Base

 PART II
Economic Value
and Investment

171
CHAPTER 7

Pathways: the health system, health

employment, and economic growth
Jeremy A. Lauer, Agnès Soucat, Edson Araújo, David Weakliam

Abstract
The principal purpose of a health system is to provide health care. However,
viewed as an economic sector, the health system contributes to growth.
Moreover, the health system offers additional benefits that contribute both to
economic growth and to health, as well as to non-health welfare. We do not
present a complete causal account of the interactions between the health system
and the economy, but focus in our discussion here on the pathways that involve
the employment of health workers and promote economic growth. The six
main pathways of interest are (a) the health pathway, addressing the intrinsic
(non-market-valued) health benefits of the health system; (b) the economic
output pathway, addressing the intrinsic (market-valued) economic benefits
of the health system; (c) the social protection pathway, addressing sickness,
disability, unemployment and old age benefits, as well as financial protection
against loss of income and catastrophic health payments; (d) the social cohesion
pathway, addressing the role of a health system in promoting equity and fostering
redistribution and growth; (e) the innovation and diversification pathway,
addressing the role of the health system in driving technological development
and in offering protection against macroeconomic shocks; and (f) the health
security pathway, addressing the role of the health system in protecting against
epidemic outbreaks and potential pandemics.

PART II: Economic Value and Investment | CHAPTER 7 173

 1. Introduction

The principal purpose of a country’s health system is to provide health care to its
population; this is its defining objective. However, when viewed as an economic
sector, the health system also contributes to economic growth. Furthermore, the
health system generates a number of additional spillover benefits at no extra cost
(that is, positive externalities) that contribute both to health and to economic
growth, as well as to broader non-health welfare. All these benefits are realized
through distinct pathways of cause and effect. The purpose of this chapter is to
enumerate and classify the main pathways that are relevant to the work of the High-
Level Commission on Health Employment and Economic Growth. The need for an
analysis of these causal pathways was identified during the work of the Expert Group
that served as one of the main advisory bodies to the Commission.

The economic concept of “efficiency” and the plain-language term “growth” are
in fact interlinked: when an economy produces more with a given quantity of
resources, in economic terms it is more efficient. In the following, we occasionally
refer to “efficiency” but more usually we employ the term “growth”, with its implicit
connotation of efficiency. In the perspective adopted here, “efficiency” refers, first of
all, to the objective of producing more benefits, in terms of income, consumption,
investment, production, and other forms of (mainly) market-valued benefits. From
the perspective of public economics, however, the concept of efficiency is often used
as an argument for public sector intervention. The main rationales for public (that
is, government) action are to correct market failures, such as negative externalities,
but also to provide public goods, such as education and health care, that would not
otherwise be produced (at least not optimally) by the market. We therefore adopt
a dual perspective: principally that of the economy as a whole, with a focus on
the operation of market forces and the outcome of economic growth, but also, as
appropriate, that of identifying rationales for correcting inefficiencies, whether in the
public1 or private sector.

1 Inefficiencies in the public sector are sometimes termed “government failure”, that is, government interventions in
the market that reduce social or economic welfare.

174 Health Employment and Economic Growth: An Evidence Base

To proceed systematically, to ensure conceptual clarity, and to avoid the double
counting of benefits, the starting point for our analysis is the health system,
rather than health employment per se. However, since the primary intention
of this chapter is to outline the main health system pathways that are relevant
to the work of the Commission because they both involve the employment
of health workers and promote economic growth, it is important to note that
recognized benefits of the health system that are not related to the themes of
health employment and economic growth are not emphasized here, although
we acknowledge that they constitute important outcomes in their own right.

2. The six pathways to economic growth

Figure 1 provides an overview of the main cause-and-effect pathways
discussed here, labelled for convenience as the following:

1. The health pathway

2. The economic output pathway

3. The social protection pathway

4. The social cohesion pathway

5. The innovation and diversification pathway

6. The health security pathway.

PART II: Economic Value and Investment | CHAPTER 7 175

 Figure 1

Pathways to economic growth

full-income growth
1. health
improved labour supply
and productivity

services
2. economic output
health good and capital assets
economic
system
growth
3. social protection reduced inequality

4. social cohesion political stability

5. innovation and technological change and

diversification risk management
commerce, trade, and the
6. health security
movement of populations

In the following, we consider each pathway in turn, identifying and discussing along
the way relevant sub-pathways and briefly elucidating how the pathways involve
health employment and contribute to economic growth. The pathways identified here
are not intended to be exhaustive, or to represent a full causal account of the relation
of the health system to the broader economy.

2.1 Health pathway

As previously noted, the starting point is the health system. The “health system”
is understood here to include all activities whose primary intention is to improve
health. Of course not all health benefits are attributable to the health system, even
broadly defined. For example, health benefits also accrue as a result of education, or
through general social and economic development, although for reasons of scope we
do not consider those aspects here.

The health pathway comprises two sub-pathways, one of which we refer to as the
“full-income” pathway. The full-income pathway is perhaps the pathway most

176 Health Employment and Economic Growth: An Evidence Base

commonly known by health policy-makers and health economists. In this pathway,
a shadow price (that is, an estimate of the per-unit value of health) is assigned to a
(usually hypothetical) quantity of health benefits so as to evaluate the contribution of
an improvement in health to full income. Full income, at least in principle, includes all
forms of market-valued as well as non-market-valued income, although we focus here
on the health dimension of this pathway.

Despite the use of monetary units for the valuation of health, it is important to note
that in this pathway health is conceived of as an intrinsic benefit (something good
for its own sake), and not as an instrumental benefit (something good for the sake
of something else, such as monetary income). In terms of economic theory, this
means that health is considered in this pathway as a direct argument in the preference
function of individuals (1). This role of health, as a direct consumption good, justifies
the central importance of this pathway in most health-related analyses: health is a
fundamental part of what people value as a good life; it plays an integral part in theories
of human well-being; and it features prominently in discussions of social welfare.

Most of the uncertainty, therefore, in accounting for health benefits in full income
involves not the importance of health per se but rather how to estimate its value.
At least in the health policy literature focused on full income (2), health benefits
are considered as a flow realized over an individual’s lifetime (that is, as a form
of income, measured in units of health per time). In the sustainable development
and economics literature, however, health benefits are usually viewed as a stock,
or endowment (that is, as a capital good, measured in units of health) (1, 3). Both
approaches, however, require an estimate of the shadow price of a unit of health.
Although individuals in principle will have different shadow prices for health (1),
both the full-income and the health capital literature rely on an average of estimates
of individual shadow prices as a proxy for the social value of a unit of health.
However the shadow price (p) of health is estimated, when it is multiplied by a
quantity (q) of health, the product (p × q) represents in these analyses an estimate of
the social value of a given improvement in health. This value is, strictly speaking, an
economic benefit, although it is not a market-valued one.

As is commonly done, for example, in burden of disease measurements, health status

can be partitioned into separable components consisting of longevity on the one

PART II: Economic Value and Investment | CHAPTER 7 177

 hand and health-related quality of life on the other (1). Though both components
are important, the longevity dimension has received greater attention because of
the availability of estimates of the value of a statistical life and the related concept
of the value of a life-year. Despite the conventional terminology suggesting that a
human life can be reduced to a dollar value, in more precise language these statistics
in fact represent an estimate of the value to an individual of a small change in
their mortality risk (2). When these estimates are averaged, individual valuations
of a small change in risk are used to provide an estimate of the social value of risk
reduction. The focus on mortality risk, however, does not imply that the direct utility
(or disutility) derived from good (or bad) health-related quality of life does not have
individual or social value; estimates of the value of small changes in health-related
quality of life are simply harder to come by, and those such as do exist are fraught
with conceptual and measurement problems.

Both the full-income and the health capital literature refer, however, to a further,
instrumental value of improved health. Here, we identify this instrumental value
of improved health with the second health-related sub-pathway, one that figures
prominently in the literature on the “health investment case” (4) 2. This pathway is
important because improved health implies that individuals can engage in increased
levels of activity (that is, in addition to enjoying increased longevity and improved
health-related quality of life, individuals can also do more of all the things they
want to do). In economic terms, this means that health also enters indirectly as an
argument in the preference function of individuals: that is, in this pathway health is
considered as an element in individuals’ production functions, one that they use to
produce other goods that they value, such as wage income, which is a market-valued
benefit. Evidently, health is also instrumental for the transformation of leisure time
into non-market-valued benefits such as visits with family, recreational activities with
friends, as well as other forms of social participation.

In any case, if the activity resulting from an improvement in health takes place in
the labour market, it constitutes a market-valued benefit and will be recorded in the
national income as an increased level of economic productivity. In general, part of
this increased economic productivity is attributable to an augmented quantity of

2 There is a growing literature on the so-called investment case for health that seeks to measure benefits realized
through increased activity, as measured in terms of gross domestic product (GDP). The reference (4) is only intended
to be indicative.

178 Health Employment and Economic Growth: An Evidence Base

labour supplied (through reduced absenteeism, disability and early retirement), but
part is also attributable to reduced presenteeism (resulting in improved quality of
labour) and increased labour productivity. Both of these benefits are market valued.

If the activity resulting from a given improvement in health takes place in a non-
market context, it still constitutes an important benefit (for example, improved
performance in family and social roles); however, such activity does not have a
market value so a shadow price would need to be estimated for it. As for the intrinsic
value of health, instrumental benefits resulting from increased activities that are not
market valued inevitably present conceptual and measurement difficulties when it
comes to estimating a shadow price.

Presumably for these reasons, at least prior to the introduction of the full-income
terminology (2), there has been a noticeable reluctance within the sphere of health
policy to “put a price on” intrinsic health benefits such as longevity. Conversely, and
for presumably similar reasons, there has been resistance outside the domain of
health policy to consider non-market-valued benefits (even such important ones as
longevity) as having the same policy relevance to decision-makers as market-valued
benefits such as increases in GDP.3 From a purely economic perspective, neither of
these positions is particularly helpful.

Since the focus of the Commission is on highlighting a set of mainly market-valued

economic benefits deriving from the health system that are realized as a result of
increased health employment, under the health pathway we emphasize the sub-
pathway that operates through the labour market, namely, through an improved
quality and quantity of labour resulting in increased economic productivity.
This benefit, properly speaking, constitutes what we have called above a positive
externality of the health system; the health system does not exist for the sake of
improving either labour supply or labour productivity, but this is nevertheless one of
its socially important spillover effects.

To reiterate: our focus on a positive externality of the health system operating

through the labour market is not intended to disregard the intrinsic value of health

3 The “Beyond GDP” movement proposes to give more emphasis to the policy relevance of non-market-valued
benefits; however, for the reasons of scope previously noted, we do not consider this in further detail here.

PART II: Economic Value and Investment | CHAPTER 7 179

 or other non-market-valued benefits deriving from improved health, but is intended
merely to place emphasis on a particular facet of the recognized benefits resulting
from the health system, one that is measured in market-denominated terms and
which has special relevance for multisectoral and whole-of-government policies
related to health in the context of sustainable development. Likewise, in the pathways
discussed below, for similar reasons we focus primarily on market-valued benefits
expressed in terms of economic growth as measured in the GDP (or in other income
statistics), leaving tacit thereby a number of important non-market-valued benefits.

2.2 Economic output pathway

A substantial justification for focusing on the market-valued benefits of the health

system is that they are widely underappreciated in both the health and non-health
policy spheres. Indeed, the health system is commonly viewed as constituting a
“cost”, with the related view that expenditure on health is a drag on the economy’s
productivity. There are some theoretical reasons to suspect that this could be the
case: since the health sector relies heavily on labour as an input, for example via the
human-to-human interactions of individuals with health workers, some economic
theorists believe that it might not be possible for the health sector to keep pace with
productivity growth in the rest of the economy, where technological change and
automation can potentially play a greater role. This thinking was formalized by the
economist William Baumol (5), whose theoretical model consisted of a “productive
sector” and an “unproductive sector”. Although in his model the “unproductive
sector” – which is said to suffer from a “cost disease” – was originally identified with
the performing arts sector, it has subsequently been identified mainly with the health
sector, and with public administration. The identification of Baumol’s cost disease
with the health sector can in part be attributed to more recent work published by
the economist Jochen Hartwig, which proposed to test empirically a particular
specification of the Baumol model and which – with that specification – found
support for the existence of a cost disease in the health sector, at least in a sample of
developed countries (6, 7).

However, this finding (which is strongly dependent on the particular specification of

Baumol’s model adopted by Hartwig) has recently been cast into doubt by research
done for the World Bank (8), which found, using the same specification employed by

180 Health Employment and Economic Growth: An Evidence Base

Hartwig, the opposite result in a broader sample of countries, including low-income
and lower middle-income countries. In addition, this same paper found – using yet
another empirical model – that countries with more developed health systems also
have higher manufacturing productivity, in other words, that a developed health
sector acts in the same way as productivity-enhancing technological change (8, 9).
Both of these findings constitute independent evidence against the idea that the
health sector is unproductive, inefficient or a drag on the economy.

Although we do not pretend to resolve these debates, they are important: if the
health sector is not an efficient investment, then its growth should be curtailed and
its costs contained (to allow other, more productive, uses of resources); however,
if the health sector is an efficient investment, then its growth promotes broader
economic growth. The reflexive view of the health system as an unproductive
sector suffering from a cost disease is now being revisited, particularly with
respect to the situation in low-income and lower middle-income countries, where
the health system is much less developed than in richer countries and where
improvements in the health system potentially have much higher impact, both in
full-income and in market-valued terms. Moreover, the weight of evidence for the
productive role of the health sector in developed economies is also changing: for
example, recent work suggests that each dollar spent in the health sector results in
an additional US$ 0.77 contribution to economic output as a result of indirect and
induced effects (10).

We might be tempted to think that the “health system” corresponds in economic

terms to what is called the “health sector”. The health system produces market-
valued economic output through the employment of staff; through non-staff
expenditures, such as the purchase of equipment, supplies and services; through
investments in manufactured capital, such as buildings and related facilities; through
the development of communications, logistics and supply networks; and through
investments in human capital, such as training and education. Although some of
these outputs are measured in conventional health sector accounts, not all of them
are. Health sector accounts, or, in short, “health accounts”, are generally based on the
measurement of expenditures, and they therefore account primarily for the value of
health-related billings, including the cost of inputs. However, certain categories of
market-valued economic output are ignored in health accounts:

PART II: Economic Value and Investment | CHAPTER 7 181

 • pharmaceuticals and medical equipment destined for export

• nutritional supplements and “healthy eating” options

• the health, fitness and “healthy lifestyle” industries

• over-the-counter medicines and home care services.

According to our definition of the health system, these latter outputs should
be included under the umbrella of the broader health system; but according to
conventional health sector expenditure accounts, they are excluded. From an
employment perspective, the situation is analogous. Health employment, narrowly
construed, might logically be limited to personnel directly involved in the delivery of
medical services (including therefore many clinical laboratory staff but excluding, for
example, those required for cleaning, laundry, maintenance and catering services in a
health facility) (11). However, broader classifications of the health workforce include
both members of non-health occupations and many informal and unpaid workers
that are required by the health workforce, in its more limited sense, to perform its
functions (12). The wages of some of these non-health workers will be captured in
health expenditure statistics as constituting part of the cost of inputs; however, due to
limitations of data, and measurement problems tied to classifications of both health
expenditure and health occupations, not all of them are.

In brief, the health sector that we know from expenditure statistics is not identical to
the health system; a better term here for the broader concept we have in mind would be
the “health economy”. While, for the reasons mentioned, there are no global statistics
corresponding to this broader definition of the health economy, we know that it is
far bigger than the health sector per se (as measured by expenditure accounts). So
determining how large the world’s health sector is in economic terms can serve as a
starting point – and an approximate lower bound – for understanding the size of the
broader health economy.

Calculated using Organisation for Economic Co-operation and Development

(OECD) estimates (13) of the share of health expenditure in GDP, along with recent
World Bank estimates of economic output (14), the aggregate size of the world’s
health sector is substantial: at over US$ 5.8 trillion (US$ 5.8 × 1012) per year, the

182 Health Employment and Economic Growth: An Evidence Base

combined health sectors of merely the 34 member countries of the OECD are
larger, in terms of economic output, than that of any country in the world with
the exceptions only of the United States and China. Moreover, the health sector
of the United States alone is larger than the entire economy of France, making the
United States health sector the sixth-largest “economy” in the world. The broader
global health economy is therefore at least the third-largest economy in the world,
and it quite possibly rivals or exceeds China’s US$ ~10.4 trillion contribution to
gross world output.

As noted, expenditure-based figures for the health sector do not include goods
and services related to the nutritional, sports and fitness industries, receipts from
over-the-counter medicines or expenditures on home care services, all of which
are important constituents of the broader health economy. Nor do expenditure
statistics include indirect and induced effects. For example, based merely on
a reclassification of existing national accounts, the expanded health economy
in Germany is estimated to contribute 11% of gross value added in terms of
production, but to contribute an additional 8% in terms of indirect and induced
effects on the value of final consumption (10). If these same estimates are applied
to the health expenditure data published by the OECD, the size of the health
economy in 34 OECD countries would be estimated at US$ ~10.3 trillion. The
global health economy, therefore, is quite possibly the second-largest economy in
the world, after that of only the United States.

A distinguishing feature of the pathway of economic output is that, other things

being equal, the health system would make the same contribution to economic
output even if no health benefit whatsoever were obtained. So the economic
output pathway can be identified with a “pure” market-valued benefit that is
separable (at least conceptually) from the intrinsic, non-market-valued, health
benefit of the health system.

In full-income terms, however, the intrinsic non-market-valued health benefit of

the health system is estimated to have a much greater value than the instrumental
benefits, mediated through the labour market, of better health on the economy
(2, 3). Similarly, at least when relying on expenditure-based calculations of the

PART II: Economic Value and Investment | CHAPTER 7 183

 value of the health sector in gross world output, the direct economic benefits
of the health system are also much larger, in terms of economic value, than the
instrumental impact of better health on the economy of the labour market.
Therefore, these two benefits – the intrinsic health benefit of the health system in
terms of health and its direct impact on economic output – are plausibly two of the
largest benefits of the health system that causally depend on health employment.

Moreover, the health sector is a growing part of the economy worldwide (13, 15).4
Growth in the health sector is believed to be driven in part by rising incomes that
create increased demand for health-related services and products, as well as by the
demand for new technologies that create new opportunities to improve health;
population ageing, and the associated increase in age-related health problems,
is another recognized source of increased demand for health-related goods and
services. As a result of these factors, the health sector has generally been growing
faster than overall growth in GDP in most economies, and has certainly done so in
high-income countries (16).

Finally, it is worth noting that, like the health pathway, the economic output
pathway comprises two sub-pathways: the services pathway, and the goods and
capital assets pathway. Given the labour-intensive nature of health care, the services
pathway usually receives more attention. The contribution of services to output
can be measured either through the wages of health workers (through income
accounting) or through the value of their billings to consumers of health services
(through expenditure accounting). However, the health economy also produces
a range of manufactured goods, such as pharmaceuticals and medical devices
and equipment, which form part of the second sub-pathway identified under
economic output. Manufactured goods contribute to the output of the broader
health economy, whether they are included in the cost of health services, are billed
separately, or are simply produced for export. Moreover, with the multiplication of
medical technologies such as new drugs and therapies, manufactured goods make
up an increasing share of expenditure in the health sector (16). Finally, the cost of

4. The importance of the health sector in the economy is the subject of a substantial literature, and institutional
investment in systems of health accounts (e.g. http://www.oecd.org/els/health-systems/health-expenditure.htm,
http://www.who.int/health-accounts/methodology/en/) designed to measure and track its growth have
been significant (13, 15).

184 Health Employment and Economic Growth: An Evidence Base

the facilities, infrastructure and human capital (that is, the capital assets) purchased
or rented by the health sector also contributes to economic growth through the
economic output pathway, whether included in conventional health accounts or not.

In summary, the economic output of the health sector is large but that of the
health economy is even larger. Debates about the efficiency of health expenditure
are evolving with an awareness of the magnitude of the contribution of the health
system to, and the ramifications of health employment in particular for, the broader
economy. Assumptions about the health system as a source of costs, rather than of
benefits, are being revised, and the traditional focus on the intrinsic value of health
improvements to broader social welfare (“full income”) is being supplemented
by new arguments and evidence about the economic contribution of health, and
of health employment, to economic growth as measured in conventional income
statistics such as GDP.

2.3 Social protection pathway

The health system offers social protection benefits that are external to its defining
purpose of improving health, which do not directly contribute to market-valued
economic output, and which are spillover effects of health employment in particular.
At base, health employment means jobs, and decent jobs (17) offer a range of social
protection benefits: for example, “child and family benefits, sickness and health-care
benefits, maternity benefits, disability benefits, old-age benefits, survivors’ benefits,
unemployment benefits and employment guarantees, and employment injury
benefits as well as any other social benefits in cash or in kind” (18). Social protection
benefits more generally are intended to “provide income or consumption transfers to
the poor, protect the vulnerable against livelihood risks and enhance the social status
and rights of the marginalised; with the overall objective of reducing the economic
and social vulnerability of poor, vulnerable and marginalised groups” (19). As a
result of reducing impoverishment and economic vulnerability, social protection
benefits offer opportunities for enhanced economic activity and growth.

One important social protection benefit the health system can provide is
direct insurance against the financial risk of catastrophic health expenditures.
Catastrophic and impoverishing spending on health is the most unambiguous

PART II: Economic Value and Investment | CHAPTER 7 185

 indicator of inadequate financial risk protection against the costs of health
services (20). Moreover, concerns about the financial risk of health expenditures
were explicitly cited in the development of major health insurance legislation,
such as the Medicare programme (21) and the Affordable Care Act in the
United States, and are also understood as being one of the main motivations
for the creation of the National Health Service in the United Kingdom in 1948.
Specifically, the public financing of health services ensures that individuals (not
just those who are employed or who can purchase private insurance) do not have
to bear the entire costs of their health care out of pocket.

Out-of-pocket health expenditures have been estimated to drive 150 million

people into poverty worldwide every year (22). Additionally, individuals
underpurchase necessary health services when they involve high out-of-pocket
costs (23), entailing the risk of significant negative externalities, such as the
spread of transmissible disease. Out-of-pocket health expenditures also reduce
opportunities for other forms of consumption, including the purchase of food
and basic amenities (24). The association of the public financing of health
services and enhanced financial risk protection explains why some researchers
(25) have identified minimum thresholds for the desirable proportion of public
financing of, and maximum ceilings for, the allowable share of out-of-pocket
expenditures on health services. In the case of certain health services, the
benefits of financial risk protection have been found to outweigh the direct
health benefits (26), highlighting the important social protection function of
publicly financed health services.

There is a strong case to be made for public sector action in health that is
redistributive (thereby reducing various forms of inequality). For example,
income equality per se is increasingly recognized as an important drag on
economic growth. In the words of a recent International Monetary Fund
(IMF) report, “inequality … tends to reduce the pace and durability of growth”
(27). This emerging consensus, based on decades of research performed in
multiple countries, effectively refutes the view popularized in the 1975 book
by Arthur Okun, Equality and efficiency: the big tradeoff (28), to the effect that
policy-makers face a stark choice between enhancing growth or promoting
equality. Recent evidence, amounting to a conclusive rejection of “trickle down”

186 Health Employment and Economic Growth: An Evidence Base

economics, has shown this to be a false dichotomy (27, 29–31). Not only is there
no trade-off between efficiency and equity, but equity is in fact one of the main
preconditions of efficiency and growth.

The financial risk of health expenditure, by causing impoverishment, diverting

resources from other expenditure, or resulting in the underuse of essential health
services, constitutes a powerful force to create persistent, intergenerational
inequalities. In addition to the forms of social protection offered by formal
employment in the health sector, the financial risk protection offered by a
health system with the public financing of a package of essential health services
constitutes an important spillover benefit that directly promotes both economic
growth and its sustainability (29, 30).

2.4 Social cohesion pathway

Exceptionally, it seems, the second half of the 20th century showed a sustained
trend towards more equal shares of incomes across social groups (that is,
between labour and capital) in many countries (32). In recent years, however,
the trend has reversed towards one of greater concentration of wealth in the
hands of a few. In this light, and also in view of persistent slow growth as a
consequence of problems such as secular stagnation (due to a high savings
rate coupled with low investment) (33), the role of fiscal policy in promoting
equality, and thereby economic growth, has become more prominent (34). In
addition to the reasons noted in the preceding section, more equal societies are
more economically productive in part simply because they have a higher level of
political and social stability.

It is practically a truism that political stability is an important precondition

for economic growth. What is less obvious is that the uprisings of the “Arab
Spring” in 2011 were to a degree motivated by the desire for decent jobs and
economic opportunities on the part of sections of the population that had yet
to see concrete benefits emerging from post-colonial independence (35–37).
In other words, the causality also works in the converse direction: persistent
socioeconomic inequalities sparked massive levels of political instability that
in turn caused catastrophic hardships, economic and otherwise, for substantial

PART II: Economic Value and Investment | CHAPTER 7 187

 populations, as well as causing significant negative knock-on effects for
neighbouring and regional governments and societies. Health employment in
particular offers the possibility of jobs to members of social groups that have
traditionally been unemployed or underemployed, such as women and youths,
as well as to populations in remote, rural or underserved communities (38–40).

In other words, fiscal policies to promote health employment are not only good
for population health, for the economy, and for the social protection of vulnerable
individuals, but they also offer an important guarantor of basic social cohesion.

2.5 Innovation and diversification pathway

The economic benefits of innovation and diversification constitute positive

externalities that extend beyond their direct contribution to national income
and to human health.

Novel genetic and biological medicines are important areas of innovation, and
such technologies are capable of providing substantial health benefits (16).
Often, but not exclusively, it is the private sector that responds to the demands
for better health through innovation in equipment, devices and drugs. Health
sector development as such can also be an important factor for economic
diversification.

A number of countries, notably in the Eastern Mediterranean region and in

Latin America and the Caribbean, have promoted economic diversification of
their economies by encouraging the development of their health care systems.
One of the benefits of promoting a strong health sector in economies dependent
on extractive industries or tourism is that health sector employment tends to
be countercyclical. This means that health employment often continues to grow
even when other sectors are shrinking, or that it shrinks less in response to
economic shocks than other sectors (41–43).

188 Health Employment and Economic Growth: An Evidence Base

2.6 Health security pathway
The health system provides an important health security function that is external to
its defining objective of improving health. Epidemic surveillance and response, in
particular, depend on well functioning health systems.

As an example, the Ebola epidemic is estimated by the World Bank to have reduced
output in the three hardest hit countries by US$ 3–4 billion (out of a prior total
output of approximately US$ 50 billion) (44, 45) as a result of the disruptions in
trade, commerce and movement of populations, causing the IMF to reduce its
growth projections for all of sub-Saharan Africa by 10% (from 5.5% to 5%) (46, 47).
Tourism and travel bookings in African countries far removed from the epidemic
were also affected. Food production fell, and the United Nations Population
Fund (UNFPA) estimated that food security was adversely affected for upwards
of 1 million people (48). Human capital and other assets were in some cases
directly affected (for example through the death of health workers), but essential
refurbishments to or investments in manufactured capital were also postponed or
cancelled as a result of the generalized social disruptions caused by the epidemic.

A recent report from the National Academy of Medicine of the United States
commented that “framed as a health problem, building better defenses against the
threat of potential pandemics often gets crowded out by more visible and immediate
priorities…. Yet framed as an issue of human security, the current level of investment
in countering this threat … looks even more inadequate”. The report notes that
“the annualized expected loss from potential pandemics is more than $60 billion”,
whereas the costs of preparedness amount only to around US$ 4.5 billion per year
(49). Human resources, including the associated training and salary costs, are an
integral part of resilient health systems capable of responding to emerging pandemic
threats (50, 51).

PART II: Economic Value and Investment | CHAPTER 7 189

 3. Virtuous cycles

So far we have identified six main pathways leading from the health system to
economic growth. Most, though not all, of these pathways explicitly involve health
employment. All of them result in economic growth. The economic growth caused
by health employment in turn has a number of knock-on (or feedback) effects
whose net result is to promote further economic growth (and increased health
employment). We refer to these effects as “virtuous cycles”. In this section we identify
briefly a number of virtuous cycles.

All these virtuous cycles operate through what we term the income pathway (Figure
2). We have in mind primarily household income, but analogous arguments apply
to other forms of income. For clarity, we focus on household income. Increased
household income has three main effects:

1. increased savings

2. increased tax revenues for government

3. increased consumption.

We identify each in turn with its main outcomes.

Figure 2

Knock-on effects: some virtuous cycles

capital
savings investment
formation

economic tax fiscal public economic

income
growth revenues space capital growth

goods and
consumption demand
services

190 Health Employment and Economic Growth: An Evidence Base

3.1 Virtuous savings cycle
Increased health employment leads to more jobs, which implies higher levels of
household income and therefore also household savings. Increased savings means
more financial space for investment, which in turn increases stocks of productive
capital and enhances economic growth.

3.2 Virtuous tax cycle

Increased health employment results in more jobs and higher wages, which in
turn increases government tax revenues, increasing the fiscal space for necessary
government action in the public sector (for example to correct market failures and
provide public goods).

3.3 Virtuous consumption cycle

Increased health employment results in more jobs and higher household incomes.
Higher incomes means improved opportunities for consumption, which increases
aggregate demand for goods and services and enhances economic growth.

PART II: Economic Value and Investment | CHAPTER 7 191

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194 Health Employment and Economic Growth: An Evidence Base

CHAPTER 8

Health and inclusive growth:

Changing the dialogue
Chris James

Abstract
This chapter demonstrates how the health care sector and better health outcomes
contribute to inclusive economic growth and how this contribution can be
further enhanced. The chapter is largely, though not exclusively, based on
experiences from Organisation for Economic Co-operation and Development
(OECD) countries.

Health systems are central to the effective functioning of a country’s economy.

Adults in good health are more productive; children in good health do better
at school. This strengthens economic performance and makes growth more
sustainable and inclusive. The health care sector is also an important source of
employment. On average, health and social work activities constituted around
11% of total employment for OECD countries in 2014. Moreover, the percentage
of workers employed in health and social work has steadily risen across much
of the OECD over time. This is likely to continue. Health care should therefore
not be viewed solely as a cost driver, but as an investment that can offer
valuable returns to society. This does not mean that more spending on health is
automatically worthwhile. Rather, it requires critically assessing the investment
case for different types of health spending, so that employment in the health
sector achieves better health outcomes and increases the overall productivity of
the sector.

PART II: Economic Value and Investment | CHAPTER 8 195

 1. Introduction

Health systems around the world not only treat the sick and prevent future illness, they
are also central to the effective functioning of a country’s economy. People in good
health are likely to be more productive than those who are sick or in poor health. In
turn, a healthier, more productive population can help strengthen its country’s economic
performance, and ensure that its economic growth is more sustainable and inclusive.
The health care sector is also an important source of employment, particularly for young
adults and women, and is likely to provide more jobs in the future.

Health professionals play a fundamental role in delivering the health services that
help achieve improvements in health outcomes and population well-being. High-
quality health services that are available for the entire population help reduce health
inequalities. While there is a growing demand for quality health services across
the globe, many countries – particularly low- and middle-income countries – face
significant labour shortages in the health sector.

The health sector is often viewed in narrow financial terms – as an expenditure

that needs to be controlled – rather than from a broader economic perspective that
recognizes the societal value of investing in health. The narrow financial view reflects
in part the fact that, in most high-income and emerging economies, health systems
are predominantly publicly funded, and in low-income countries they often have
substantive donor funding. Both public and donor funding carry the expectation of
a closer scrutiny of expenditure than is the case when funding comes from private
sources. The narrower focus on expenditure also reflects that the principal outputs of
the health sector – better health outcomes – are non-monetary, making the economic
returns harder to quantify.

Nevertheless, increased health spending and a growing health workforce should not
be seen as ends in themselves. This is because not all health spending provides added
value in terms of better-quality and more accessible care. More employment in the
health sector should be focused on achieving better health outcomes and increasing
the overall productivity of the health care sector.

This chapter demonstrates how the health care sector and better health outcomes
contribute to the economy and encourage inclusive growth, and suggests how

196 Health Employment and Economic Growth: An Evidence Base

this contribution can be further enhanced. The chapter is primarily based on
experiences from Organisation for Economic Co-operation and Development
(OECD) countries, although examples from low- and middle-income countries
are also included. It provides evidence on the importance of health to economic
growth and development; discusses the contribution of the health care sector to
employment and economic activity in OECD countries; and concludes with some
overall policy options.

2. Importance of good health to economic growth

and development
Health outcomes are closely linked with economic growth and development. Good
health allows individuals to contribute to society to their maximum potential, thus
making health throughout people’s lives critical to human capital accumulation and
labour productivity.

2.1 Health and schooling

2.1.1 Effect of ill health in early life on cognitive development

Infant malnutrition and childhood diseases have lasting impacts on cognitive

development and can also lead to stunting, anaemia, and iron, iodine and zinc
deficiencies (1). Malnourished children tend to score lower on tests of cognitive
function and have poorer motor skills and psychomotor development than children
who are well nourished. They also interact less frequently with their environments
and are unsuccessful in acquiring skills at normal rates (2).

Three meta-analyses found that iodine deficiency in children is associated with a

lowering of intelligence quotient (IQ) by 8 to 13.5 IQ points (3). Interventions that
provide iodine to pregnant women may prevent this effect but provision of iodine
to school-aged children does not seem to reverse cognitive damage (4). Further,
anaemia may affect a child’s success in school independently of earlier impaired
brain development. More than 40% of children from developing countries who are
aged under 4 years are affected by anaemia; addressing this problem is critical to
improving schooling outcomes (5).

PART II: Economic Value and Investment | CHAPTER 8 197

 2.1.2 Effect of ill health in children and adolescents on educational
outcomes
Children and adolescents with poor health are more often absent from school
and more likely to drop out of school. In developing countries, various infectious
diseases, such as malaria and worm infections, have particularly adverse effects on
children. For instance, in Kenya, randomized evaluations of intermittent preventive
treatment of malaria (6) and deworming drugs (7, 8) found improved cognitive
ability and reduced absenteeism among schoolchildren.

In high-income countries, sleep disorders and mental health problems are common
health conditions that impact future developmental outcomes for children and
adolescents (9). For example, shortened sleep duration, especially among young
infants, is associated with hyperactivity-impulsivity and poor test results in
cognitive performance (10). Studies focusing on mental health problems show that
anxiety and depression are significantly and negatively associated with short- and
long-term educational outcomes (11, 12).

2.2 Health and work

2.2.1 People in ill health: adverse impacts on employment, productivity

and earnings

Adults in ill health are more likely to be unemployed than healthier people. When
unhealthy people have jobs, they are more likely to be absent from work and less
productive at work than healthier people. Older adults with chronic diseases and
other health conditions are at risk of quitting the workforce prematurely.

Being in ill health adversely affects one’s employment prospects. For example,
unemployed people in Great Britain are almost twice as likely as employed people
to have a long-standing illness or disability (13). Moreover, being unemployed
is likely to worsen an individual’s health status, largely because unemployment
worsens mental health (14). The psychosocial literature suggests this results
from reduced social contact, a less defined social identity and loss of an ordered
structure to daily living (15). Such insights are supported by data. For example, in
Australia, Canada and the United Kingdom, evidence from time series data shows

198 Health Employment and Economic Growth: An Evidence Base

that changing from employment to unemployment significantly increases mental
distress (16).

The number of employed individuals who experience absence from work due to
illness can be substantial. Across 15 OECD countries, an average of 11 days per
employed person were lost from work in 2013. Absentee rates were particularly high
in Germany (18 days per person) and Norway (16 days per person), equivalent to
approximately 7.2 million working days lost in Germany and 0.42 million working
days lost in Norway in 2013.1 In addition, many workers are less productive on the
job than they could be because of poor health – a phenomenon that is commonly
referred to as presenteeism. Presenteeism at work was estimated to have cost the
United States of America’s economy US$ 150 billion a year in the early 2000s (17).

Individuals with poor health status have lower wages than healthier workers at
all ages, with the wage gap widening as age increases. For example, in 24 OECD
countries there was a noticeable wages rise less steeply with age for workers with
health problems as compared with their healthy peers, leading to a growing gap in
hourly earnings over the life course (Figure 1) (18).

Figure 1

Normalized hourly earning by age and health status in

24 European OECD countries

“Good” or very “good” health “Fair”, “Bad” or “Very bad” health

Men Women
140 120
120
100 100

80
80
60
40 60
20
0 40
20 25 30 35 40 45 50 55 60 65 20 25 30 35 40 45 50 55 60 65
Age Age

Source: Boulhol and Scarpetta (18).

1. OECD health statistics: http://www.oecd.org/els/health-systems/health-data.htm.

PART II: Economic Value and Investment | CHAPTER 8 199

 2.2.2 Mental ill health, chronic diseases and poor lifestyles: key drivers of
labour productivity losses
Mental ill health is an important cause of absenteeism and presenteeism in OECD
countries. This is because people experience the effects of mental illness during their
working lives, as opposed to the burden of most other noncommunicable diseases,
which commonly affect older individuals who are no longer working. There is also
the indirect effect of increased presenteeism, absenteeism and unemployment on the
carers of individuals with mental disorders (19).

Data suggest that in over 21 European OECD countries the sickness absence
incidence is roughly double for workers with severe mental health problems and 50%
higher for those with moderate problems, compared to those with no mental health
problems. Sickness absence duration is also longer for those with mental health
problems. Many people with mental health problems who do not take sick leave
accomplish less than they would like at work due to their health problems (Figure 2).

Figure 2

Incidence of absenteeism and presenteeism (%) and average absence

duration (days) by mental health status, average over
21 European OECD countries in 2010
Panel A. Sickness Panel B. Average duration Panel C. Presenteeism incidence
absence incidence of sickness absence Percentage of workers not absent
Percentage of persons who have Average number of days absent in the past four weeks but who
been absent from work in the past from work in the past four weeks accomplished less than they would
four weeks (apart from holidays) (of those who have been absent) like as a result of an emotional or
physical health problem
45 8 90
40 80 88
42 7 7.3
35 6 70
5.2 69
30 60
5
25 28 5.6 50
4 4.8
21
20 40 35
19 3
15 30
10 2 20 26
5 1 10
0 0 0
Severe Moderate No mental Severe Moderate No mental Severe Moderate No mental
disorder disorder disorder disorder disorder disorder disorder disorder disorder

Source: OECD (19). OECD compilation based on Eurobarometer 2010.

200 Health Employment and Economic Growth: An Evidence Base

The poor labour productivity outcomes for people with mental health problems are
a matter of concern, as mental illness is highly prevalent: at any moment in time, one
in five people in OECD countries suffers from a mental disorder that is often chronic
or recurring. This has a massive impact on labour productivity on an aggregate level.
Moreover, the incidence of presenteeism has been shown to have increased in the
recent past, which could be a contributing factor to productivity slowdown (19).

Chronic diseases and poor lifestyles can also lower productivity and harm
employment prospects and wages. For example, in France the cost of overall
productivity losses related to alcohol use and smoking has been estimated at 9
billion and 8.6 billion euros respectively (20). In Germany, sickness absence and
forced early retirement due to smoking cost an estimated €4.9 billion and €3.5
billion respectively (21). In the United Kingdom, nearly 11 million working days
were lost by alcohol-dependent workers in 2001, and the total cost of absenteeism
due to alcohol was estimated to be £1.2 billion (13). In the European Union,
alcohol accounted for an estimated €59 billion worth of lost production through
absenteeism, unemployment and lost working years through premature death in
2003 (22).

Obesity and diabetes also affect labour market outcomes. For instance, diabetes was
significantly associated with a 30% increase in the rate of workforce exit across
16 countries studied (23). The total cost for sick leave and disability pension related
to obesity in Swedish women was estimated at 10.5 billion Swedish kronor
(US$ 1.2 billion) per year (24).

In developing countries, infectious diseases have had a major impact on labour

markets, in addition to the impacts of mental ill health, chronic diseases and poor
lifestyles, with that of the HIV/AIDS epidemic being substantial (Box 1).

PART II: Economic Value and Investment | CHAPTER 8 201

 Box 1

Labour force impact of HIV/AIDS in low- and middle-income

countries

The HIV/AIDS epidemic has a large impact on labour markets in many low-
and middle-income countries, particularly in sub-Saharan Africa.
HIV/AIDS limits African countries’ productive capacity by damaging human
capital development and decreasing the possibility for people to find jobs.
Studies from South Africa found that being HIV positive increases the
likelihood of unemployment by 6–7%, with the poor and less educated more
likely to be HIV positive (25).

2.2.3 Effective health policies: labour productivity and cost benefits

Preventing and tackling chronic diseases and mental ill health more effectively
have pay-offs in labour force participation and labour productivity. For example,
prevention policies to tackle harmful use of alcohol help to reduce the occurrence
of alcohol-related diseases in the working-age population. In Germany, policies
ranging from the implementation of targeted brief interventions aimed at changing
behaviour of drinkers to tax increases on alcoholic beverages are projected to prevent
thousands of people in the working-age population from incurring alcohol-related
diseases, based on OECD modelling (26).

In Europe, potential productivity gains generated with obesity prevention strategies

are estimated to be between US$ 224 million and US$ 2760 million (purchasing
power parity) (27). In most cases, the value of potential productivity gains in
addition to the reductions in health expenditures were estimated to be large enough
to make policy interventions cost-effective.

The biggest challenge for health systems in addressing mental health problems is the
very large treatment gap resulting from considerable unawareness of such problems
and the social and self-imposed stigma experienced by people living with mental
health conditions. Many of those people receive no or only insufficient treatment, and

202 Health Employment and Economic Growth: An Evidence Base

treatment compliance is often low. This situation calls for efforts to scale up evidence-
based treatments and to invest in psychological therapies and e-mental health to help
address the treatment gap for mild-to-moderate mental disorders. The primary care
sector can play an important role in delivering better mental health care. Training
for primary care practitioners, promoting collaboration between primary care and
specialist services, implementing appropriate clinical guidelines and using financial
incentives to promote care provision are all key policies to be explored.

2.3 Economic benefits of good health beyond the individual

Good health has benefits that extend beyond the individual, particularly in
developing country contexts. Better population health can encourage greater
domestic savings and foreign investment, and improve social stability. In countries
with high fertility rates, a reduced likelihood of premature maternal mortality
(deriving from fewer pregnancies) can positively influence household decisions
on family planning. This contributes to a faster demographic transition and its
associated economic benefits.

In all countries, poor health affects the ability and motivation to save money.
However, the impact is larger in low- and middle-income countries that are
still transitioning to universal health coverage. In such countries, incomplete
prepayment systems mean households will often have to pay out of pocket
for needed health services. This can lead to severe financial hardship and
impoverishment (28).

Better population health can also raise per capita income by changing individuals’
decisions about expenditure, saving and investment. With increased longevity
and the associated greater prospect of retirement, new generations have more
incentive to save. At the same time, companies tend to invest in economies where
the workforce is healthy and move away from environments with high burdens of
disease (2).

The prospect of better health outcomes will also impact family planning and
consequently fertility rates. This can create a “demographic dividend” in terms of a
lower dependency ratio. That is, as fertility begins to slow, the number of children

PART II: Economic Value and Investment | CHAPTER 8 203

 shrinks and the proportion of workers increases. This creates a favourable situation of
more workers supporting fewer dependents, which is positive for economic growth.
Many Asian and Latin American countries have already achieved this shift, and there
are indications that some African countries (for example, Ethiopia and Rwanda) are
beginning to follow. However, a demographic dividend does not automatically follow
from lower fertility rates; investment is also required, in areas such as girls’ education
and good governance (29).

In summary, better individual and population health can have substantial impacts on
economic growth and development. For instance, Bloom, Canning and Sevilla found
that one extra year of life expectancy raised steady-state GDP per capita by about 4%,
based on a cross-country econometric analysis using data from 1960 to 1990 (30).

3. Health care sector employment and economic

activity

3.1 Health and social care: a large and rapidly growing source of
employment

People employed in health care and social work represent a large and growing share
of the labour force in many OECD countries. On average, health care and social work
activities constituted around 11% of total employment for OECD countries in 2014
(Figure 3). The employment share is particularly pronounced in Denmark, Finland,
the Netherlands, Norway and Sweden, where people with jobs in health and social
work represent 15–20% of the workforce.

The percentage of workers employed in health and social work has steadily risen
in 31 of 34 OECD countries over time. For the OECD overall, there was an average
increase of 1.8 percentage points from 2000 to 2014. Some of the greatest increases
have taken place in Ireland (5.3 percentage points), Chile (4.9 percentage points),
Republic of Korea (4.0 percentage points), Luxembourg (3.8 percentage points),
Japan (3.7 percentage points) and Portugal (3.5 percentage points). Three countries
have experienced a decrease in share of employment in health and social work:
Iceland (-1.7 percentage points), Sweden (-0.8 percentage points) and Poland
(-0.6 percentage points).

204 Health Employment and Economic Growth: An Evidence Base

Figure 3

Employment in health and social work as a share of total employment, OECD

countries, 2000 and 2014 (or latest year available)

20 20
19 2014 2000
18
16 15
16 16
14 14
14 13
13 13 13
13 13 12
12 12 11
11 11 11
10 10 10
9 8 8
8 7 7
7 7 6 6 6
6 6
5
4 4
3
2

0
Norway
Denmark
Finland
Netherlands
Sweden
Belgium
France
United Kingdom
USA
Ireland
Switzerland
Canada
Germany
Australia
Japan
Iceland
New Zealand
Israel
OECD average
Luxembourg
Austria
Portugal
Spain
Italy
Slovak Republic
Czech Republic
Republic of Korea
Hungary
Slovenia
Estonia
Greece
Poland
Chile
Turkey
Mexico
Note: 2014 data follow ISIC Rev.4, except for Australia, Canada, Chile and Ireland (ISIC Rev.3); 2000 data follow ISIC
Rev.3, except for Republic of Korea (ISIC rev.4). Annual Labour Force Statistics data are given for all countries except
France, Switzerland and the United States (System of National Accounts data). Data for Sweden and Republic of Korea
start respectively in 2003 and 2004 (rather than 2000) due to a break in the series. 2012 data are given for Australia
instead of 2014. Information on data for Israel: http://oe.cd/israel-disclaimer.

Sources: OECD.Stat, Annual Labour Force Statistics (ALFS), employment by activities and status; and National
Accounts, detailed tables and simplified accounts, Table 7A: Labour input by activity, ISIC Rev.4.

The rapid growth of employment in health and social care contrasts markedly with
the situation in other sectors (Figure 4). Across the OECD, employment in health
and social work grew on average by 48% (with a median value of 37%) during the
period 2000–2014. Over the same period, there was a decline in the number of jobs
in agriculture and industry in most OECD countries. Employment growth in health
and social work was also noticeably higher than employment growth in the service
sector and in total employment.

Looking forward, employment opportunities in health and social work are likely
to increase as a result of several factors. Ageing populations will change the pattern
of demand for health and social services. This could include greater demand for

PART II: Economic Value and Investment | CHAPTER 8 205

 Figure 4

Employment growth by sector, 2000–2014 (or latest year),

OECD average

50% 48
OECD mean OECD median
Change in employment since 2000

40% 37

30% 27
23
20% 14
12
10%

0%
-5
-10% -8

-20%
-23
-26
-30%
Total Agriculture Industry Services Health & social
work

Note: Average of 30 OECD countries for which data are available in both time periods (excludes Chile, France,
Japan and the United States). Health and social work is classified as a subcomponent of the service sector.
Source: OECD employment database, http://www.oecd.org/els/emp/onlineoecdemploymentdatabase.htm.

long-term care services, which are particularly labour intensive (31). Over time,
rising incomes and new technologies will increase consumers’ expectations related to
the quality and scope of care (32), with consequent impacts on staffing requirements
in the health sector.

It is not only the number of jobs provided by the health care sector that matters for
the economy, but also the range and scope of opportunities that these jobs offer.
The health care sector offers employment across all localities in a country, rather
than primarily in capital cities or commercial centres. Indeed, the health sector
can be an important employer in rural and remote locations, where other jobs
are scarcer. In addition, the health care sector offers employment for people with
a wide variety of skill sets, including low-skilled workers such as care assistants
(where much of the training is on the job), as well as those educated in specialized

206 Health Employment and Economic Growth: An Evidence Base

health-related disciplines. The health sector also provides jobs with non-sector-
specific requirements, from information technology and finance positions to drivers
and porters (33).

3.2 Productivity gains through innovative workforce policies

Despite ongoing technological advances, health and social care remain labour
intensive. This characteristic implies that productivity growth may lag. That is,
output gains in health and social care are constrained because labour cannot easily
be replaced by capital inputs (a phenomenon commonly referred to as Baumol’s
cost disease). While the nature of outputs in health care makes productivity hard to
measure, some studies have suggested that wage increases over time have been in
excess of productivity growth (34, 35). Although evidence on Baumol’s cost disease
model remains inconclusive, studies nevertheless point to the need to carefully
evaluate whether increased health spending is contributing sufficiently to better
health outcomes. Studies also suggest the importance of innovative health
workforce policies.

3.2.1 Expanding the scope of practice for non-physicians to boost

productivity

To boost the productivity of health care, some countries are re-examining the
traditional functions of health professionals. For example, between 2007 and
2012 about half of OECD member countries expanded the scope of practice for
non-physician providers, such as nurse practitioners and pharmacists. In Canada,
the Netherlands and the United States, student intakes in advanced education
programmes for nurse practitioners are increasing the supply of these mid-level
providers (36). Policies supporting the use of mid-level providers can be part of
broader efforts to enhance primary health care in countries. The introduction or
expansion of such non-physician roles is often met with initial opposition from
medical professionals, which needs to be overcome; integration of mid-level
providers into health care delivery may depend in part on the future supply of
physicians. It also requires an enabling funding environment, as well as legislative
and regulatory support.

PART II: Economic Value and Investment | CHAPTER 8 207

 Changes to the staff mix within health systems can maintain or increase access to
services in a cost-efficient way, thereby increasing health workforce productivity.
Indeed, evaluations show that advanced practice nurses with proper training can
improve access to primary care services and manage and deliver the same quality
of care as general practitioners (GPs) for many types of patients, particularly those
with chronic conditions requiring routine follow-up (37). Effective use of advanced
practice nurses can also allow doctors to focus on patients requiring more complex
medical diagnoses or treatments. For example, projections for the Netherlands
estimate that a reallocation of tasks from GPs to nurse practitioners will reduce the
demand for GPs by 0.6–1.2% per year (38). Similarly, in Switzerland, promoting
greater task substitution between GPs and nurse practitioners is forecast to reduce
the growth rate of GP consultations over time, from 13% in a scenario with no
substitution to 2% with task substitution (39).

3.2.2 New care models for improved productivity

Digital technology has made the collection, processing and transfer of information
efficient and powerful, transforming a range of industries in the public and private
sector to improve services. Application of digital technology in the knowledge- and
information-intense endeavour of health care holds great potential. For example,
an integrated and interoperable electronic health record allows real-time access
to the same clinical information by a team of practitioners involved in a patient’s
management. Web-enabled portable devices can improve patient self-management
and facilitate more accurate diagnosis and monitoring, triggering timely
intervention as clinically appropriate. Reliable high-speed Internet and modern
telecommunications hardware (for example, the smartphone) have made remote
consultations more feasible. Powerful computer processing, analytical techniques and
machine-learning algorithms can analyse masses of big data to generate information,
enabling better diagnoses while improving the timeliness and accuracy of clinical
decision-making (40).

Applied sensibly and with due regard for privacy and security of personal
information, digital technology can reduce duplication and errors, improve

208 Health Employment and Economic Growth: An Evidence Base

coordination between different parts of the health system and better align services
with patient needs (41). This can free up time for providers (and patients), thereby
boosting productivity.

3.2.3 Innovative provider payments to incentivize more efficient

service provision

Provider payment reform (at both the individual and health facility level) can be an
important policy lever to drive health system performance. All modes of payment
contain financial incentives that affect provider behaviour, and some modes of
payment can stimulate the efficient use of inputs. Within OECD countries, payment
reforms are being introduced to improve coordination, quality and efficiency of the
health care system. Reforms include population-based payments that bundle a wide
range of services involving several providers, as well as pay-for-performance add-on
payments affecting individual providers. For example, England recently introduced a
bundled payment for cataract surgery based on best-practice tariffs that incentivize
a shift from performing the surgery in inpatient settings to using outpatient or
day surgery facilities. Similarly, the Netherlands introduced bundled payments
for diabetes care. Such reforms reward care coordination and better integration of
different health services, and consequently have the potential to generate quality or
efficiency gains (42). Financial incentives can also be used to redress geographical
imbalances in availability of health workers. For example, basic income guarantees
are used in Denmark and France, and in the Canadian province of British Columbia
physicians working in isolated areas receive annual bonuses (36).

4. Conclusions: reassessing the contribution

of health care
Effective health systems can make a substantive contribution to economic
performance, enabling sustainable and inclusive economic growth. Good health
allows countries’ populations to realize their full potential, which directly affects the
labour market. Adults in ill health are more likely to be unemployed than healthier
adults, and when they have jobs they are more likely to be absent from work and

PART II: Economic Value and Investment | CHAPTER 8 209

 less productive at work than their healthier counterparts. Good health begins in
early life with adequate infant and child nutrition, which is essential to cognitive
development and subsequent educational outcomes. The health care sector is central
to maintaining and improving health outcomes; it also provides a steadily increasing
source of employment in most OECD countries, offering jobs that are highly valued
by citizens.

Therefore, health care should not be viewed solely as a cost driver; it is also an
investment that offers valuable returns to society. Reassessing health care in terms
of its broader economic impacts is a more useful perspective than focusing only on
its cost. However, more spending on health is not automatically worthwhile. Critical
assessment of the investment case for different types of health spending is required,
so that spending can be clearly focused on services that provide the best value in
terms of improved health outcomes.

The opinions expressed and arguments employed herein are solely those of the author
and do not necessarily reflect the official views of the OECD or of its member countries.

Acknowledgements

Contributions from Liliane Moreira, Francesca Colombo, James Buchan

and Luke Slawomirski are gratefully acknowledged.

210 Health Employment and Economic Growth: An Evidence Base

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212 Health Employment and Economic Growth: An Evidence Base

CHAPTER 9

Paying for needed health workers

for the SDGs:
An analysis of fiscal and financial space
Jeremy A. Lauer, Agnès Soucat, Edson Araújo, Melanie Y. Bertram,
Tessa Edejer, Callum Brindley, Elina Dale, Amanda Tan

Abstract
In spite of the projected creation of millions of new health worker jobs in the
coming years, achieving the Sustainable Development Goals by 2030 implies
a still greater need for health workers of all types. This chapter addresses two
questions: Can governments worldwide meet the wage bills of their needed
health workers from public revenues (“Is there enough fiscal space”)? and, Can
low-income and lower middle-income countries meet the additional wage bills
from both public and private financing sources (“Is there enough financial
space”)? To investigate these questions, we used estimates of the number of
current and projected health workers (“supply”) and of the number of needed
health workers (“needs”), and we multiplied these figures by the wages of
health workers as estimated from International Labour Organization data on
earnings. The resulting wage bills were then compared with different public
revenue and health expenditure scenarios. Conditional on current trends
in economic development and population growth, sustainable financing for
health workers, mostly domestic, can be secured in most low-income and lower
middle-income countries. Progressive fiscal policies and the reprioritization of
government expenditure can also mobilize additional private financing. With
the necessary conditions in place, all but a small number of countries worldwide
should be able to meet the recurrent cost of their health workforce. Finally,
targeted international assistance can be used to support catalytic investments in
developing human capital and skills.

PART II: Economic Value and Investment | CHAPTER 9 213

 1. Introduction

Efforts to achieve the Millennium Development Goals (2000-2015) revealed

substantial shortages1 in the numbers of needed health workers, estimated to be in
the order of 14 million jobs at 2013, with such needs concentrated particularly in
low-income and lower middle-income countries. In spite of the projected creation of
millions of new health worker jobs in the coming years, in the absence of bold new
measures, an even larger shortage of needed health workers – estimated at 18 million
missing jobs, again concentrated mainly in low-income and lower middle-income
countries – is to be expected by 2030. Yet without these additional health workers
it will be impossible to attain the health-related Sustainable Development Goals
(SDGs) by 2030 (1).

1.1 The research questions

The objective of this chapter is to assess to what extent governments and other actors
can meet – in a sustainable manner and under plausible scenarios – the financing
needs implied by the growth in the health workforce required to meet the SDGs. To
do so, we examine two related questions:

• Can increased public financing be relied upon to finance health worker wage
bills? In other words, is there sufficient fiscal space to finance the projected total
wage bills for health workers by 2030?

• Can increased public and private financing be relied upon to finance the health
worker wage gap? In other words, is there sufficient financial space to meet the
additional projected wage bills for health workers by 2030?

1 A “shortage” is a condition of excess demand (that is, when supply is too low). A “deficiency”, on the other hand,
is a gap between needs and supply, and suggests demand is too low. Globally, there are both deficiencies and
shortages in the numbers of needed health workers, according to setting. In this brief - given the concentration of
the need for additional health workers in low-income and lower middle-income countries (which are subject to the
substantial emigration of health workers) - we prefer the term “shortage”, while acknowledging that the technical
denotation may not in every case strictly apply.

214 Health Employment and Economic Growth: An Evidence Base

1.2 Fiscal and financial space: definitions and domains
We refer to the term “fiscal space” as first proposed by Heller (2, 3): fiscal space can
be defined as “room in a government’s budget that allows it to provide resources for a
desired purpose without jeopardizing the sustainability of its financial position or the
stability of the economy”. Researchers (2-5) have identified a variety of mechanisms
that influence fiscal space for health. In the typology adopted here, the mechanisms
can be arranged into seven “domains”:

a. taxation, including raising government revenues or improving tax collection and

administration;

b. fiscal impacts of economic and population growth;

c. earmarking funds through indirect taxes or social insurance contributions;

d. borrowing from domestic or external lenders;

e. monetary expansion;

f. efficiency gains, through improving allocative efficiency by reprioritizing existing

expenditure or through improving technical efficiency;

g. securing external grants.

The domains are not mutually exclusive – for example, earmarked taxes (c) are a
form of taxation (a). Moreover, many of the domains are interacting – for example,
monetary (e) and tax (a) policies are determinants of economic development (b).
However, with the exception of the fiscal impacts of economic development and
population growth (b), the items in the above list are directly associated with public
policy levers, that is, they result from actions that a government can in principle
undertake. The fiscal impacts of economic development and population growth
(b), on the other hand, are sometimes referred to as “conducive macroeconomic
conditions” (4), presumably to indicate their (partial) exogeneity from the sphere
of government action, at least in the health sector. Note also that all the policy-
relevant domains, with the exception of monetary policies (e) and efficiency (f),

PART II: Economic Value and Investment | CHAPTER 9 215

 are examples of financing, in the sense of “raising funds for a specific purpose”. For
its part, the domain of efficiency concerns expenditure planning and management,
while monetary expansion typically involves (though is not limited to) central bank
operations. Thus, in an alternative classification, the determinants of fiscal space
consist of financing, expenditure, or monetary policies (or a combination thereof).

While Heller’s conception (2, 3) focused on four classical policy levers of public
financial management, Tandon and Cashin (4) broadened the scope to include
the fiscal impacts of “conducive macroeconomic conditions”; they also added
“earmarking” as a means of generating fiscal space specifically for health. Barroy,
Sparkes and Dale (5), however, focus on expenditure management and in particular
identify means for improving technical efficiency to create fiscal space. The
concept of “fiscal space” has both broadened and deepened since Heller’s initial
use of the term.

To investigate the availability of fiscal space for health workforce expansion, we look
at scenarios for taxation (a), economic development and population growth (b)
and allocative efficiency (f). However, since economic development and population
growth (b) and effective public policies on tax (a) and spending (f) can in addition
catalyse investments by the private sector, and since external investments such as
(d) and (g) – which can include both private and philanthropic financing – can be
instrumental in supporting public policy, we further extend the concept of fiscal
space to include the availability of financing from private sources, both domestic
and external. We refer to this broader concept as “financial space”. Figure 1 presents
a (partial) depiction of the domains and interactions of fiscal and financial space.
To show coherence with the categories employed in its historical development, our
diagram expands outwards from the original policy-oriented conception of fiscal
space to include first the fiscal impacts of the broader economic context, and then
the interactions of these domains with non-public actors.

Financial space has nearly the same determinants (and restrictions) as fiscal space,
except it is not limited to the public sphere. One might object that monetary policy
(e) is the exclusive domain of government action; however, private entities such as
banks and investors nevertheless play a role in monetary expansion, not of course
through the government prerogative of seigniorage but rather as a result of their

216 Health Employment and Economic Growth: An Evidence Base

Figure 1

Fiscal and financial space, domains and interactions

FINANCIAL SPACE

PUBLIC POLICY LEVERS

INDIRECT EFFECTS
OF PUBLIC POLICY REVENUE GENERATION

taxation
social investment
MONETARY
CONTROLS borrowing
public-
social
private
businesses central bank
partnerships earmarking
operations
fiscal impacts
of economic
and population external grants
private private not-
for-profit for-profit growth
entities entities
EXPENDITURE
MANAGEMENT
out of
pocket
co-payments technical efficiency

FISCAL SPACE allocative efficiency

excess out-of-pocket expenditure

willingness to lend and to invest. On the other hand, since (lawful) private actors
do not raise funds through taxation (a), not only the specific lever of seigniorage –
which is a part of (e) – but also any form of “private taxation” – that is, the whole
of (a) – should be understood to be explicitly excluded from the scope of action of
private actors.

“Financial space” then refers to a situation in which governments and private actors
have the flexibility to direct resources to a specific purpose without jeopardizing
their financial position or long-term financial prospects; financial space can be said
to include fiscal space as a subset. A particular advantage of the broader concept of
financial space is that it brings into scope actions that increase the capacity of both
public and private actors to spend — and to manage effectively their expenditure
of — financial resources. Effective expenditure management for private actors is
not limited (as for government actors) mainly to concerns about technical and

PART II: Economic Value and Investment | CHAPTER 9 217

 allocative efficiency but also includes the constraint of the “absorptive capacity of
the economy”. The ability of the economy to absorb new financing without facing
harmful bottlenecks is affected by a range of factors mainly falling within the
scope of action of private actors (but, to a certain extent, also within the scope of
public actors), including the availability of human resources (human capital), the
availability of natural and manufactured capital, the availability of physical and
social infrastructure, and the availability of administrative capacity, as well as by
institutional factors such as the nature and enforceability of contracts and prevailing
norms and standards.

1.3 The research questions revisited

We analyse the implications of the wage bills of additional needed health workers
from both a fiscal space (public sector) perspective and a financial space (public and
private sector) perspective. The period analysed is 2016–2030, corresponding to the
time horizon of the SDGs; however, to harmonize with the estimates of projected
health worker supply and health worker needs taken from Cometto et al. (1), the base
year (that is, the starting point) used for projections (except as noted below) is 2013.

“Additional needed health workers” are defined as “the projected needed health
workers minus the projected supply of health workers” (1). The wage bills
corresponding to additional needed health workers are termed “the financing gap”.

The fiscal space scenarios examined here rely on assumptions about taxation
(a), economic development and population growth (b) and the reprioritization
of expenditure (f). The scenarios are described in more detail below (section 3).
Given the focus of these scenarios on public budgets, they can be said to represent
a traditional, public sector-driven, view of development. As such, fiscal space
scenarios represent an upper bound on the scale of demands that could be made on
public budgets; that is, even if additional, socially beneficial private financing should
become available, the stewardship function of public governance nevertheless makes
it interesting to examine the potential implications for specifically public budgets.

218 Health Employment and Economic Growth: An Evidence Base

On the other hand, the financial space scenarios, which in principle rely on both public
and private financing, should be understood in the context of a presumed broad-based
health financing reform, one made possible in an environment where continued
economic growth, combined with effective public tax and expenditure policies,
can catalyse socially beneficial private co-investments (for example, through social
businesses, social investments and public-private partnerships), co-investments that in
turn can support the objectives of public policy while also extending the scope of the
resource base that can be mobilized.

Therefore, in light of the discussion in the previous section – and specifically because
the different domains are interacting and not mutually exclusive – the financial space
scenarios should be interpreted as relying not only on explicit assumptions about
economic and population growth but also on a set of implicit assumptions about the
effects of effective public tax and expenditure policies on the other domains of both
financial and fiscal space (see Figure 1).

Finally, whenever referring to the potential role of increased private financing in

health expenditure, we need to stress an important caveat about out-of-pocket
expenditures (which are included in most estimates of private health expenditure).
While, for technical reasons, we do not explicitly exclude (excess) out-of-pocket
financing in our financial space calculations, increasing reliance on out-of-pocket
expenditure is nevertheless to be strongly deprecated since, once it exceeds a
certain threshold, out-of-pocket expenditure is associated with negative outcomes
for both poverty and health. In other words, the out-of-pocket financing of health
expenditure (at least above a certain threshold) cannot be considered to contribute
to financial space (see Figure 1) because excess out-of-pocket expenditure is strictly
incompatible with the restriction noted above that it must not jeopardize the
financial position of economic actors or threaten the stability and growth prospects
of the economy as a whole. Therefore, the impact of “effective public policies and
broad-based health financing reform” should be further understood to involve strict
controls on the reliance on out-of-pocket financing.

PART II: Economic Value and Investment | CHAPTER 9 219

 2. Data sources
The following estimates were relied on for the analysis presented in this chapter:

i. estimates of the needs for and the supply of health workers projected to 2030;

ii. estimates of health worker wages projected to 2030;

iii. estimates of gross domestic product (GDP) growth projected to 2030;

iv. estimates of population growth projected to 2030.

Estimates of (i) were obtained from the analysis performed by Cometto et al. (1);
estimates of (ii) were derived from wage indexes estimated from country-specific
earnings data for health workers and other relevant occupational groups published
by the International Labour Organization (ILO) (as described in more detail below);
estimates of (iii) are taken from work done at the World Health Organization
(WHO) based on figures published by the International Monetary Fund (IMF) in
the World Economic Outlook database (and are described in more detail below);
finally, estimates of (iv) come from the United Nations Population Division
(medium variant). All these estimates are subject to uncertainty; however, as this
policy chapter presents a fiscal and financial analysis in which we take externally
determined2 data as given, we focus our discussion of uncertainty exclusively on (ii),
by investigating a plausible range of health worker wages.

2.1 Estimates of health worker wages

Estimates of health worker wages were derived from an econometric model based
on available earnings3 data, as described more fully in Bertram et al. (6). Earnings
data were retrieved from the ILOSTAT database of reported earnings estimates (7)
for a variety of job titles, then classified into occupational levels according to the
four ISCO-08 major groups. Data for medical professions were selected wherever
available and relevant: for level 4, data extraction focused on earnings for general

2 “Externally determined data” are data obtained from sources external to this analysis, and whose assumptions,
strengths, and weaknesses are discussed in the original publications.
3 Here we use “earnings”, “wages”, and “salaries” as (more or less) interchangeable terms expressing the value of
the (gross) remuneration (in cash and in kind) received by employees for their work (but excluding social security and
pension benefits). The “cost of employment” to employers will generally be higher than their employees’ earnings.

220 Health Employment and Economic Growth: An Evidence Base

physicians, dentists and professional nurses; for level 3, data extraction focused
on earnings for medical X-ray technicians, physiotherapists and auxiliary nurses;
for level 2, data extraction focused on clerks and secretaries; and for level 1, data
extraction focused on physical labourers. Data from the most recent available year
were used. In total, 324 observations from 193 countries were available for analysis.

The health worker wage estimation model employed a Heckman two-stage procedure
to model missing country-specific earnings data: that is, a probit model was used
to model the probability of observing earnings data, and an ordinary least squares
model was used for wage estimation. In the former case, mortality statistics were
used to predict the probability of observing earnings, since higher levels of mortality
are plausibly associated with lower levels of development, specifically within the
health system, and would thus lead to poor data collection.

In this analysis, we assume that the predicted mean of category 4 (equivalent to the
second stage of tertiary education) provides an estimate of the average wages of
doctors. For the wage estimates for nurses and midwives, we use an average of the
predicted means of category 4 and category 3 (the latter being equivalent to the first
stage of tertiary education). Although professional nurses are classified by ILO at level
4, auxiliary nurses are classified at level 3, which still demands some tertiary-level
training. For “other health workers”, we use an average of the predicted means of
categories 3, 2 and 1. While other classification strategies for health worker wages are
possible and would potentially be reasonable, we adopted the described strategy as
being in our view both plausibly consistent with the actual situation in most low-
income and lower middle-income countries and in addition the one most consistent
with the available data and therefore requiring the fewest number of auxiliary
assumptions.

The resulting monthly earnings estimates for the three cadres of health workers were
converted to annual earnings figures and then expressed in terms of GDP per capita
indexes (that is, as multiples of GDP per capita). Expression of annual earnings in

PART II: Economic Value and Investment | CHAPTER 9 221

 terms of units of GDP per capita has the desirable feature that, for projection purposes,
per capita wage indexes can be assumed to remain constant, while estimates of GDP
per capita change according both to projections of economic growth and to United
Nations Population Division projections of population growth (medium variant).
Wage indexes therefore also represent a hypothesis about labour market conditions;
while wage indexes undoubtedly can change with changing economic conditions, the
assumption of constant projected wage indexes (that is, constant relative wages) is a
standard form of ceteris paribus restriction. Table 1 gives the estimates of cadre-specific
health worker wage indexes (as a multiple of GDP per capita) stratified according to
World Bank income groups. Global figures are shown for comparison purposes.

Table 1

Wage indexes for health workers by cadre

World Bank income Average wage index

categories Health worker cadre (multiple of GDP per capita)
Physicians 1.9
High-income countries Nurses and midwives 1.5
Other health workers 0.9
Physicians 2.7
Upper middle-income
Nurses and midwives 2.2
countries
Other health workers 1.3
Physicians 5.1
Lower middle-income
Nurses and midwives 4.2
countries
Other health workers 2.4
Physicians 7.8
Lower-income countries Nurses and midwives 6.4
Other health workers 3.7
Physicians 4.4
Global Nurses and midwives 3.6
Other health workers 2.1

222 Health Employment and Economic Growth: An Evidence Base

We further calculated a weighted average health worker wage index (for all cadres)
for each World Bank income group using the corresponding cadre-specific estimates
of the supply of health workers obtained from Cometto et al. (1) as weights. Although
there are no alternative sources of data on health worker wages that we are aware
of, we were able to cross-check our econometrically derived wage indexes using
independently obtained estimates of total health worker wage bills. Again, using the
cadre-specific estimates of the supply of health workers obtained from Cometto et al.
(1) as weights, average health worker wage indexes (for all cadres) were independently
derived, this time from estimates of aggregate country-specific wage bills available in
the Global Health Expenditure Database (GHED).4 The side-by-side comparison of our
econometrically derived estimates with the “top-down” estimates obtained from the
GHED is shown in Figure 2.

Estimated wage indexes, by cadre (Table 1) or averaged across all cadres (Figure
2), show an inverse gradient with income, in the sense that higher-income regions
show lower estimated health worker wage indexes. In other words, the wages of
health workers are higher as a multiple of GDP per capita in low-income and lower
middle-income countries than in upper middle-income and high-income countries.
This said, wages in absolute terms are clearly higher in the higher income groups,
since GDP per capita is higher in those groups. Figure 2 further shows, however, that
when aggregate figures on health expenditure from the GHED are used for top-down
analysis of health worker wages based on available aggregate wage bill data, the
aggregate data imply systematically higher wage indexes than our econometric
analysis of wage levels using data published in ILOSTAT.

4 Wage bill data are not reported in the publicly available GHED and were estimated internally at WHO.

PART II: Economic Value and Investment | CHAPTER 9 223

 Figure 2

Comparison of average health worker wage indexes estimated from

ILOSTAT and from the GHED, displayed by World Bank income group

GHED ILOSTAT
10
9

8
GDP per capita index

6 5.5
5

3.5 3.7 3.8

4 3.3
2.3 2
2 1.3

0
high upper lower low global
middle middle

Both the data published by the ILO and those obtained from the GHED are subject
to measurement error, and they also both have numerous missing observations. Yet
these two sources of estimates of health worker earnings agree in important respects,
and in our view they therefore can be used to establish a “plausibility range” for
GDP per capita wage indexes for health workers. In our subsequent calculations
we employ such “plausible ranges”, relying on our (subjective) interpretation of the
strength of the evidence contained in both data sources (ILOSTAT and GHED).
As health worker wages are a key parameter affecting the analysis, we return to this
point when discussing our results for fiscal and financial space.

2.2 Estimates of economic growth

We used GDP growth projections for 2022 to 2030 prepared at WHO using the
IMF’s published GDP projections5 to 2021 and each country’s historical data (8). As

5 April 2016.

224 Health Employment and Economic Growth: An Evidence Base

described in that report, a non-parametric bootstrapping method was adopted
to obtain expected average GDP growth rates, with lower and upper bounds, for
the years 2022 to 2030. A bootstrapping approach was adopted because of its
simplicity and the minimal reliance on additional assumptions about the data.
Greater weight was placed on more recent years (2011-2021) in resampling, a
procedure that gives more prominence to current growth patterns as predictors
of future growth out to 2030. A comparison of GDP growth rates obtained using
our bootstrapping method with independently estimated GDP growth rates
available from other sources showed our estimates to be consistent and robust,
especially when interpreted in terms of ranges (that is, estimates from other
sources were consistently within our upper and lower bounds) (8). However,
in cases where country-specific GDP forecasts to 2030 were available from an
official domestic institution, such as the national central bank, these were used in
place of the internally produced projections just described.

3. Fiscal space analysis

Fiscal space refers to the availability of specifically public funds (see section 1.2).
Here we report on a fiscal space analysis for 183 countries with data available
in the GHED. To estimate the scope of what public finance alone might achieve
in the expansion of the health workforce, we examined a simple fiscal scenario
relying on assumptions about what could potentially be realized in the domains
of taxation (a), economic and population growth (b) and the reprioritization of
expenditure (f).

More specifically, we make assumptions about the extent to which governments

can successfully increase their tax revenues over the period 2016–2030 (“fiscal
growth”) and the extent to which health can receive a greater priority within the
envelope of government expenditure (“priority increase”). These assumptions
are then combined with the estimates of health worker needs and supply, health
worker wages, and economic and population growth described above (see
section 2).

PART II: Economic Value and Investment | CHAPTER 9 225

 The fiscal scenario was calibrated to start in 2014 (not in 2013, as for other
projections). Results are presented with respect to only the final year of the
SDG period, 2030.

3.1 Fiscal space scenario

3.1.1 Baseline

For each country, we assume:

• that general government health expenditure as a proportion of total government

expenditure is equal in 2014 to its average value in the GHED during the period
2010-2013;

• that total government expenditure as a proportion of GDP is equal in 2014 to its

average value in the GHED during the period 2010-2013.

3.1.2 Fiscal growth

For each country, we assume:

• that the value of total government expenditure in 2030, as a proportion of GDP,

increases by 5% from the 2014 baseline if it was not already at 45% of GDP or
greater (and that otherwise it remains constant);

• that the estimated 2014 value of total government expenditure as a proportion of

GDP increases to the projected 2030 value linearly.

3.1.3 Priority increase

For each country, we assume:

• that the 2030 value of public health expenditure as a proportion of total

government expenditure increases by 4% if it was not already at 15%
or greater of total government expenditure (and that otherwise it
remains constant);

226 Health Employment and Economic Growth: An Evidence Base

• that, if public health expenditure was between 11% and 15% as a proportion
of total government expenditure in 2014, it increases to 15% but not beyond
by 2030;

• that the 2014 value of public health expenditure as a proportion of total

government expenditure increases to the 2030 value linearly.

3.1.4 Wages

In line with the findings reported above (see section 2.1), we assume that
average health worker wages for all cadres in 2014 are either 3 times GDP
per capita (plausible lower bound) or 6 times GDP per capita (plausible
upper bound).

3.1.5 Wage bill ceilings

There are no accepted international benchmarks for the ratio of wage bills
to total public spending on health. Nevertheless, raw calculations (that is,
uncorrected for on-budget development assistance) from unpublished data
in the GHED reveal that, for 136 countries with available data, the global
unweighted average wage bill, expressed as a proportion of public spending
on health, is 57%. In high-income countries that are not recipients of
development assistance, the figure is also 57%. We therefore take 60% as
a (slightly ambitious) “feasible lower bound” for the magnitude of wage
bills expressed as a proportion of total public spending on health. For the
sake of defining an “upper bound” that might nevertheless be at the extreme
limit of feasibility, we assume 90%, noting that approximately one quarter
of lower middle-income countries currently show wage bills above this
level (Figure 3).

PART II: Economic Value and Investment | CHAPTER 9 227

 Figure 3

Sample statistics (mean, median, percentiles) for wage bills expressed

as a proportion of general government expenditure on health, estimated
from unpublished data in the GHED (n = 136), displayed by World Bank
income group

75th pct 25th pct median mean

100

80

60
Percentage

40

20

0
High Upper middle Lower Middle Low

The 60-90% range adopted here for the purposes of this analysis should not be
interpreted as a norm or policy recommendation, but merely represents values
we are using to draw conclusions about the limits of the modelled fiscal scenario.
Indeed, when health worker wages are above 60%, expressed as a proportion of total
government expenditure on health, and almost certainly when they are above 90%,
there will generally be concerns about the implications for efficiency in the mix of
inputs required for service delivery, as well as about the financial burden that a lack
of public resources to fund other inputs (such as medicines and supplies) is liable to
place on patients who could have to pay for these inputs out of their own pockets.
More particularly, the allocation of 60-90% of government health spending to health
worker wages should by no means be interpreted as a target. Such high levels of
spending on wages might be sustainable only in contexts in which external funding
can finance a substantial proportion of non-salary inputs.

228 Health Employment and Economic Growth: An Evidence Base

3.2 Results for the fiscal space scenario
Assuming both fiscal growth and reprioritization of health as described above, and
with an estimate of average health worker wages for all cadres of 3 times GDP per
capita, only four countries would require an amount greater than 60% of projected
health expenditure from public sources in order to meet their financing needs for
health worker wages in 2030. In contrast, with an upper bound for health worker
wages of 6 times GDP per capita, as many as 69 countries would require an amount
greater than 60% of health expenditure from public sources in order to meet their
health worker wage bills in 2030. This is shown in Figure 4 (rightmost bars), along
with visualizations of the implications of the individual components of the fiscal
scenario, in other words of “baseline”, of “fiscal growth” only, and of “priority
increase” only.

Figure 4

Number of countries where the wage bills of meeting normative health

worker targets would amount to more than 60% of projected public
spending on health in 2030 (n = 183)

3 x GDP per capita 6 x GDP per capita

140
124
120
102
100 93

80 69

60
42
40 29
20 11
4
0
Baseline Fiscal growth Priority increase Fiscal and priority

Under the more extreme assumption that health worker salaries can rise to 90%,
expressed as a proportion of public expenditure on health, and thus that very high
levels of external funding are available to fund the recurrent costs of non-staff inputs,

PART II: Economic Value and Investment | CHAPTER 9 229

 0 (zero) countries would not be able to meet their projected wage bills for health
workers in 2030 for the lower bound of 3 times GDP per capita for average health
worker wages (for all cadres). For the upper bound of 6 times GDP per capita for
health worker wages, 16 countries would not be able to meet their projected wage
bills in 2030 without exceeding the 90% ceiling. This is shown in Figure 5 (rightmost
bars), along with visualizations of the implications of the individual components
of the fiscal scenario, in other words of “baseline”, of “fiscal growth” only, and of
“priority increase” only.

Figure 5

Number of countries where the wage bills of meeting normative health

worker targets would amount to more than 90% of projected public
spending on health in 2030 (n = 183)

3 x GDP per capita 6 x GDP per capita

80
71

60 55

37
40

20 17 16
8
3 0
0
Baseline Fiscal growth Priority increase Fiscal and priority

Our analysis of fiscal space suggests that, if wage bills are expressed as a proportion
of projected public spending on health under our fiscal scenarios, and conditional
on estimates of a plausible range of health worker wage indexes of 3–6 times GDP
per capita, only a small number of countries (4–16 countries; see Figures 4 and
5) are projected to show wage bills outside the upper range of the distribution of
some currently observed wage bills (that is, above the range 60–90%). Therefore,

230 Health Employment and Economic Growth: An Evidence Base

assuming progress can be made in managing wage bill growth and in improving
fiscal capacity and priority setting in public spending, our analysis suggests that
all but a small number of countries should be capable of meeting their projected
SDG financing needs for health worker wages in 2030, even relying primarily
on government expenditure on health. Sustained development assistance may
nevertheless be required to meet the investment costs in pre-service training in a
larger number of countries (not quantified in this analysis). Finally, for countries
where meeting the health worker targets could require more than the more
conservative ceiling of 60% of public spending on health (possibly 4-69 countries,
depending on wage levels; see Figure 4), additional assistance may be needed to
support the financing of non-salary inputs and to ensure access to care, quality of
care and the productivity of health workers.

4. Financial space analysis

The analysis of financial space builds on that of fiscal space in the sense that
we assume additional resources from non-public sources can be mobilized as
a result of economic and population growth, effective public policies on tax
and expenditure, and broad-based health financing reform (see section 1.2 for
a discussion of the indicative underlying assumptions). For financial space, we
restrict our analysis solely to aggregate quantities for low-income and lower
middle-income country groups.

We claim that there is sufficient financial space for the necessary expansion of
health employment in low-income and lower middle-income countries if the
following conditions can be (jointly) met:

• the projected annual financing gap for the wages of needed health workers
is a “small” proportion of total annual economic output (i.e. GDP) in those
countries;

• the projected annual financing gap for the wages of needed health workers is a
“reasonable” proportion of total health expenditure in those countries.

PART II: Economic Value and Investment | CHAPTER 9 231

 Globally, for 136 countries with wage bill data in the GHED, the health workforce
currently is estimated to absorb an average of 2.3% of GDP and 34% of total health
expenditure from all sources, public and private; therefore, we take these observed
averages as reference points for determining what additional amounts might be
considered “small” and “reasonable” in our analysis of financial space.

4.1 Financial space for low-income countries

Using projections of GDP growth previously described (8) and population

projections from the United Nations Population Division, and assuming an average
health worker wage index (for all cadres) of 3 times GDP per capita, the financing
gap for needed health worker salaries in 29 low-income countries is projected to
start at US$ 9.5 billion (in constant 2013 US dollars) per year in 2016, and to rise to
US$ 16.9 billion per year in 2030. As a proportion of projected GDP, the financing
gap averages approximately 2% of GDP over this period (implying that roughly a
doubling of the share of GDP going to health worker wages is required to meet the
financing gap). As a percentage of projected total health expenditure, the projected
financing gap averages approximately 32%, again implying that, to meet the financing
gap, approximately a doubling would be required in the share of total health
expenditure going to health worker wages (Figure 6).

If, on the other hand, an average health worker wage index (for all cadres) of 6 times
GDP per capita is assumed, the financing gap for needed health worker salaries in 29
low-income countries is projected to start at US$ 18.9 billion (in constant 2013 US
dollars) per year in 2016, rising to US$ 33.8 billion per year in 2030. As a proportion
of projected GDP, the projected financing gap in this less optimistic scenario averages
approximately 4% of GDP over this period (implying approximately a tripling of
the share of GDP going to health worker wages). As a percentage of projected total
health expenditure, the projected financing gap averages approximately 65%, again
implying approximately a tripling in the share of overall health expenditure going to
health worker wages.

232 Health Employment and Economic Growth: An Evidence Base

Figure 6

Projected financing gap for wages, and % of GDP and total health
expenditure required to pay additional wage bills, in low-income
countries over the period 2016–2030, assuming an average health
worker wage index (for all cadres) of 3 times GDP per capita

THE GDP
40% 2.5%

38%

36% 2.0%

34%

32% 1.5%

30%

28% 1.0%

26%

24% 0.5%

22%

20% 0.0%
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
% GDP 2.23% 2.20% 2.17% 2.12% 2.09% 2.06% 2.02% 1.99% 1.96% 1.92% 1.89% 1.85% 1.82% 1.79% 1.75%
% THE 38% 36% 34% 33% 32% 31% 31% 30% 30% 30% 30% 30% 30% 30% 30%

(low-income countries)

4.2 Financial space for lower middle-income countries

Assuming an average health worker wage index (for all cadres) of 3 times GDP
per capita, the financing gap for needed health worker salaries in 46 lower middle-
income countries is projected to start at US$ 52 billion (in constant 2013 US dollars)
per year in 2016, and to fall to US$ 48 billion per year in 2030, implying an average
annual growth rate in the financing gap for needed health worker salaries in lower
middle-income countries of –0.6% per year. As a proportion of projected GDP, the
projected financing gap averages approximately 0.5% of GDP over this period, but
falls from an initial value of around 0.9% of GDP per year to a final value of 0.3% of
GDP per year. As a percentage of projected total health expenditure the projected

PART II: Economic Value and Investment | CHAPTER 9 233

 financing gap averages approximately 10% over this period, but falls from an initial
value of around 20% of total health expenditure per year to a final value of around
7% of total health expenditure per year (in all cases, these percentages are over
and above what would already be spent on health workers in a business as usual
scenario) (Figure 7).

Figure 7

Projected financing gap for wages, and % of GDP and total health expenditure
required to pay additional wage bills, in lower middle-income countries over
the period 2016–2030, assuming an average health worker wage index (for all
cadres) of 3 times GDP per capita

THE GDP
25% 0.9%

0.8%
20% 0.7%

0.6%
15%
0.5%

0.4%
10%
0.3%

5% 0.2%

0.1%

0% 0.0%
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
% GDP 0.8% 0.8% 0.7% 0.7% 0.6% 0.6% 0.6% 0.5% 0.5% 0.5% 0.4% 0.4% 0.4% 0.4% 0.3%
% THE 19% 14% 12% 11% 11% 10% 10% 9% 9% 9% 8% 8% 8% 8% 8%

(LMICs)

If, on the other hand, an average health worker wage index (for all cadres) of
6 times GDP per capita is assumed, the financing gap for needed health worker
salaries in 46 lower middle-income countries is found to start at US$ 104 billion
(in constant 2013 US dollars) per year in 2016, falling to US$ 97 billion per year
in 2030. As a proportion of projected GDP, the projected financing gap averages
approximately 1% of GDP over this period. As a percentage of projected total health
expenditure, however, the projected financing gap averages approximately 20%

234 Health Employment and Economic Growth: An Evidence Base

per year, although it has an initial value of 40% of total health expenditure per year
and falls to a final value of 15% of total health expenditure per year when this much
higher salary level is assumed.

5. Discussion and conclusions

The fiscal space analysis looks at fiscal implications mainly at the end point of 2030,
whereas the financial space analysis examines the whole financing trajectory from
2016 to 2030. The fiscal space analysis uses “country” as the unit of analysis, whereas
the financial space analysis considers only aggregate income groups of countries.
The fiscal space analysis examines total wage bills (compared to various “ceilings”),
whereas the financial space analysis examines the financing gap of meeting
additional required wage bills.

The fiscal space analysis focuses on the role of governments, under a scenario
composed of assumptions about projected economic and population growth,
projected growth in public funds, and the potential for the reprioritization of
health in government expenditure; however, on the assumption that effective public
policies will have broader effects on the private economy, the financial space analysis
examines projected economic development, population growth and growth in overall
health spending (in other words, it includes the full scope of available public and
private resources that could potentially be mobilized by effective public policies and
broad-based health financing reform).

As the fiscal space analysis focuses on general government expenditure on health,

it therefore reveals challenges in a (small) number of countries (optimistically, as
few as 4-16 countries; less optimistically, as many as 69 countries) with low baseline
levels of government expenditure on health. This finding highlights the important
role of adequate general government expenditure on health in meeting the challenges
of the SDGs. On the other hand, as the financial space analysis is driven primarily
by assumptions about growth in overall economic output (GDP) and total health
expenditure, the latter analysis therefore reveals challenges mainly in the group of
29 low-income countries, especially at higher wage levels. Considering both the

PART II: Economic Value and Investment | CHAPTER 9 235

 fiscal and financial scenarios together, however, one is nevertheless entitled to
conclude (at least optimistically) that the number of countries requiring sustained
development assistance for wage bills from donor nations is likely to be limited,
possibly to as few as 20–30 countries or even fewer.

5.1 Fiscal space

There is the potential for public funds to meet the recurrent costs of needed
health workers in many countries. Countries that are projected not to meet their
wage bills in 2030 from public finances display the common feature of low levels
of general government expenditure on health. For example, the 69 countries
reported as potentially not meeting their wage bills in 2030 (Figure 4), even in
the optimistic scenario of fiscal growth and increased prioritization of health
spending, show an average share of general government expenditure on health
of only 2% of GDP in data from the GHED (whereas a target of 5% has been
recommended by some) (9).

Available public spending on health nevertheless needs to support a technically

efficient mix of inputs to health care, including elements such as medicines and
medical supplies that might otherwise be paid for only out of pocket. More
generally, there is a need for public finance to support adequately, and as essential
public goods, all health system building blocks (not only human resources but
also facilities, logistics and supply, monitoring and evaluation, and governance),
failing which the effective delivery of health care and the possibility of sustained
improvements in population health will be gravely hindered. While a detailed
discussion of technical efficiency is outside the scope of this chapter, it is important
to note that there is evidence that more could be done with existing resources
by introducing efficiency measures such as those described in a recent review of
analyses of fiscal space for health (5). Relevant measures discussed there include
reforms in public financial management systems, particularly budget execution;
reforms in provider payment methods, especially in moving away from input-based
financing to output-based payment methods; and reforms in human resource
policies and facility management practices, particularly with respect to measures to
reduce absenteeism.

236 Health Employment and Economic Growth: An Evidence Base

5.2 Financial space
At any wage levels, low-income countries show a rising financial gap over the SDG
horizon, a gap that grows at an average rate of 4.2% per year. At any wage levels,
lower middle-income countries show a falling financial gap over the SDG horizon.
This is mainly because the supply of health workers in these latter countries is
expected to increase over the period of the SDGs, whereas the supply of health
workers is expected to grow much more slowly over the horizon of the SDGs in
low-income countries.

At lower wage levels, the implications for financial space of paying additional required
health workers appear challenging but potentially manageable, that is, feasible under
assumptions of appropriate public policy (including broad-based health financing
reform) and international engagement (including targeted aid, where necessary).
Low-income countries face a fairly steady demand on available sources of financing, such
as growth in output (GDP) and total health expenditure, over the horizon of the SDGs.
Lower middle-income countries face falling demands on available sources of financing
over the horizon of the SDGs, although both groups of countries face dramatic initial
projected financing needs at higher wage levels.

If average wage levels are as high as 6 times GDP, the financial implications of
funding the wage gap begin to appear unrealistic in low-income countries (since the
additional resources required amount to as much as 4.5% of projected GDP and 75%
of projected total health expenditure, at least initially). At such higher wage levels,
the implications for total health expenditure are also quite challenging in lower
middle-income countries, again, at least initially.

5.3 Implications of health worker wages

The average level of health worker wages is accordingly a major determinant of the
availability of both fiscal and financial space. According to available data, average
health worker wage indexes may lie anywhere in the range of 1.3 to 9 times GDP per
capita, depending on income region and data source.

PART II: Economic Value and Investment | CHAPTER 9 237

 In this analysis, we adopted two assumptions about health worker wage indexes.
First, they could be at a “low” average level (for all cadres) of 3 times GDP per capita,
a value that is consistent with global averages shown in available data and also with
the values estimated in lower middle-income and upper middle-income regions (see
Figure 2). On the other hand, for sensitivity analysis we adopted a “high” average
wage level (for all cadres) of 6 times GDP per capita, which is consistent with current
values observed in lower middle-income countries and in low-income countries (see
Figure 2).

An even higher estimate for average health worker wages than 6 times GDP per capita
would not be incompatible with existing data, especially in low-income countries.
In economic terms, health workers are “tradable goods”, in the sense that they cross
international boundaries in search of better employment conditions, including notably
higher (absolute) wage levels (10). There are thus economic reasons to suspect that
lower-income countries may have to offer higher (relative to the rest of their workforce)
wages in order to retain health workers. In higher-income countries, (relative) health
worker wages appear to be much lower, at least in available data. Thus, if the barriers,
both fiscal and institutional, to creating the necessary supply of health workers in all
countries can be addressed, such that the demand for health workers in rich countries
does not result in shortages of health workers in poor countries, it is possible that
relative health worker wages may stabilize towards the currently observed global mean
of 3.3 times GDP per capita (or even lower), especially over a medium-term horizon
showing sufficient economic growth in lower-income countries to allow absolute
health worker wages in such countries to rise appropriately.

In any case, it is clear that average health worker wages higher than 6 times GDP
per capita would pose serious challenges to both fiscal and financial space, in both
low-income and lower middle-income countries. Therefore, an implicit background
assumption to the scenarios examined here involves the effective management of
wage bill growth, not through arbitrary caps, but rather through addressing the
shortages of health workers – as well as the persistent mismatches in skills mix and in
modes of service delivery as compared with population health needs (11, 12) – that
have been affecting low-income and lower middle-income countries, and that will
continue to affect these countries in the absence of bold new measures to increase the
supply of (and, where appropriate, the demand for) health workers.

238 Health Employment and Economic Growth: An Evidence Base

Acknowledgements
Jean-Louis Arcand, Hélène Barroy, James Campbell, Francesca Colombo,
Giorgio Cometto, Ibadat Dhillon, David Hunter, Chris James, Joe Kutzin, Gaetan
Lafortune, Liliane Moreira, Mark Pearson, Christophe Perrin, Stephen Pursey,
Xenia Scheil-Adlung, Susan Sparkes and Christiane Wiskow are gratefully
acknowledged for their comments.

PART II: Economic Value and Investment | CHAPTER 9 239

 References

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240 Health Employment and Economic Growth: An Evidence Base

CHAPTER 10

Evidence on the effectiveness and

cost-effectiveness of nursing and
midwifery interventions:
A rapid review
Marc Suhrcke, Yevgeniy Goryakin, Andrew Mirelman

Abstract
This rapid review considers evidence of (a) effectiveness of nursing and
midwifery-related interventions, including studies on the role of nursing and
midwifery as determinants of health; and (b) cost-effectiveness of nursing
and midwifery-related interventions. In light of what remains a still scarce,
underdeveloped cost-effectiveness evidence base, it is especially important to
consider evidence on effectiveness. We have focused in particular on two types
of policy questions: (a) increasing the number of nurses and midwives; and
(b) shifting the skills mix away from more expensive medical staff (especially
doctors) to nurses and midwives. The good news is that there is certainly selected
evidence to support the effectiveness and cost-effectiveness case for nursing and
midwifery. However, we need to acknowledge that the evidence base as a whole
appears fairly limited and mixed, if less so in terms of effectiveness than cost-
effectiveness. Many of the systematic reviews discussed in this chapter concluded
that the evidence base was “inconclusive”. More often than not this was attributed
to the several methodological challenges involved in the assessment of (cost)
effectiveness of nursing and midwifery policies. What evidence exists is also –
not surprisingly – biased towards high-income countries.

PART II: Economic Value and Investment | CHAPTER 10 241

 1. Introduction

This chapter seeks to provide a rapid review of the evidence on the effectiveness
and cost-effectiveness of nursing and midwifery-related interventions or policies.
We note the challenge involved in adhering to common definitions of the
professions “nurse” and “midwife”. Definitions often vary between countries and
between different organizations, but usually include some formal qualification
and registration in most countries. According to the Organisation for Economic
Co-operation and Development (OECD), nurses are defined as “all the ‘practising’
nurses providing direct health services to patients, including self-employed nurses”
(1).1 Midwifery – according to the recent Lancet series on the subject – involves
“skilled, knowledgeable and compassionate care for childbearing women, newborn
infants and families across the continuum throughout pre-pregnancy, pregnancy,
birth, post-partum and the early weeks of life” (2).

The chapter was commissioned as a background note to the High-level Commission

on Health Employment and Economic Growth and its Expert Group. Our primary
target audience comprises policy-makers and practitioners in the nursing and
midwifery domain that are interested in making use of economic analysis to inform
decisions about investment in nursing and midwifery, but who may not be fully
aware of what economic arguments and analysis best make the case, and how
far the relevant, current economic evidence goes. Conducting proper economic
assessments of nursing and midwifery investments is important, as it can guide
resource allocation decisions towards those investments that provide greatest health
gains (or otherwise defined objectives) for a given set of resource constraints. Since
no country has unlimited financial resources, informing optimal resource allocation
is of universal relevance, particularly in the heavily resource-constrained low-income
countries.

1 Note that definitions used across the studies reviewed in this chapter may also differ, thereby potentially compromis-
ing the comparability of the results.

242 Health Employment and Economic Growth: An Evidence Base

2. What do we mean by “cost-effectiveness”?

In health care, assessing whether a given policy or intervention represents “good

value for money” is commonly done via what has become known as cost-effectiveness
analysis. There is some subtle but important distinction of terms between cost-
effectiveness analysis in a narrow sense and cost-utility analysis. The latter considers
someone’s quality of life and the length of life they will gain as a result of an
intervention. The health benefits are typically expressed either as quality-adjusted
life-years (QALYs) or as disability-adjusted life-years (DALYs) – both indicators that
try to capture mortality and morbidity in a single metric. In the United Kingdom, the
recommendation is that interventions costing less than £20 0002 per QALY are deemed
to be “good value for money” or “cost-effective” (this threshold of £20 000 corresponds
to about 70% of the value of the United Kingdom’s 2015 gross domestic product (GDP)
per capita). Those costing between £20 000 and £30 000 per QALY may be considered
cost-effective under certain circumstances. In the absence of country-specific cost-
effectiveness thresholds for most countries, the World Health Organization (WHO)
has recommended the rule of thumb that an intervention is considered highly cost-
effective whenever the cost per DALY saved is less than the GDP per capita of
the country considered, and it is still considered cost-effective when it is between
1 and 3 times GDP per capita (3, 4).3

By contrast, cost-effectiveness analysis in a narrow definition expresses effectiveness

in terms of a single natural health unit, for instance life-years gained or lost, changes
in blood pressure, or body mass index. While these outcomes are more intuitive and
often closer to the intervention in question, their limitation lies in the resulting lack
of comparability across studies that employ different outcomes.

A further, much less frequently used approach to assessing value for money in health
care is cost–benefit analysis. Unlike cost-effectiveness analysis and cost-utility analysis,
in this case all consequences of an intervention are converted to a monetary metric,
allowing for the expression of the return on investment in purely monetary terms.

2 Around US$ 25 000 (November 2016).

3 It is important to note that there are limitations to both the United Kingdom approach (3) and the WHO recommen-
dation (4) in terms of how appropriate the proposed thresholds really are. Hence there is ample scope and need for
more work to identify appropriate cost-effectiveness thresholds that can be applied in health care in general but also
in the nursing and midwifery domain specifically.

PART II: Economic Value and Investment | CHAPTER 10 243

 While applying suitable prices for most goods and services that are used in a health
care intervention is reasonably straightforward, as typically some actual market
prices at which they can be valued do exist, this is more controversial when it comes
to putting a monetary value on health. Commonly, “willingness to pay” estimates are
used for this purpose, based on either implicit or explicit valuations people assign to
small changes in the risk of mortality and morbidity, though those estimates can vary
considerably between studies.

In this chapter we shall use the more common term “cost-effectiveness analysis” as
the overall umbrella concept to include cost-utility analysis and narrowly defined
cost-effectiveness analysis. For a brief summary of a broader set of economic
evaluations as applied in health care see Annex 1.

3. Empirical evidence on the cost-effectiveness

of nursing and midwifery interventions
There is no overarching, overall return on investment or cost-effectiveness
assessment of nursing and midwifery – and neither should one expect that there
would be, as such a figure would inevitably be quite meaningless. What would be
more informative for policy is cost-effectiveness evidence for reasonably specific
nursing and midwifery-related interventions or policies. In the (still limited)
literature, there have arguably been two important focal points – first, on the
impact of nursing and midwifery staffing levels; and second, on the effects (and
costs) of differences in skills mix on patient-level health outcomes. In what follows
we review the relevant evidence in these two domains, while acknowledging that
there are other potential nursing and midwifery interventions that have been
examined in the literature or that would merit attention.

As the direct evidence on cost-effectiveness even in these two domains is known

to be limited (5), we take into account not only cost-effectiveness evidence but
also selected evidence of sheer effectiveness. This is useful because the presence of
credible effectiveness evidence is obviously a key precondition for any potential
cost-effectiveness argument that might be developed. The effectiveness evidence we
consider may draw on both cross-country studies of the relationship between certain
nursing and midwifery staffing indicators and health outcomes, or on within-country

244 Health Employment and Economic Growth: An Evidence Base

analysis of such relationships or of relevant randomized controlled trial (RCT)
evidence, where available.

3.1 Empirical evidence on the impact of the staffing intensity or

density of nurses and midwives

3.1.1 Evidence on nursing and midwifery staffing as a “determinant”

of health

There is a small body of evidence that uses country-level data on (highly aggregate)
nursing and midwifery indicators (especially density of nurses and midwives)
within a cross-country regression framework to assess its impact on (or at least
association with) a range of mortality outcomes. While this evidence contains no
economic assessment at all, it is potentially informative for an assessment of the
cost-effectiveness of increasing the density of nurses and midwives, in that it can tell
us something about the potential effectiveness (in terms of health) resulting from
changes in that density.

The existing cross-country econometric evidence on the mortality effects of the

staffing density of nurses and midwives is mixed.4 For example, in a sample of
mostly low-income and lower middle-income countries, one study found that
the combined density of nurses and midwives was significantly negatively related
to maternal mortality, but not to infant and under-5 mortality (6).5 Similarly,
Speybroeck et al. (7) found that the density of nurses and midwives only showed
the expected, significant negative association with maternal mortality, but not with
four other mortality outcomes. Likewise, Carr-Hill and Currie (8) found in a more
recent study that the rate of physicians per capita, but not of nurses, was negatively
related to these mortality rates, even after controlling for gross national product
(GNP) per capita, income inequality and the female literacy rate, including when
the sample was restricted to developing countries only. In another study relevant to
the context of low- and middle-income countries, Castillo-Laborde (9) found that
the density of nurses and midwives was unrelated to the country-level DALYs. They

4 A relevant caveat to most if not all cross-country econometric studies is in the potentially varying definition of what
is included in the category “nurses and midwives”, potentially introducing bias in any resulting impact estimate.
5 The authors justified combining nurses and midwives in the sample by arguing that in countries where they exist as
separate health worker categories they are trained similarly and undertake similar tasks.

PART II: Economic Value and Investment | CHAPTER 10 245

 also found that the higher the proportion of physicians to nurses and midwives,
the greater the decrease in DALYs. In yet another country-level study restricted
to low- and middle-income countries, density of nurses was unrelated to health
outcomes such as measles immunization, tuberculosis case diagnosis and care for
acute respiratory infection, while the concentration of doctors was significantly
related to measles immunization rates (10).

In a more high-income country context, using cross-country, yet more fine-

grained, data, a recent Lancet study based on data from nine European countries
found an increase in the nurse workload by one patient to be associated with an
increase of about 7% in the risk of a patient dying within 30 days after hospital
admission (11). Another European-focused cross-country study suggested that
patient experience is superior in hospitals with higher nurse–patient staffing
ratios (12).

Looking at the arguably more relevant individual-level analysis, the evidence is

also somewhat mixed but perhaps more encouraging. For instance, in a systematic
review of this evidence, Kane et al. (13) concluded that greater levels of staffing of
more qualified, registered nurses were positively related to some patient outcomes.
Similarly, the review by Griffiths et al. (14) noted that an increasing number of
studies have found a negative relationship between nurse staffing levels and adverse
outcomes, such as mortality rates. Nevertheless, the authors concluded that causal
evidence remains insufficient to infer major claims about the outcomes of nursing,
both in terms of sheer health effects and in terms of cost-effectiveness (14).

3.1.2 Cost-effectiveness evidence

While the economic evaluation evidence on nurse staffing is thin, one cost–benefit
study evaluated a programme in Massachusetts, United States, where full-time
registered nurses provided care for the Massachusetts Essential School Health
Services programme, with 477 163 students from 933 schools participating during
2009/2010 (15). While the authors concluded that the programme appeared to
provide good value for money, generating a seemingly impressive US$ 98 million
net benefit to society, this finding needs to be treated with caution, as it relied on

246 Health Employment and Economic Growth: An Evidence Base

several assumptions, including about avoided medical care costs, as well as on the
extent of parental and teacher productivity losses. Also, the benefits and costs were
estimated compared to the assumed absence of any school services.

Likewise, Dall et al. (16) concluded that adding 133 000 registered nurses to the
hospital workforce in the United States would lead to medical savings of US$ 6.1
billion, or an average of US$ 46 000 per additional registered nurse per year. Again,
while such numbers might sound impressive, once we investigate the underlying
distinct assumptions, it remains persistently difficult to make a meaningful
judgement as to how “large” or “small” they really are.

In trying to assess the cost-effectiveness of increasing midwife staffing, Sandall et al.

(17), in an analysis of a large number of delivery records from the Hospital Episode
Statistics in the United Kingdom, National Health Service workforce statistics and
the Care Quality Commission Maternity Survey of women’s experiences, as well as
National Health Service reference costs, found that greater investment in medical
staff did not generally have a significant effect on the chosen outcomes. Interestingly,
however, they did find that increased midwife staffing had the greatest effect on
outcomes in low-risk women. They also found that some tasks could be shifted from
midwives to cheaper support workers for lower-risk women, and in that sense, there
is a potential economic case for investing in midwives, as well as in support workers
that take care of low-risk pregnant women.

In one notable study (18), the economic value of alternative nurse staffing levels was
determined using more traditional incremental cost-effectiveness ratio estimation.
The authors found that investing in nurse staffing was cost-effective, comparable to
commonly accepted medical interventions such as thrombolytic therapy for acute
myocardial infarction and routine cervical cancer screening. On the other hand, in
a study from Australia, Twigg et al. (19) concluded in a recent review (focusing on
full economic evaluations only, where both costs and outcomes where considered)
that the evidence on the cost-effectiveness of different nurse staffing levels was
inconclusive, due to the “small number of studies, the mixed results and the inability
to compare results across studies”. This conclusion coincides with that of an earlier
review of a very small number of cost-effectiveness studies (20).

PART II: Economic Value and Investment | CHAPTER 10 247

 3.2 Empirical evidence on the impact of shifting the skills mix
towards nursing and midwifery
While the evidence on the cost-effectiveness of more intensive nursing or midwifery
staffing remains inconclusive, there appears to be greater support for the notion
that shifting the skills mix towards nursing and midwifery (that is, away from more
expensive medical staff, such as doctors, or potentially from registered nurses to
care assistants) could be a cost-effective use of limited resources in health care (5,
14). While cost-effectiveness in a traditional sense is not usually estimated in such
studies, evidence to support this case comes predominantly from effectiveness
evidence indicating that nurses provide at least as good health care as doctors (as
measured by a range of outcomes, including health outcomes). To the extent that
one can assume the use of nurses and midwives to be less costly than that of doctors,
this would suggest that “some” task shifting towards nurse-provided care could be
an efficiency-increasing and hence economically sensible approach, in that it would
produce better (health) outcomes for a given budget (or the same outcomes for less
resources) (5). One rare cost-effectiveness study that was conducted alongside an
RCT in general practices in the Netherlands confirms this hypothesis by finding that
average costs, which included both direct costs of care and productivity loss costs for
patients, were lower for nurse practitioners than for GPs (21–25).6

In terms of effectiveness evidence, a slightly dated Cochrane systematic review (22)

concluded that care provided by appropriately trained nurses would be as good as
that by primary care doctors, although the authors cautioned that – yet again – the
evidence for this was still inconclusive due to lack of sufficiently powered studies, as
well as several methodological shortcomings, including short follow-up. Likewise,
OECD researchers concluded, based on a more recent review of several evaluations
conducted in high-income countries, that advanced practice nurses provided as

6 A caveat is in order here, in that while it might seem reasonable to assume that nurses are cheaper to employ than
doctors (while noting that the relative cost of employing a nurse versus a doctor varies significantly in different
countries), the impact of nurse–physician substitution on overall resource utilization is still unclear. Laurant et al.
(22), for instance, noted that increasing the ratio of nurses and midwives to physicians may lead not only to cost
savings attributable to cheaper costs of employing nurses and midwives, but also to cost increases due to potentially
lower productivity of nurses and midwives compared to physicians (22). (It may though be that part of the “lower
productivity” of nurses and midwives is a reflection of their traditionally narrower range of permissible clinical
interventions compared to physicians.) Similarly, Delamaire and Lafortune (23) concluded that savings from employing
the cheaper nurse workforce may be offset by longer consultations times and higher rates of patient referrals. A
modelling study (24) based on two randomized controlled trials conducted in the United Kingdom corroborated this
further by showing that there was little difference in costs of employing a nurse practitioner compared to a salaried
GP. In addition, a recent systematic review concluded that the available evidence on the impact of nurse-led care on
costs was insufficient (25).

248 Health Employment and Economic Growth: An Evidence Base

good care as doctors for a range of services, with high satisfaction rates reported by
patients (23).

Another review article (26) cited evidence that a higher proportion of registered
nurses in the health workforce was associated with better health outcomes, and
also noted the evidence that registered nurses might provide more cost-effective
care than less costly licensed practical nurses, as the former will save both time
and money compared to the latter. In another study, Aiken et al. (27) found that
a greater proportion of nurses with International Baccalaureate degrees in the
hospital staff was inversely related to mortality. However, this does not necessarily
prove that investing in the education of nurses is cost-effective from a health care
system perspective, as one also needs to consider the cost of education and of
higher salaries.

A recent systematic review focusing on RCT studies (25) summarized evidence

showing that nurse-led care was associated with higher patient satisfaction and
reduced risk of hospital admission and mortality, although the authors commented
on numerous methodological limitations (for example, lack of concealment of
treatment, small sample sizes, and heterogeneity of reported outcomes and settings).

In one example of a high-quality RCT study conducted in the United States (28),
patients randomly assigned to primary care by nurse practitioners or physicians
after emergency department and urgent care visits were found to have no significant
differences in most measured outcomes, which included patient satisfaction, health
status, psychological test results after six months of follow-up, and service utilization
for one year after initial appointment. The only exceptions were average satisfaction
ratings, which were slightly higher for those assigned to physicians (4.2 versus
4.1 on a 5-point scale); and diastolic blood pressure, which was lower for nursing
practitioner patients (82 versus 85 mm Hg).

In a low- or middle-income country context, HIV-positive patients in South Africa

received similar standards of care regardless of whether they were randomized to be
treated with antiretroviral therapy drugs by primary care nurses or physicians (29),
with no difference in health outcomes between the two groups.

PART II: Economic Value and Investment | CHAPTER 10 249

 Another study estimated the effectiveness of different models of care during
pregnancy. A particular interest of this study was the comparison of a “midwife-led
continuity model” with alternative, more expensive care approaches (for example
using obstetricians, or doctor led), finding that midwife-led models were associated
with a superior outcome in several cases (30), including fewer instrumental vaginal
births, preterm births less than 37 weeks, cases of fetal loss before and after 24
weeks, and neonatal deaths. A similar positive conclusion applied to the effects
of midwife-led care for low-risk women (compared to more expensive doctor-led
care), as was found in another review (20). Further encouraging evidence about the
positive impact midwifery can make to outcomes can be found in studies by Tracy,
Hartz et al. (31) and Tracy, Welsh et al. (32), and in the recent reviews included in
the Lancet series on midwifery by ten Hoope-Bender et al. (2) and Renfrew et al.
(33).

3.3 Methodological challenges

As alluded to several times above when referring to the conclusions of previous

systematic reviews in this field, the existing evidence base is fraught with multiple
challenges that make drawing relevant, credible conclusions on the effectiveness
and cost-effectiveness of nursing and midwifery interventions more difficult than
for standard clinical interventions. Here we emphasise and briefly discuss two
principal challenges: (a) assessing the causal impact of interventions; and (b)
choosing the correct perspective for the cost-effectiveness analysis.

3.3.1 Assessing the causal impact of nursing and midwifery interventions

One of the most important issues common to all studies is the difficulty of
establishing causality, as assignment of people to care by doctors or nurses/
midwives is typically non-random, and usually depends on the severity of
the underlying illness. Thus, nurses are more likely to treat healthier patients
(compared to doctors), and midwives tend to focus more (compared to
obstetricians) on women who are less likely to have serious complications (34).
In their recent systematic review, Twigg et al. (19) could not identify a single RCT
that considered both nurse staffing levels and health outcomes simultaneously. In

250 Health Employment and Economic Growth: An Evidence Base

general, studies should correct for a number of potential sources of confounding,
such as the case mix of patients and the competence and training of nurses and
midwives, as well as other medical staff (14).

The question of causality in particular is difficult to resolve, but some efforts

have been undertaken to apply advanced econometric techniques in order to
maximize the degree of causal inference in cases where no RCT evidence was
available or feasible. For example, Daysal, Trandafir and van Ewijk (35) exploited
a unique policy rule in the Netherlands (using data from 2000 to 2008) requiring
that pregnant low-risk women are supervised by midwives when they give
birth. By using fuzzy regression discontinuity design, they found that there was
no benefit (measured by 7-day and 28-day mortality and Apgar scores) from
using more expensive obstetrician care compared to the care by midwives, again
suggesting that nurses offer good value for money (at least in low-risk cases)
compared to a more expensive workforce, and that their utilization may lead to
potential cost savings. Likewise, using a quasi-experimental design, Miller (34)
estimated that midwife-promoting public policies in the United States led to a
statistically significant drop in neonatal deaths. The author suggested that this
could be due to multiple potential benefits of midwifery care, including fewer
medical interventions, better health outcomes and better patient experience,
which probably comes at lower costs, though they caution that in more difficult
pregnancies there is a greater risk of complications, which midwives may be less
qualified to deal with than doctors.

Even sophisticated econometric or statistical designs though will struggle to

overcome the problem that, as argued by Castillo-Laborde (9), nurses (and midwives)
usually work as part of a multidisciplinary team, making their specific contribution
difficult to isolate from that of other medical staff, particularly doctors (36, 37).

Estimating the effect of nursing and midwifery on resource utilization (and hence
costs) alone is also challenging. This is because these costs may be offset as a result
of various events (related to changes in staffing scenarios for nurses and midwives)
that are difficult to capture empirically, such as reduced length of stay due to better
patient care, fewer readmissions, less sickness absence, less use of emergency

PART II: Economic Value and Investment | CHAPTER 10 251

 rooms, reduction in the number of adverse events, better staff retention of nurses
(who may appreciate staff training opportunities, for example, or a less stressful
work environment), or other benefits, such as greater productivity (5, 26, 37–39).7

3.3.2 Choosing the “right” perspective to adopt in cost-effectiveness

evaluations

Another important issue to consider when assessing the cost-effectiveness of

nursing and midwifery is the question of which perspective to adopt (especially
with respect to the costs incurred). If, for example, nursing is not directly
reimbursed in the hospital setting, then nursing may be considered a “cost” that
needs to be controlled from the hospital point of view (26), and lower-than-
optimal nursing levels may result. However, such a decision may entail adverse
effects on patient safety, potentially causing medical errors (37). There might also
be different incentives for different payers. For example, in the United States,
Medicaid may pay for nurse staffing in nursing homes, while Medicare would
benefit from the resulting reduced hospital expenditures (26). On the other hand,
payers may care more about cost savings for patients that may result from the
better provision of nursing care (16), and may therefore take into account a wider
range of outcomes related to nursing care. Alternatively, changes in nurse staffing
levels or skills mix may be judged cost-effective from the societal but not from the
payer or provider perspectives (19).

Other challenges include differences in the definition and classification of

the workforce of nurses and midwives across different locations, which – at
least in cross-country studies – may produce measurement error, leading to
underestimation of, for instance, the association between nursing and midwifery
staffing levels and health outcomes (7). The results may also vary depending on the
population studied and variable definitions and conceptualization of nurse staffing
or skills mix (19). Studies in the nursing and midwifery area have also been noted
to suffer from a commonly small sample size, variations in cost measurements
across locations, lack of consideration of potential indirect costs, and a lack of
more widely comparable outcome indicators such as QALYs (5).

7 For example, one review found that increased nurse staffing levels led to reduced length of stay by 24% in inten-
sive care units and by 31% in surgical patients (13, 37).

252 Health Employment and Economic Growth: An Evidence Base

4. Concluding remarks

In this chapter we have tried to convey what is meant by “cost-effectiveness” of

investment in nursing and midwifery; and we have reviewed what the current
state of the empirical evidence tells us about the extent to which various nursing
and midwifery interventions could be considered effective or even cost-effective.
We have focused in particular on two types of policy questions: (a) increasing the
numbers of nurses and midwives; and (b) shifting the skills mix away from more
expensive medical staff (especially doctors) to nurses and midwives.

We have drawn on evidence of both effectiveness (which included studies on

the potential role of nursing and midwifery as determinants of health) and
– where available – cost-effectiveness. In light of what remains a still scarce,
underdeveloped cost-effectiveness evidence base, it is important to consider
evidence of effectiveness, in the absence of which there can be no reason to assume
that cost-effectiveness could ever result.

On the whole, the good news is that there are certainly selected primary studies
that can support both the effectiveness and cost-effectiveness case for nursing and
midwifery interventions. However, we need to acknowledge that the evidence
base as a whole appears decidedly mixed, if less so in terms of effectiveness
than cost-effectiveness (where there is much more limited evidence to start
with). Many of the systematic reviews discussed in this chapter concluded that
the evidence base was “inconclusive”. More often than not this was attributed
to the several methodological challenges involved in the assessment of (cost)
effectiveness of nursing and midwifery policies. What evidence exists is also – not
surprisingly – biased towards high-income countries. Most of the evidence on
the impact of nurse staffing levels was collected in acute care settings, and hence
may not be generalizable to health care more broadly (40). The evidence on the
impact of the skills mix has been limited mostly to primary care settings in – yet

PART II: Economic Value and Investment | CHAPTER 10 253

 again – high-income countries, with the focus on the role of nurse practitioners,
although in some studies the role of nurses in inpatient care has also been studied
(40).

Looking ahead, there is great scope for more work in this area, especially for
low- and middle-income countries. As there remain uncertainties in the precise
contribution of nursing and midwifery to health outcomes, we recommend as a
priority more work on the sheer effectiveness of related policies, possibly trying
to exploit natural experiments in this area, along the lines of Daysal et al. (35) or
Miller (34).

254 Health Employment and Economic Growth: An Evidence Base

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256 Health Employment and Economic Growth: An Evidence Base

ANNEX 1: Brief overview of the most common methods
of economic evaluation in health care

1. Cost-consequences analysis
All benefits of an intervention are listed, no matter in which area or in what
kind of unit they occur. The same is done with costs. No surrogate benefit unit
is built and no ratio is calculated. Therefore it is not considered a full economic
evaluation.

Strengths: Shows benefits and costs beyond budgetary boundaries, easy to

measure;

Weaknesses: No comprehensive unit, so hard to define the value for money

compared to other interventions.

2. Cost-effectiveness analysis
The health benefits in this type of evaluation are measured in a single natural unit
(e.g. life-years gained, weight loss, increase in condom use). All alternatives have
to use the same natural unit in order to be comparable.

Strengths: Easy to measure

Weaknesses: Focus on one benefit only (hard to choose the most relevant one);
comparability of different interventions might be difficult.

3. Cost-utility analysis
Health outcomes are measured in a comprehensive unit representing quantity
and quality of life (for example QALYs, DALYs). This surrogate unit is derived
from an algorithm using life-years multiplied with utility scores for the respective
health states, which represent the quality of life during the time frame under
analysis.

Strengths: Comprehensive unit; comparable regardless the intervention; highly

relevant to health goal (measure of quantity and quality of life);

PART II: Economic Value and Investment | CHAPTER 10 257

 Weaknesses: Sophisticated method to derive health states as primary data, therefore
often use of theoretical models and secondary data; focus on health benefits only.

4. Cost–benefit analysis
All consequences of an intervention are converted to their monetary equivalent using
methods such as “willingness to pay”. Money units become the common currency to
compare across alternatives.

Strengths: Most comprehensive unit; interventions even comparable across

budgetary borders (e.g. traffic, education);

Weaknesses: Methodological difficulties with the empirical investigation of

monetary values for health outcomes; society still has some ethical constraints
putting a monetary value on health outcomes.

258 Health Employment and Economic Growth: An Evidence Base

 PART III
Education
and Production

259
CHAPTER 11

The economics of health professional

education and careers:
A health labour market perspective
Barbara McPake, Edson Araújo Correia, Gillian Lê

Abstract
Taking a labour market perspective, this chapter investigates current obstacles
to and potential policy solutions for the transformation of health professional
education that is required to reorientate the health workforce over the next
15 years towards Sustainable Development Goals for health.

At the core of the Sustainable Development Goal for Health is universal health
coverage. Universal health coverage is not possible without an adequate volume
of educated and trained professionals to deliver quality health care services. The
processes by which health professionals are educated, trained and supported
throughout their careers are therefore critical. The health care profession
is currently facing a triple challenge of changing population health needs,
professional preference for specialization and the variable quality of education.
An integrative review of 206 academic papers was undertaken to consider
these issues.

This chapter argues that the evolution of professional clinical education and
health labour markets reflects underlying market failures by which the social
return to those health professions most important for responding to population
need is undervalued. It calls for policy-makers to recognize the importance of
market forces in professional education, training and labour policies; to redirect

(continued on page 262)

PART III: Education and Production | CHAPTER 11 261

 ABSTRACT (continued)
public investments in education to primary care, low and mid-level providers and
innovative pedagogy; to balance professional with public representation in key
policy and regulatory bodies that influence the rate of return within all clinical
professions; to mobilize private international investment in systems for regulating
private training providers; and to prioritize research that includes evaluation of the
social rate of return in economic analyses.

1. Introduction
Sustainable Development Goal 3, under the 2030 Agenda for Sustainable
Development, aims to “ensure healthy lives and promote well-being for all at all ages”
(1). The goal identifies 13 targets that have universal health coverage at their heart.
Universal health coverage is not possible without an adequate number of educated
and trained professionals to deliver high-quality health care services. The processes
by which professionals are selected for training, educated and deployed are therefore
critical. Most governments recognize the importance of these processes and heavily
subsidize the education and ongoing training of health professionals, while seeking
to regulate the numbers and types of jobs as well as the quality of health workers’
training (2).

However, market forces are often more influential than government policies on
professional career choices. The interaction between two markets – the education
system and the health system – is mediated by a third, namely the labour market for
health workers. Ideally, these intersecting markets produce a balance between the
health needs of the population; the numbers and types of health workers required
to meet those needs; and the supply of these health workers from educational
institutions. But the market for health professional training and its outcomes is
skewed by market failures inherent to health care that result in two significant
mismatches (Figure 1).

262 Health Employment and Economic Growth: An Evidence Base

Figure 1

Interaction between education and labour markets,

and health systems

HEALTH LABOUR
MARKET
HEALTH
POPULATION PROFESSIONALS
HEALTH NEEDS DEMAND SUPPLY
TRAINING &
Illness that can Perceived need Availability CAREER CHOICES
be changed for care of staff to fill
Demand & supply
through health positions
+ of training places
promotion, Willingness to for generalists/
prevention willingness accept pay &
to pay for it specialists.
or curative conditions
interventions Public subsidy
levels

MISMATCH MISMATCH
Results in neglect of poor, Results in labour shortage,
rural, remote populations underemployment or
& promotive/preventative unemployment
interventions

Professional wage rates do not reflect the contribution of the work of health
professionals to public health (that is, its social return). This is because individuals
purchasing health care do not always know what they need to promote their own
health, while individuals with high need for primary care tend to have low ability
to pay, thereby reducing demand. Government efforts to replace patient ability to
pay with public subsidy are hampered by weak fiscal capacity, weak governance or
weak political will. Taken together, these conditions contribute to the undervaluing
in the marketplace of the social return to the types of health professional work that
are most responsive to population need. Trends in the development of the health
professions and in health professional training reflect these market failures. This
briefing will consider:

• global and regional trends related to the development of health professions,

disaggregated by national wealth where possible;

PART III: Education and Production | CHAPTER 11 263

 • value and effectiveness of health professional education of different types,
particularly in the context of universal health coverage;

• evolution of health labour and care markets and their interaction with health
professional education;

• policies to better align education, employment and health labour market forces
to meet population health needs.

An integrative review approach was used to synthesize academic literature. The

review included all literature relevant to the topic of interest but did not aim to
evaluate methods or address study weaknesses. PubMed, CINAHL and SciELO
databases were searched using search terms reported in Annex 1. Articles
published before 1990 were excluded, along with opinion papers and grey
literature. Articles published in English, Portuguese and Spanish were included,
and 1334 sources were retrieved. Clearly irrelevant material was excluded. Articles
were further reviewed for relevance, coded by clinical profession and geographical
region, and categorized according to the four topics listed above. A total of 206
sources remained. To ensure consistency in analysis, only the clinical health
professions (doctor, nurse, midwife, dentist) were chosen. This briefing then
addresses particularly clinical professions and their development.

2. Global trends related to development of

health professions
The most recently available Global Burden of Disease Study shows that declining
mortality and consequent ageing of populations is correlated with increased
incidence of chronic illness and disability, and with absolute increases in years
lived with disability. This is not a phenomenon of high-income countries alone:
years lived with disability increased between 1990 and 2013 for 139 out of 188
countries. The fastest growing condition has been diabetes, with back pain, neck
pain and other musculoskeletal disorders as the dominant conditions in the
disease burden. That increasing numbers of people now suffer from multiple
conditions (“multimorbidity”) is an equally important phenomenon (3).

264 Health Employment and Economic Growth: An Evidence Base

Most of these conditions call for preventive and promotive action in the primary
care system and at the community level. By the time such conditions have become
acute and require specialist (tertiary) care, opportunities to reduce morbidity are
more limited and costs associated with intervention much greater. Multimorbidity
challenges the specialist model of care, as the multiple conditions do not fall into
a single specialist area and interact in ways that require a breadth (rather than
depth) of medical and clinical knowledge. There is, therefore, an increasing need
for clinical professionals with broad, general knowledge operating at primary and
community levels of the health system.

An increasing burden of multimorbid conditions at tertiary level reflects the

failure of health systems to invest adequately in health promotion, primary and
secondary prevention and disease management. The average Medicare patient
in the United States of America with one chronic condition sees four physicians
per year, while those with five or more chronic conditions see 14 different
physicians per year, which in 2002 already accounted for 76% of national
Medicare expenditures (4).

In countries at all stages of development, there are growing shortages of

professionals in community and primary health care. A 27% shortage of adult
generalist physicians is projected for the United States by 2025 (4). Similar
problems have been identified in Australia and New Zealand (5), and it is
determined that Brazil, China, India and the Russian Federation will have to
prioritize primary care development and the redistribution of their health
workforce if universal health coverage is to be achieved in those countries (6).
With the shortage of generalists and the difficulty for government to redirect those
with clinical qualifications to generalist primary and community-based roles,
greater attention has been paid to task shifting to nursing professions and “mid-
level providers” who may be equally competent in delivering a large proportion of
the services traditionally provided by primary care practitioners.

In many countries, mid-level providers play a major role in providing primary

care services (7, 8). In the United States, both the nurse practitioner and physician
assistant professions were originally created to strengthen the primary care
workforce. However, these cadres have increasingly themselves specialized and

PART III: Education and Production | CHAPTER 11 265

 a declining proportion now enter primary care. For instance, 42% of patient
visits to these cadres in the United States were in the offices of specialists,
not primary care providers, while the number of graduates fell between 1998
and 2005 (4). By contrast, in sub-Saharan Africa mid-level providers (often
known as clinical officers in anglophone countries) work across primary
care settings (9).

Parallel with mid-level providers, low-level workers have been increasingly

promoted (10). In high-income countries, the roles of unlicensed or
unregistered assistive personnel who function as patient care assistants to
nurses and allied health professionals in hospital and long-term care settings
has expanded. In low- and middle-income countries, community health
workers have been used to improve access to care and widen promotion of
health education (11, 12).

A growing body of evidence has demonstrated the value of all these low-
and mid-level providers to improve patient outcomes in primary care and
other settings (7, 8, 13, 14). The shorter training time for these providers has
helped health systems respond more rapidly to local demands for preventive
and primary care services. The HIV/AIDS epidemic in sub-Saharan Africa
illustrates how mid-level provider roles have emerged and enabled primary
care and obstetric services to expand (15, 16).

3. Value and effectiveness of clinical education

Trends in specialty preference vary by cadre, and most literature concerns
trends for doctors, dentists and nurses. The literature for high-income
countries shows an increasing trend for doctor specialization in surgical and
medical subspecialties and a declining trend in the popularity of general
practice. In the United States, between 2001 and 2010 there was a 6.3%
decrease in the number of graduate residents entering primary care but a 45%
increase in residents entering subspecialties (17). This led the United States
Institute of Medicine to call for major reforms in graduate medical education,
including reduced subsidy of specialized training (18).

266 Health Employment and Economic Growth: An Evidence Base

In the United Kingdom, the proportion of medical graduates choosing general
practice decreased from 45% in 1983 to 23% in 2002 (19–21). After reforms in
2004 there have been almost two applicants for every general practitioner (GP)
specialty training vacancy, although the trend is in decline (22). In Germany,
between 1996 and 2008, the proportion of specialists increased from 45% to 52%,
while more than 2000 medical offices for general practitioners went vacant in
2009 (23). In Canada, the proportion of medical graduates in family medicine
residencies fell from 32% in 1994 to 26% in 2004 (24).

National-level data on specialization over the course of a medical career in

low- and middle-income countries is limited to preference surveys carried out
in medical schools or hospitals. These showed high preference for specialization
and low popularity of general practice (25, 26). Less than 10% of physicians in
emerging markets such as Egypt, India, Jordan, Tunisia and Turkey choose family
medicine (27).

Globally among dentists, willingness to undertake specialty training appears

mixed. In the United States, one survey showed that only 24% of practising
dentists were specialists (28), while in Saudi Arabia the majority of dentists
are specialists (in areas such as restorative dentistry), but this includes a
specialization in general dentistry (29). Dental students in the United Kingdom
and the United States in recent years have showed increasing intent to specialize
(30, 31). Likewise, an emerging trend in low- and middle-income countries is
specialization, even though significant proportions of their populations are yet to
access basic dental services. In Mexico, specialist dentists increased from 5% to
11% between 2000 and 2008 (32), with similar findings in Brazil (33).

There is little longitudinal evidence that follows graduates through their training
and into employment to understand career progression. This is important, because
it is known that students in a clinical or primary care phase of their study are
more likely to report that phase as a career preference. In Lao People’s Democratic
Republic, nurse students demonstrated significant differences in their respective

PART III: Education and Production | CHAPTER 11 267

 preferences for rural job posting compared to practising nurses (34). Gender has
a strong influence on preferences, followed by career motivation and life goals
(35). For instance, United Kingdom medical students cited life goals and work–life
balance as key reasons for choosing general practice. There has been little evaluation
of initiatives that incentivized change between specialities (including a primary care
specialization), particularly in relation to continuous professional development.
The impact of policy experiments that created a rural GP specialization, such as in
Australia (36), is yet to be robustly demonstrated.

The trend towards specialization by doctors appears to be driven by a significantly

higher rate of return to specialized education over a general medical education and
a widening gap between the two in Organisation for Economic Co-operation and
Development (OECD) countries, although there are outliers (37) (Figures 2 and 3).

Figure 2.

Hours-adjusted internal rate of return on additional training for five

surgical specialties and primary care medicine

60 General surgery
Otolaryngology
50
Internal rate of return, %

Orthopedics
Urology
40
Ophthalmology
30 Primary care

20

10

0
1992 1993 1994 1995 1996 1997 1998
Year

Source: Reprinted from The Economics of Health Professional Education and Careers:
Insight from a Literature Review, World Bank (2015).

268 Health Employment and Economic Growth: An Evidence Base

Figure 3

Growth in the remuneration of GPs and specialists, 2005–2013 (or

nearest year)

GPs Specialists
7
6.2 6.3
6
Average annual growth rate

5.5
(%, in nominal terms)

5 4.8 4.8
4.6
4.1 4.1 4.2
4 3.7
3.4
3 2.9 3.0 2.8 2.9 2.9
2.4 2.6
2.3
2
1.5
1.2
1
0.3
0
ria

da

ce

ry

el

s
nd
an

an

ur

ic
ra
ga
iu
st

na

an

ex
bo
nl

el

Is

rla
lg
Au

un
Ca

Fr

M
Fi

Ic
Be

he
H

xe

et
Lu

Note: Growth rate for the Netherlands and Luxembourg is for self-employed GPs and specialists. N
Source: OECD (37).

Studies of financial returns to specialist nurse training show more mixed results, with
some types of advanced training evaluated showing negative returns (38). Differences
in economic return influence the status and prestige attached to different clinical
professions. This includes the influence of technology, in which certain specialist
roles are associated with increasing productivity, and the greater role of specialists
in institutionalized price-setting processes, such as setting reimbursement levels of
major insurers. Training schools reflect those dual pressures, with organizational
and cultural influences reinforcing trends towards ever greater specialization and
movement away from primary care, particularly for the clinical professions but also
for other health professionals.

Few studies have either evaluated separately, or included in any evaluation, the social
rates of return to health professional training and specialization. However, changes

PART III: Education and Production | CHAPTER 11 269

 in the global burden of disease and illness suggest that social rates of return would
favour generalist education, equipping health professionals to work at primary and
community levels. There is evidence that training institutions based among rural or
other underserved populations, and focused on primary and community care, are more
successful in encouraging careers in those areas (39–41).

The market failure by which the health needs of the population are not reflected in
relative pay means that clinical professionals are directed away from where they are
most needed for universal health coverage. However, it should be recognized that
the factors shaping higher returns to specialization are not entirely driven by market
forces. Where prices and pay are in some part determined by regulatory systems,
such systems are often captured by specialists who clearly face conflicts of interest in
that role.

4. Evolution of health labour and care markets and

their interaction with professional education
There is a marked difference between market trends in professional education in
low- and middle-income countries as compared to high-income countries. Private
professional training schools in high-income countries are usually state funded
and non-profit-making. In low- and middle-income countries, private educational
institutions have proliferated, are dependent on tuition fees, and are profit-oriented
(42). Here the focus is on private education.

Private clinical and medical education of doctors has been a relatively new
phenomenon in Africa (Figure 4), emerging in the 1990s and strengthening since
2000 (43). In Asia, India has more private medical schools than any other country
in the world; more than half of the schools in Bangladesh, China, Japan, Nepal,
Pakistan, the Republic of Korea and Taiwan (China) are private; the Islamic Republic
of Iran and Mongolia have far fewer private medical training institutions, while the
Democratic People’s Republic of Korea, Israel, Kuwait, Myanmar, Sri Lanka and
Thailand have none. In the Middle East, private medical and clinical training is
wholly dominant (44).

270 Health Employment and Economic Growth: An Evidence Base

Figure 4

Founding dates of medical schools in sub-Saharan Africa by sector

40
Public
33
Number of medical schools

Private, non-profit, other

30
Private, non-profit, faith-based 25
(N=100)

20 Private, for profit

16
13
10
6
3 2
1 1
0
0
1910 1920 1930 1940 1950 1960 1970 1980 1990 2000
-19 -29 -39 -49 -59 -69 -79 -89 -99 -09

Note: Five schools did not respond

Source: Mullan et al. (43).

The growth of private education for doctors is most documented in India.

Privatization of clinical education in India has been rapid, and correlated with
inadequate and corrupt regulation and poor quality of teaching (45–49). With
such rapid expansion, faculty shortfalls are experienced (50), multiplying concerns
about the quality of education on offer. Demand for faculty members in private
institutions also attracts staff from public institutions through higher wages. Faculty
shortfalls in the public sector result, especially in sectors with acute shortages,
such as forensic medicine and radiodiagnosis (51). In addition, public wage
regulated systems, which set pay scales by seniority rather than market forces,
are undermined. The task of regulation is complex in a large country with a mix
of regulatory responsibilities between federal and state levels, and several studies
suggest that it is ineffective (46, 49, 52).

India, Kenya, South Africa and Thailand are experiencing increased private sector
provision of nurses. South African nurses graduating from private institutions
increased from 45% in 2001 to 66% in 2004, while in Thailand this proportion
grew from 20% in 2001 to 24% in 2010. In Kenya, 35 out of 68 nursing institutions

PART III: Education and Production | CHAPTER 11 271

 were privately run in 2009/2010. Concerns about quality have inevitably arisen.
Over 61% of nursing colleges in India were reported as unsuitable for training
nurses. Thailand was judged to have lower graduate quality among privately trained
students, while in Kenya the tutor–student ratio was nearly 3 times higher in
private than in public training institutions (53). In Nepal, opportunities for student
nurse placements were a key obstacle to students gaining the requisite experience
to graduate, thereby creating a subsidiary market in placement opportunities.
Evidence also exists of failures in the licensing authority and external examination
system. In addition, high demand for places in training institutions was linked
to expectations of working abroad – curricula of both public and private training
institutions were reformed explicitly to cater to the international market (54).

The commercialization of clinical professional training appears to be associated

with a lowered quality of education that is rooted in market failure. Failures in the
health care market, associated with the inability of patients to distinguish between
the products of reliable and unreliable health professional training systems, allow
demand for poor-quality training to rise. In all settings regulation is essential,
but the capacity of low- and middle-income countries to manage the complex
regulatory issues involved appears insufficient at this time.

5. Aligning health education, employment and

labour markets with population health needs
This chapter has argued that the evolution of professional clinical education and
health labour markets reflects underlying market failures by which the social
return to those health professions that are most important for responding to
population need is undervalued. However, many evidence gaps exist. There is very
little evidence particularly in low- and middle-income countries. We have little
understanding of the impact of mid-level providers on the health system. And
there is little understanding of how the growth in private sector health professional
training institutions is impacting on health and education systems generally. Taking
these gaps into account, the following five policy options are proposed:

272 Health Employment and Economic Growth: An Evidence Base

Policy option 1
Recognize the importance of market forces in professional education,
training and labour policies
Any policy intended to rebalance the health system towards primary care should
seek to align regulatory and market signals to support that intention. Planning
and regulatory policies that ignore market forces will fail. There are examples of
policies that invested in training of health worker cadres deemed in shortage while
maintaining unattractive pay and working conditions, resulting in a supply of trained
personnel who were hard to attract to empty posts, difficult to retain, and likely to
seek further training to redirect their careers. Evidence from the United Kingdom’s
experiment with a sharp increase in general practice pay suggests that where market
and regulatory signals are aligned, a significant and quick response in favour of
primary care can result.

Practically, if the cost of education borne by any one student is deemed too
expensive, low student numbers will result, as will student expectations of overall
lower lifetime earnings for a career in primary care. This could be offset by
redirecting public investments in health professional education.

Policy option 2
Redirect public investments in education to primary care and to
low- and mid-level providers

Primary care education should receive higher public subsidy than specialist
education on the rationale that public subsidy should be focused where public
returns are highest. Students of clinical specializations could fund their own
education on the basis that returns on specialization are mostly private. Most
countries generally do not distinguish between specialist and generalist training
in allocating educational subsidy. The allocation of subsidy should also reflect
recognition that students from rural backgrounds are more likely to take up rural
general practice, and students from lower socioeconomic backgrounds are more
willing to take up community-based practice. This has been established in several
contexts. Institutions in such settings should be prioritized for public investment
over urban and higher socioeconomic contexts.

PART III: Education and Production | CHAPTER 11 273

 Education and training of mid- and low-level providers should be prioritized, as
there is good evidence of a high social rate of return. This appears most effective
where opportunity to specialize is limited or there is an opportunity to specialize in
primary care. It is still essential to ensure that labour market signals align with any
such redirection, for instance by ensuring that working conditions are attractive to
new cadres. Practically, policy would need to address the ways in which new cadres
substitute and complement existing cadres so that effective teams may be configured,
with implications for training curricula, numbers and ongoing professional
development.

Policy option 3
Balance professional with public representation in key policy and regulatory
bodies that influence the rate of return within all clinical professions

A conflict of interest for professional representatives in determining the relative

rates of return to specialist over generalist education is apparent if professional
representatives on policy and regulatory bodies are predominantly specialists.
Decisions about the investment of public resources for the public good should be
separated from that of professional vested interest (promoted through professional
associations and colleges). It may be difficult to ensure greater representation of
generalists given the usual hierarchies within the professions; public representation
may provide the more feasible route to balance. Practically, political will is needed for
this to occur.

Policy option 4
Mobilize private international investment in systems for regulating private
training providers

Private hospitals and training institutions could collaborate to invest in regulatory

mechanisms such as accreditation for overseas practice. Current accreditation
focuses on evaluating the skills of individuals interested in migration. However, there
is an opportunity to improve the quality of locally employed graduates by making
use of foreign accreditation standards to educate all students, in part as marketing
to the middle classes that they usually serve. In this way, local education standards
could be driven up. Funding could be acquired from companies that place graduates

274 Health Employment and Economic Growth: An Evidence Base

overseas, as they have a clear profit motive to achieve higher education standards and
internationally recognized rigour in their regulation.

Policy option 5
Prioritize research that includes evaluation of the social rate of return
in economic analyses

Over the midterm, research to ensure that social returns are appropriately evaluated
in economic analyses will assist decision-makers in government and influential
regulatory bodies to reduce the impact of market failure.

Acknowledgements

This paper draws significantly on Barbara McPake, Allison Squires, Agya Mahat,
Edson Araujo (2015): The economics of health professional education and careers:
insights from a literature review, unpublished literature review prepared for the
World Bank.

The Economics of Health Professional Education and Careers: Insights from a Literature
Review. World Bank Studies. Washington,
DC: World Bank. doi:lO.1596/978-1-4648-0616-2.
License: Creative Commons Attribution CC BY 3.0 IGO
© by International Bank for Reconstruction and Development/The World Bank

PART III: Education and Production | CHAPTER 11 275

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278 Health Employment and Economic Growth: An Evidence Base

ANNEX 1: Literature search strategy

Table 1

Search terms

Entry Barrier Nurs Assist Public

Specialty Choice Doctor Role Private

Career Choice Physician Educat

Education Market Dent Auxil

Training School Pharmac Technic

Vocational Training School Mid(-)Level

Technical Training School Clinic

Bachelor Training School

Graduate Training School

Post(-)Graduate Training School

Rate Of Return

Regulation

Education Quality

Education Impact

Curricul

Health Labo(u)r Market

Note: Items in the same column were searched using the Boolean term “OR” or its equivalent and those in
other columns using the Boolean term “AND”. MeSH terms were searched in PubMed only.

PART III: Education and Production | CHAPTER 11 279

 Table 2

MeSH terms

Higher-level heading Subheading (not all available for all terms)

Nursing specialty Economics
Medical specialty Education
Career choice(s) Manpower
Nursing education research Supply and distribution
Nurse training school(s) Statistics and numerical data
Education, professional Trends
Nursing auxiliaries

280 Health Employment and Economic Growth: An Evidence Base

CHAPTER 12

Transforming the health workforce:

Unleashing the potential of technical and
vocational education and training
Julian Fisher, Keith Holmes, Borhene Chakroun

Abstract
This chapter argues that special attention should be given to education and
training for the achievement of universal health coverage. An intersectoral
approach to Sustainable Development Goals 3 and 4 would help to unleash the
potential of technical and vocational education and training (TVET) for health
workforce employment, economic growth and social equity, supporting the
implementation of the 2030 Agenda for Sustainable Development as a whole.

The conventional model of health workforce education, premised upon a

narrowing formal schooling pipeline, oriented towards pre-service education and
training and founded on a biomedical approach, will be unable to meet the needs of
the future health workforce. Significant bottlenecks are the proportion of students
attaining upper secondary education and the shortage of qualified teachers,
particularly in low-income countries. TVET is a well established and increasingly
prominent subsector within education. Its potential for transforming the health
workforce has, however, been largely overlooked. TVET, as part of lifelong
learning, can facilitate school-to-work transitions, youth apprenticeships,
employment and decent work, continuing professional development, recognition
of prior learning, and development of the range of skills and competencies
required in the health sector. The chapter identifies four related domains of policy
action to unleash the potential of TVET through intersectoral collaboration:
governance and programming; data, knowledge and research; innovation and
technology; and funding and investment.

PART III: Education and Production | CHAPTER 12 281

 1. The 2030 Agenda for Sustainable Development:
a basis for intersectoral action

Education and training should be a strategic priority for universal health coverage,
employment and decent work, and inclusive economic growth. Stakeholders in
health and social care, in their actions towards Sustainable Development Goal (SDG)
3 (Ensure healthy lives and promote well-being for all at all ages) should give focused
attention to SDG 4 (Ensure inclusive and equitable quality education and promote
lifelong learning opportunities for all) and the associated Education 2030 Framework
for Action (1), including target 4.3 (By 2030, ensure equal access for all women
and men to affordable and quality technical, vocational and tertiary education,
including university). SDG 4 recognizes that education has a unique enabling role
across, between and within the SDGs. As the implementation of the 2030 Agenda for
Sustainable Development (2) gets under way, it will be critical to maximize synergies
to ensure that efforts towards meeting the SDGs are convergent, coordinated
and mutually reinforcing.

It is important to recognize the broad scope and aims of technical and vocational
education and training (TVET). According to the 2015 Recommendation concerning
Technical and Vocational Education and Training, adopted by the General
Conference of the United Nations Educational, Scientific and Cultural
Organization (UNESCO),

TVET, as part of lifelong learning, can take place at secondary, post-secondary

and tertiary levels and includes work-based learning and continuing training and
professional development which may lead to qualifications. TVET also includes
a wide range of skills development opportunities attuned to national and local
contexts. Learning to learn and the development of literacy and numeracy skills,
transversal skills and citizenship skills are integral components of TVET (3).

TVET is a well established policy area and increasingly prominent subsector within
education. It is attracting increased interest from various sectors, but has been
largely overlooked for the health workforce until now. An intersectoral approach
to health and education could help to connect TVET systems with strategies on

282 Health Employment and Economic Growth: An Evidence Base

human resources for health planning, including transformative health workforce
education and training, for sustainable development outcomes (4). The development
of education plans for health workers aligned with national health plans should
consider and take into account TVET and the implementation of the 2030 Agenda
for Sustainable Development. These actions would provide diverse learning
pathways needed for the expansion and continuous transformation of health
and social care services and offer a better choice of courses and other learning
opportunities linked to health employment. An integrated, analytical approach that
combines economic growth, social equity and sustainability concerns in a balanced
and strategic manner (5) could assist governments and relevant authorities to
connect TVET systems, including health workforce education and training, with
changing needs and demands.

This chapter focuses on the health workforce – those workers with expertise in
health and social care. However, it also has relevance for the wider group of workers
in health and social sectors and supporting industries (6, 7). It argues that a shift
towards intersectoral SDG 3–SDG 4 planning for health workforce education and
training is needed to respond effectively to evolving health needs and changes in
health labour market demands, health services and local communities, including
those resulting from public health emergencies. Such an approach could catalyse
and drive new thinking and enhance collaboration and cooperation between
ministries of education, health, labour and finance, and other ministries,
professional organizations and stakeholders.

The next section of this chapter elaborates on the shortcomings of the conventional
model of health workforce education and training and on why focused attention
should now be given to education and training systems. The chapter then shows how
TVET within a lifelong learning framework could make a powerful contribution
towards expanding and transforming the health workforce.

The final section proposes four related domains of policy action to unleash
the potential of TVET through intersectoral collaboration: governance and
programming; data, knowledge and research; innovation and resources; and
funding and investment.

PART III: Education and Production | CHAPTER 12 283

 2. Focused attention on education and training
systems as an imperative

Globally, the demand and need for workers with expertise in health and social care is
growing. Projections developed by the World Health Organization (WHO) and the
World Bank identify the need to train and deploy at least 18 million additional health
workers, primarily in low-resource settings, by 2030 (8).

The conventional model of health workforce education and training is premised

upon a narrowing formal schooling pipeline that continues to tertiary education,
and is largely founded upon the biomedical approach to health and illness. This
conventional model is oriented towards formal pre-service health workforce
education and training and it has limited alignment and integration with in-service
training, continuing education and professional development. A rigid and narrowing
pipeline model will be unable to adequately expand, enhance or diversify the health
workforce sufficiently to meet future demands with respect to workforce quantity,
quality and relevance. Hence focused attention on education and training systems,
within the framework of lifelong learning, is an imperative.

As authorities reorient their health workforces towards people-centred and

integrated health services (9), there will be new and various demands on the skills
of physicians, nurses, midwives and other health workers. The conventional pipeline
model cannot satisfactorily adapt competencies and skills of health workers to the
evolving health needs of communities and populations or allow health workers to
acquire competencies and skills necessary for effective cross-sectoral collaboration
and teamwork. Furthermore, because of its orientation towards pre-service health
workforce education and training, this generally impermeable model has difficulty
accommodating increasing occupational and geographical mobility.

The shortcomings of the conventional narrowing pipeline model are most serious
in low-income countries. Significant bottlenecks are the proportion of the student
cohort attaining upper secondary education – projected to be only 26% in low-
income countries by 2030 (10) – and shortages of qualified teachers. Projections
for sub-Saharan Africa have indicated that an extra 2.5 million teachers for lower
secondary education are needed by 2030 (11, 12). Teacher supply for upper

284 Health Employment and Economic Growth: An Evidence Base

secondary education and specialized programmes at the post-secondary and
tertiary levels is also a constraining factor.

Non-inclusive and inequitable access to formal schooling is a compounding

issue. Communities in rural settings suffer disproportionately (13–15). Poorly
nourished children are more likely than well nourished children to have lower
levels of school enrolment and complete fewer years of schooling (16). Girls
from poor backgrounds are particularly at risk of being out of school. The lack of
health workforce students from rural areas is a major reason for the inadequate
supply of rural health workers in developing countries. Yet a health workforce
that is fit for purpose and fit to practice in rural and remote areas will be crucial
to instituting and maintaining universal health coverage with primary health care
access (17).

A significant barrier to increasing the number of primary and secondary

school graduates is the dramatic shortfall in the number of teachers; resultant
overcrowded classrooms lead to poor-quality learning, a restricted number of
subjects available and very limited, if any, capacity for career guidance.

The uneven geographical distribution of health workforce education and

training facilities at national and regional levels reinforces unequal access and
lack of inclusiveness, restricting numbers and limiting the diversity of potential
health workers (18). University-level health workforce education and training is
inadvertently biased towards urban settings and is most abundant in wealthier
countries.

The privatization of health workforce education and training in low- and middle-
income countries is rapid and insufficiently regulated. Faculty recruitment,
retention and increased mobility are also acute challenges
for low-income countries. For example, in the Eastern Mediterranean
Region, countries are experiencing serious shortages due to out-migration
to high-income countries (19).

The critical shortage of health workers is only part of the problem. WHO
guidelines include quality and relevance as core issues that must be addressed

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 in the expansion and reform of health workforce education and training (20).
The conventional knowledge transmission approach does not adequately prepare
health workers, and the biomedical model of health and illness is not well suited
to the development of integrated, people-centred health services. Together, these
two approaches act as a constraint to advancing understanding of the social
determinants of health (21, 22). Despite the shortcomings of conventional models,
health workforce education and training institutions have typically given insufficient
attention to advances in education research, pedagogical innovations and lifelong
learning. A strong focus on education and training system reforms, and the potential
of TVET in particular, is essential.

3. Unleashing the potential of TVET for transforming

the health workforce
Because of its roles in the development of skills in a wide range of occupational fields
and sectors, TVET is a well established policy area that finds itself at the centre stage
of the 2030 Agenda (23). So far the potential of TVET for transforming the health
workforce in support of universal health coverage is largely untapped and unfulfilled.
This is partly due to the priority that has been given to hospital- and university-based
education and training at the undergraduate and postgraduate levels over learning in
other settings, through other modalities and at different levels.

It is important to recognize the broad scope and significance of the 2015

Recommendation concerning Technical and Vocational Education and Training (3).
TVET can potentially offer future and current health workers inclusive, accessible
and flexible interconnected learning opportunities for the development of low-,
middle- and high-level skills that are responsive to community needs. For example,
social protection or first job programmes could help motivate young people to initiate
learning and career pathways in health occupations.

TVET can take place at different levels and sites, and as such might play a role in
helping to connect education subsystems, including health workforce education and
training. Schools, colleges, universities and other tertiary education institutions,
community-based learning facilities, and health workplaces could gradually become
integrated learning centres, which together – as learning networks – would become

286 Health Employment and Economic Growth: An Evidence Base

mutually reinforcing. TVET could also be a strategic modality for addressing
inequalities and promoting equality of opportunity in learning and the world of
work, thereby promoting gender equality, social inclusion and social cohesion.

TVET within a lifelong learning framework could help to establish diverse learning
pathways with multiple entry and exit points, supporting learning and career
progression. Learning pathways could enable learners to navigate between different
sites or levels and to gain recognized skills and qualifications throughout the life
course. Together, such learning networks and learning pathways could form more
flexible and responsive lifelong learning systems.

To promote lifelong learning, many countries have developed a national

qualifications framework as an enabler of effective education, training and
employment policies, and a strategy for strengthening the governance of labour
market and qualification systems.

Qualifications frameworks have been adopted to address various policy issues,

including coordinating and improving education and training quality; making
qualifications more responsive to labour market needs; assisting citizens who have been
historically excluded from national education, training and skills development systems;
supporting horizontal and vertical mobility within and between countries; and fostering
learning and the development of learning and career pathways (24).

The development of national education plans for health workers aligned with
national health plans should take into account the strategic potential of TVET. A
better choice of courses and other learning opportunities linked to health sector
employment should foster the expansion and continuous transformation of health
and social care services in support of universal health coverage (25).

Such education plans for health workers would help to promote the role of teachers
and students in developing creative and critical thinking in interaction with other
actors. This would advance understanding of the synergies between learning
pathways and health pathways. Extending the concept of lifelong learning, including
the provision of global citizenship education (26), to include early childhood can
help harmonize home, family, health and educational environments over time. This

PART III: Education and Production | CHAPTER 12 287

 should support intergenerational health and social care and implies a long-term
relationship between people, providers and health systems.

Other sectors are already benefiting from TVET in terms of the quality and relevance
of their workforces, youth employment and decent work, equity and gender equality,
and inclusive and sustainable economic growth (27, 28). Multistakeholder education
and health systems would need to be increasingly networked to support learning
and complex interactions between their subsystems, as described by the Lancet
Commission (29).

Health and education systems are highly contextualized. The shape and form of
TVET within a lifelong learning framework should be responsive to domestic
circumstances and the evolving global, regional and national health workforce
education and training environment. By drawing attention to issues around the
development relevance of education, TVET can also promote learning about
environmental sustainability as a citizenship and values education issue as well as
an important workplace issue.

The 2015 Recommendation concerning Technical and Vocational Education

and Training (3) provides policy-makers with guidance and a strong impetus
for intersectoral action in the field of lifelong learning. Furthermore, UNESCO’s
Executive Board has recently adopted a new strategy for TVET for the period 2016
to 2021 (30).

To unleash the potential of TVET for the health workforce, intersectoral policy
action could be taken in the following interrelated domains: governance and
programming; data, knowledge and research; innovation and technology; and
funding and investment.

288 Health Employment and Economic Growth: An Evidence Base

4. Implications and policy options

The following subsections elaborate upon the four interrelated domains and
policy options.

4.1 Governance and programming: key policy messages

A joint intersectoral SDG 3–SDG 4 approach can build and strengthen cooperation
within, between and across education and training systems, enabled through
multistakeholder governance arrangements, joint planning and accountability
mechanisms. TVET could facilitate such an approach and should be prioritized
as a modality characterized by diverse programmes, proximity to the world of
work, interconnecting learning pathways and career guidance for social mobility.
Social accountability mechanisms can ensure that TVET within a lifelong learning
framework is responsive to the evolving health needs of communities and attuned to
national and local contexts. The skills and skills mix of the future health workforce,
and the teachers and trainers required, should be taken into account.

Joint intersectoral SDG 3–SDG 4 planning could catalyse and foster the
implementation of TVET for the health workforce within a framework of lifelong
learning. This will necessitate a change in approaches to policy and strategy, shifting
from prioritizing investment in the rigid, selective and specialized pre-service
education and training pipeline towards the development of more flexible lifelong
learning systems. Such changes could include intersectoral approaches to the design
of learning and career pathways for all levels, and mechanisms for developing
learning pathways and school-to-work transition programmes for unemployed
youths into the health sector. Policy-makers should examine and reflect upon the
processes by which health and education sectors can best cooperate to support the
implementation of the 2030 Agenda.

New, more participatory governance arrangements and institutional mechanisms

should be implemented that reflect the need for shared accountability between
the ministries responsible for health and education and other related ministries,
agencies and relevant stakeholders. Efforts in health include the Roadmap for Health
Measurement and Accountability and the 5-Point Call to Action supported by

PART III: Education and Production | CHAPTER 12 289

 WHO, the World Bank and the United States Agency for International Development
(USAID) (31).

Sector skills councils or similar apex bodies could develop plans to admit, educate,
train, deploy, develop and retain health workers, according to health and social care
needs, the absorptive capacity of labour markets and development contexts. This
could include the development of national education plans for health workers – with
an emphasis on youth employment and part-time work – that are aligned with
national health plans.

The case of India, a country taking significant actions towards transforming the
health workforce, is informative here (Box 1).

Box 1

Transforming the health workforce in India

In India, the National Human Resources for Health Cell in the Ministry of
Health and Family Welfare seeks to ensure coordinated and collaborative
efforts towards generating a skilled and qualified health care workforce. The
cell provides constant policy and technical support on overall issues related
to human resources for health (HRH), including and going beyond existing
cadres in the health system. It assists in quantifying and forecasting the need
for various health care professionals and in generating evidence for effective
policy formulation in close coordination with the states. The cell advocates
and is working towards the scale-up of innovative models on HRH issues,
including transforming health workforce education in support of universal
health coverage and liaising with stakeholders to build strategic intelligence
and strengthen capacity in the relevant departments of the ministry. It aims
to facilitate the creation and maintenance of a national health workforce
registry. The cell currently works closely with and provides technical

(continued on page 291

290 Health Employment and Economic Growth: An Evidence Base

 expertise to the departments responsible for medical, nursing, allied health
(including pharmacy) and dental education.

The Ministry of Health and Family Welfare is currently considering

innovative models of care, including integrated health care teams and
greater use of cadres such as physician assistants, nurse practitioners and
integrated behavioural health counsellors. It is focusing on standardizing the
education, training and practice of various unregulated allied and health care
professionals. Experts within various technical teams are working to develop
progressive career pathways in health care with desired qualifications and
experience in addition to a competency-based curriculum. This involves
dialogue and coordination with multiple public and private stakeholders,
more than 1000 specialized institutes across the country, professional
associations and regulatory structures, including state councils, the
Rehabilitation Council of India, the Medical Council of India and the
Indian Nursing Council.
Sources: 32, 33.

Lifelong learning is facilitated by systems for the recognition, validation and

accreditation of learning and competencies. National quality assurance and
accreditation agencies, sector skills councils and other apex bodies can contribute
to regulation through accreditation, licensing and registration processes. The
relicensing of health workers should be linked to in-service training, continuing
education and professional development to ensure that competencies relevant to the
evolving health needs of populations are maintained and updated (34, 35).

Particular efforts should be made to ensure lifelong learning opportunities,

including through TVET, for all health workers. Physician assistants and similar
cadres provide essential services, especially to rural and underserved communities.
Box 2 presents the example of clinical associates in South Africa to illustrate the
versatility of such cadres.

PART III: Education and Production | CHAPTER 12 291

 Box 2

Clinical associates in South Africa

“Clinical associate” is a category of health professional introduced in

South Africa in 2008 with the aim of expanding human resources for
health capacity within the health system. Since then the focus has been on
increasing access to care, not only in district hospitals, but also for rural,
underserved communities. The first group qualified from Walter Sisulu
University in 2011. Clinical associates provide medical services within their
scope of practice, as delegated to them by the supervising physician. Their
practice is team based.

The competency-based curriculum is nationally standardized. It is a three-year

Bachelor of Clinical Medical Practice degree, which qualifies for registration
with the Health Professions Council of South Africa. Currently there are three
universities training clinical associates: the University of Pretoria, Walter Sisulu
University and Witwatersrand University. Most clinical associate students
at the University of Pretoria are recruited from rural areas, where there is a
huge shortage of doctors; graduates are required to go back and work in their
communities for three years after qualifying. The South Africa Military
Health Service also benefits by using clinical associates to help strengthen
its medical teams.
Sources: 36–38.

Accreditation standards that include social accountability as an integral element

could help to ensure that health workforce education and training is attuned to
national and local contexts. As an element of national education plans for health
workers, in-service training, continuing education and professional development
should take into account national policies, strategies and plans for transforming
TVET, and strategies for integrated people-centred health services (39). A social
accountability framework, such as that developed and implemented by Training for
Health Equity Network (THEnet) schools (40), provides peer-developed strategies

292 Health Employment and Economic Growth: An Evidence Base

and tools to move educational programmes towards meeting changing health and
health system needs.

Job and career mobility across national boundaries and new patterns of knowledge
and skills transfer call for policies and mechanisms that recognize, validate and
accredit formal, non-formal and informal learning (35). Forecasts of the skills and
skills mix needed in the future health workforce, and the teachers and trainers
required, should be conducted, taking account of relevant factors, including an
understanding of outward and return migration. Transforming education and
training for the achievement of universal health coverage will require institutional
and instructional reforms (25). At an institutional level, selection and admission
policies for health workforce education and training programmes should seek to
broaden the socioeconomic, cultural and geographical diversity of students, in line
with recommendation 7 of the WHO guidelines on transforming and scaling up
health professionals’ education and training (41). TVET could build and strengthen
capacity to empower and enable the recruitment and training of local students
from underserved areas (42, 43). Similar approaches should be introduced for the
expansion of institutional teaching staff through the recruitment of community-
based clinicians and health workers as educators, as suggested by recommendation 3
of the WHO transformative education guidelines (41). This should be accompanied
by reward systems and merit-based career development opportunities with
appropriate levels of flexibility and autonomy.

Institutional commitment and leadership are required. Curricula for health

workforce education and training programmes should be developed through
multistakeholder partnerships and the active participation of communities, with
special attention to those in geographically disadvantaged areas, in line with
recommendation 4 of the WHO transformative education guidelines (41). This
should be accompanied by mechanisms to ensure regular and continuous review
of curricula with stakeholders, and programme delivery measured against the
attainment of core competencies and national education plans for health workers.
Box 3 illustrates how a change of mindset across the Ateneo de Zamboanga
University School of Medicine in the Philippines has empowered socially
accountable and transformative health workforce education and training.

PART III: Education and Production | CHAPTER 12 293

 Box 3

People-centred and integrated health services in the Philippines

In contrast to the conventional approach, Ateneo de Zamboanga University

School of Medicine in Mindanao, Philippines, develops and structures
learning around local community health problems and priorities. The
curriculum combines competency- and problem-based instruction with
experiential learning in the community, using an approach that is responsive
to the changing patterns of health care development and the needs of
communities, and sensitive to the social and cultural realities of south-
western Mindanao.

The two notions underlying the approach – that health is produced socially
and that health care should include both treating illness and addressing
the social determinants of health – have major implications for the
training needs of doctors. As doctors have considerable influence in health
programmes, any paradigm shift must start with redesigning doctors’
training. Ateneo de Zamboanga University School of Medicine is pioneering
innovative use of social media to connect, communicate and empower
community-based and community-engaged learning.

Ateneo de Zamboanga University School of Medicine is part of the Training

for Health Equity Network, which is a growing global movement advocating
socially accountable and transformative health workforce education.
Source: THEnet (44).

Strategies for interprofessional education for collaborative practice (IPECP) should

ensure that two or more professions learn about, from and with each other to enable
effective collaboration and improve health outcomes. IPECP should promote a culture
of team-based critical enquiry and reflection and should take place in both academic

294 Health Employment and Economic Growth: An Evidence Base

institutions and workplaces, including in primary health care settings, in accordance
with recommendation 9 of the WHO transformative education guidelines
(41). IPECP competencies and skills, including cross-sectoral interprofessional
collaboration, play an important role during global health emergencies and health
crises and can be essential to improving health outcomes (45).

Health workers should be educated on the social determinants of health and use
this knowledge in their practice. Education that enables health workers to address
and take action on the social determinants of health, including the Health in All
Policies approach (46), should be integrated into the assessed health workforce
education curricula.

It will be important to recognize the tensions involved in the politics of health and
education policy change. Mechanisms for inclusive and transparent dialogue should
be an integral part of intersectoral SDG 3–SDG 4 planning and partnerships.

4.2 Data, knowledge and research: key policy messages

Knowledge and information systems for TVET – including research on labour

market health and social trends – should be built and strengthened across
sectors, and should ensure interoperability and comparability for monitoring and
evaluation, including with WHO national health workforce accounts. Performance
evaluations should assess how an intersectoral approach contributes to, or
influences, health outcomes and sustainable development.

Information and data at all levels will be critical to support evidence-based

intersectoral SDG 3–SDG 4 planning, and to monitor and evaluate health
workforce education, training and opportunities for lifelong learning. Intersectoral
approaches can assist in reducing duplication, as well as in helping to produce
dividends in terms of the interoperability of data and comparability for monitoring
and evaluation over time and space. Approaches should include analysis of
contextual information and data from other SDGs where relevant and appropriate.

Education data collection and analysis within a lifelong learning framework would
enable a better understanding of how learning outcomes from early childhood,

PART III: Education and Production | CHAPTER 12 295

 primary and secondary education relate to the quantity and quality of potential
entrants into the health workforce and their eventual geographical distribution
and retention where most needed. Health professional graduate tracking, such
as the longitudinal tracking system for graduates of the James Cook University
in Australia (47), could provide valuable data on education and employment
outcomes. Tracer studies of primary and secondary school leavers are needed to
provide a more complete picture to inform and guide health workforce education
and training planning (47), including in-service training, continuing education
and professional development.

Data are also needed on entry into and participation in health workforce
education and training. For many countries, some data are available on
graduations from tertiary health and welfare programmes at International
Standard Classification of Education (ISCED) level 5 and above (48). However,
more data are needed on ISCED levels 2, 3 and 4, which will be crucial for SDG 3
and SDG 4.

WHO national health workforce accounts (49) and health workforce registries are
first steps toward standardizing the health workforce information architecture.
Efforts have been made to support the lifelong learning approach, including
the use of disaggregated data for national and subnational decision-making.
The inclusion of TVET and adult learning and education in data collection and
analysis for national health workforce accounts would enhance data sharing for
the 2030 Agenda as a whole. An example is the Health Data Collaborative, a new
initiative working on a common agenda in health measurement and accountability
and tracking progress towards SDG 3 and the broader 2030 Agenda (50).

4.3 Innovation and technology: key policy messages

A priority policy action is to ensure that TVET is integrated into transformative

planning and reforms of health workforce education and training in order to
promote diverse learning pathways; bridging and youth transition programmes;
apprenticeships; work-placed learning; the acquisition of transversal employability
skills; the recognition of prior learning; certification; career guidance; and other
innovative strategies to foster lifelong learning. Information and communication

296 Health Employment and Economic Growth: An Evidence Base

technology (ICT), open and distance learning, and teleworking will expand
opportunities to enter and navigate the world of work.

Joint SDG 3–SDG 4 collaboration should support the development of innovative

systems to expand and transform health workforce education and training (51, 52)
in support of universal health coverage and lifelong learning. While institution-
based programmes will remain important, work-based learning and apprenticeships
are part of a growing trend towards hybrid programmes and a diversification of
learning pathways. Hybrid approaches should seek to develop both technical and
applied experiential knowledge, skills and attitudes that are relevant to the world of
work. Institutional commitment should involve synergizing and distributing all the
resources available, including open educational resources, by blending face-to-face
instruction and digital networking as appropriate (53).

Apprenticeship (54) is a social institution with a long history, having ensured, over
centuries, the transmission of work skills from one generation to the next. Around
the world apprenticeship takes different forms, including traditional apprenticeships,
which are self-organized. Many countries are exploring the option of introducing
or improving apprenticeship schemes as a way to better address youth employment
and skills mismatches. Efforts are under way to modernize and formalize informal
and traditional apprenticeships as a way to expand quality TVET (Box 4). UNESCO
notes that promoting learning for the world of work has led to one of the most
significant trends in vocational education in recent years: a rediscovery of the value
of apprenticeships (55).

ICT is a major driving force for change and innovation in the health and education
sectors but its relative absence in low-income countries is a significant constraint.
Health workforce education and training must take advantage of rapid technological
advances, while acting proactively to ensure wider development benefits and
equitable learning opportunities. The potential of ICT for education and training,
including distance learning and massive open online courses (MOOCs), should be
explored for driving learning and innovation by individuals and organizations.

ICT can help to build lifelong learning systems that can enable all actors and
providers to be responsive to changing workplace needs and demands (60). However,

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 Box 4

Apprenticeships in Benin, Malawi and the United States

of America

Benin has sought to modernize its traditional apprenticeships into a

regulated dual training system that is designed to help young, uneducated
individuals to acquire vocational qualifications. The system works through
the employment of traditional master craftspersons, who train their
apprentices to the level of Certificat de Qualification Professionnelle. These
trainers are themselves invited to update their skills beforehand, with the
intention of improving the quality of the training given to apprentices (56).

In Malawi, traditional apprenticeship is widespread. It is self-organized with

apprentices receiving no or little pay during the training period. The quality
depends largely on the master craftsmen or craftswomen and the economic
fortunes of the business. Trades in which traditional apprenticeship is
common include baking, basket weaving, bicycle repair, boat building,
construction, tailoring and net mending. Trainees from the traditional
apprenticeship system have the option to undergo trade testing in specific
trades (57).

The Ready to Work Partnership in the United States of America is an

initiative to support and scale up innovative collaborations between
employers, non-profit organizations and federal job training programmes
to help connect ready-to-work Americans with ready-to-be-filled jobs (58).
The partnership supported the District 1199C Training and Upgrading Fund,
which launched a Community Health Worker Apprenticeship with local
employers and expanded employment of nurses and health information staff
at Temple University Health System, the Children’s Hospital of Philadelphia,
long-term care facilities and physician practices (59).

298 Health Employment and Economic Growth: An Evidence Base

evidence is emerging of knowledge inequalities, in terms of ICT literacy, access
to quality information and the financial burden in paying for access, materials
or information. Innovation and expanding opportunities should therefore give
due attention to social inclusion, equity and social protection, including gender
equality considerations (61). Workplace and home-based learning, especially for
women in part-time employment, could be supported and enhanced through the
use of blended learning, mobile technologies and the use of social media. Data
protection and ethical considerations of patient and learner information and data
also deserve increased attention.

A promising strategy for promoting lifelong learning is the introduction of

mechanisms for the recognition of prior learning (RPL). The full spectrum of
formal, non-formal and informal learning and training outcomes deserve to
be valued and validated, and RPL could support entry to and mobility within
and between occupational areas. The potential benefits for the health workforce
of RPL and other innovations in the area of qualifications should be explored,
drawing insights from relevant country experiences. In France, for example,
46 576 people were awarded a qualification in health and social care between
2008 and 2014 through RPL assessment processes (62). In the United Kingdom,
the Belfast Health and Social Care Trust took a multi-agency approach to RPL
with the aims of improving the qualification level of health care support workers,
increasing access to the nursing profession and creating a more diverse
workforce (63).

4.4 Funding and investment: key policy messages

Intersectoral accounting methods for disaggregated expenditures are needed.

Funding should be mobilized from diverse sources – domestic and external, public
and private – and leveraged to reinforce intersectoral cooperation for sustainable
development. Effective co-financing and targeted investments can promote health
equity and gender equality, especially through prioritizing the development of
nurses and midwives.

PART III: Education and Production | CHAPTER 12 299

 Ministries of finance have an important role in supporting an effective and equitable
financing and investment architecture that should strengthen the intersectoral
collaboration between health and well-being on the one hand, and education and
lifelong learning systems on the other hand (25).

Domestic public spending on education and training as a percentage of total public

spending is below what is required (64, 65). Reviews of 2014 data on aid to education
show that there is little sign of that situation changing. Around the world, especially in
low-income countries, millions of children and young people are paying the price, in
years of lost or low-quality schooling (66).

The proportion of total public expenditure on education dedicated to health workforce

education and training is largely unknown. Private finance for health workforce
education and training is growing rapidly, but efforts are needed to strengthen the
regulatory environment to ensure the quality and relevance of learning outcomes to the
world of work and to the evolving needs of communities.

Intersectoral policy dialogue among the relevant ministries, including ministries of

education, health and finance, would support the conversations and networking that
would facilitate the development of intersectoral SDG 3–SDG 4 skills councils or similar
apex bodies. The formation of such apex bodies could support and enable effective
channelling of resources and investments to increase the quantity and improve the
quality and relevance of the health workforce. Mapping and tracking investments in
health workforce education and training should help to inform investment priorities
for countries at various levels of development. TVET can facilitate assessment of new
economic opportunities and can act as an entry point to wider industrial or trade and
investment strategies. However, returns on investment in TVET are not only economic
(Box 5).

300 Health Employment and Economic Growth: An Evidence Base

Box 5

Measuring the return on investment in TVET

The report of a UNESCO-UNEVOC virtual conference on measuring the

return on investment in TVET notes that:

The recent international attention to the importance of education

might encourage governments and other stakeholders to explore the
return on investment (ROI) from investing in TVET, and understand
the different types of benefits individuals, enterprises and governments
obtain from investing in training. Although TVET systems are often
considered in relation to labour market outcomes, the benefits TVET
brings to individuals, employers and society are not only economic.
The country context (political, economic and education system) and
the types of stakeholders involved also have an influence on the ROI in
TVET (67).

The International Labour Organization (ILO) analysed case studies that used
cost–benefit calculations to assess returns on investment in apprenticeship. The
findings underscored the “overall consensus on the fact that apprenticeships
bring value to the companies across different trades, sectors and regions”. The
report highlights that such surveys also assess additional qualitative benefits,
such as retention and the contribution of apprenticeships to overall work culture,
aiding understanding of the hiring motivations of enterprises. It finds that hiring
apprentices yields both monetary and qualitative advantages, which are highly
relevant to health workforce employment and economic growth (68).

PART III: Education and Production | CHAPTER 12 301

 Multilateral agencies could play a critical role in helping countries to navigate
different types of innovative finance and facilitate partnerships between the
government and private investors interested in supporting education (69), bearing
in mind that “education is a public good, a fundamental human right and a basis for
guaranteeing the realization of other rights” (1).

Joint SDG 3–SDG 4 planning should identify and coordinate domestic public
investment, with public subsidy considered where there is good evidence of high
social returns (70), for example in cadres such as nurses and midwives. These efforts
could promote health equity and gender equality to ensure that efforts towards the
SDGs are convergent, coordinated and mutually reinforcing.

Agenda 2030-wide scoping exercises for financing health workforce education and
training could include assessing the merits of innovative funding mechanisms that
could deliver a triple win for health, employment and education. While the various
options need to be carefully assessed and explored, one option might be measures to
reclaim costs from, or to introduce a levy on, the private cross-border recruitment
of health workers that have completed publicly funded education and training. The
funds generated could be reinvested directly into future health workforce education
and training.

Disclaimer

The ideas and opinions expressed here are those of the authors; they are not necessarily
those of UNESCO and do not commit the Organization.

302 Health Employment and Economic Growth: An Evidence Base

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306 Health Employment and Economic Growth: An Evidence Base

CHAPTER 13

Enabling universal coverage

and empowering communities
through socially accountable health
workforce education
Björg Pálsdóttir, Nadia Cobb, Julian Fisher, John H.V. Gilbert, Lyn Middleton,
Carole Reeve, Mariela Licha Salomon, Roger Strasser

Abstract
This chapter presents contemporary evidence on the positive role of socially
accountable education in improving the availability, distribution and impact
of health workers. Evidence is presented from a variety of country contexts,
including Australia, Bolivia, Brazil, Canada, Cuba, the Philippines, South Africa
and Thailand.

Key strategies of this agenda include alignment of education curricula

to community needs, targeted student selection with priority given to
underrepresented populations, interprofessional training in underserved
locations and in areas of need, expansion of faculty in rural areas, and close
partnership with communities. The socially accountable interprofessional
stepladder programme of the School of Health Sciences, University of the
Philippines Manila (UPM-SHS), which utilizes these strategies, is provided as
one important example. A recent study highlighted that UPM-SHS medical
graduates were 10 times more likely to practise in small towns and 8 times more
likely to practise in poorer towns than graduates of more traditional medical
schools in the same region, with over 80% of UPM-SHS midwifery, nursing and
medical graduates choosing to remain in underserved regions.

(continued on page 308)

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 ABSTRACT (continued)
To reduce inefficiencies and maximize benefit from such strategies, governments
and education institutions should engage in cross-sectoral participatory
planning, increase their investment in underserved regions, and apply the
concept of right-touch regulation to ensure quality.

1. Introduction
The health workforce is increasingly being recognized as central to delivering on
the ambition of the 2030 Agenda for Sustainable Development (1). Improving
the availability, relevance, distribution and performance of the existing and
future health workforce is critical to making progress towards the Sustainable
Development Goals (SDGs), including poverty elimination (SDG 1), quality
education (SDG 4), gender equality (SDG 5), decent work and economic growth
(SDG 8) and reduced inequalities (SDG 10) (1).

The Ebola epidemic in West Africa is a reminder of the devastating consequences

to human health, peace and prosperity that results from health systems with too
few, poorly distributed, and inadequately trained and supported health workers.
The estimated US$ 2.2 billion loss of gross domestic product (GDP) traceable to the
epidemic in Guinea, Liberia and Sierra Leone in 2015 threatens not only health and
economic stability but also food security and private sector growth (2).

The Global Strategy on Human Resources for Health: Workforce 2030 highlights the
growing mismatch between health workforce demand and supply and population
needs (3). It speaks not only to increasing investments in the health workforce but
also to the need to optimize the current and future health workforce to better address
the needs of populations, particularly those who are underserved. The less educated
and the poorest members of society, along with migrants, minorities, and those living
in rural and remote areas, are often the most neglected (4).

308 Health Employment and Economic Growth: An Evidence Base

The disconnect between national health and education systems, as well as the
absence of cross-sectoral and multistakeholder collaboration in financing,
planning and evaluation, has resulted in health systems that are fragmented,
inefficient and costly (5–7). Fragmentation and inefficiencies are also challenges
within health workforce education systems (8).

Most efforts to address health workforce shortages have focused on the planning
and scaling up of production of health workers without taking into account labour
market challenges (9). The effects of institutional and educational strategies on
where graduates choose to work and their career choices have also been largely
ignored. Several long-standing challenges continue to hamper much needed
reforms in health workforce education and regulation. These include education
strategies and programmes designed by particular professions with inadequate
focus on population health needs; a notable lack of learning in the primary care,
community settings where many graduates are expected to work; insufficient
focus on interprofessional learning, collaborative practice and teamwork; student
admission policies that are not optimized for recruitment or retention of graduates
in underserved areas; community-based health workers and unregulated cadres
that are not formally supported or incorporated into the workforce; weak or
absent accreditation and quality assurance systems; and a lack of education
and career pathways that promote recruitment and retention in underserved
areas (5, 8, 10).

While the challenges are complex, evidence is emerging that socially accountable
health workforce education, which aims to ensure that education programmes
are relevant to the local context and that needs are identified in collaboration
with key stakeholders, can strengthen health systems and positively influence
the availability, distribution and performance of health workers (8, 11–17). For
example, an evaluation of schools with a social accountability mandate showed
significantly higher graduate deployment and retention rates in underserved
communities compared to graduates from traditional schools (18). Another
recent study demonstrated that the presence of students and graduates from
socially accountable schools in poor rural communities in the Philippines is

PART III: Education and Production | CHAPTER 13 309

 associated with significant improvements in the level of care infants receive in their
first five years, as well as with an increased utilization rate of local health services
(19). Investment in the Northern Ontario School of Medicine (NOSM), a new
socially accountable medical school where students spend close to 50% of their
time learning in 70 rural and remote communities, resulted in increased graduate
retention in rural areas and a total economic contribution of Can$ 67.1 million (14).

Key strategies associated with social accountability in health workforce education

include the alignment of curricula with local needs, targeted student selection,
training taking place in the primary care contexts in which graduates are expected
to serve, regional postgraduate training and career pathways in underserved
regions, interprofessional education and practice, and meaningful partnerships
with communities and other stakeholders. The Training for Health Equity
Network (THEnet), a partnership of health professional schools committed to
social accountability, has identified common effective strategies of their member
institutions. These strategies are aimed at preparing a fit-for-purpose workforce
that is motivated and empowered to work in areas where the needs are greatest
(Box 1) (18).

Box 1

Social accountability within health workforce education

WHO definition of socially accountable workforce education institutions
The World Health Organization (WHO) has defined the social accountability
of health workforce education institutions as: “The obligation to direct
their education, research and service activities towards addressing the
priority health concerns of the community, region, or nation they have a
mandate to serve. The priority health concerns are to be identified jointly by
governments, health care organizations, health professionals and the public.”
Source: Boelen and Heck (21).

(continued on page 311

310 Health Employment and Economic Growth: An Evidence Base

BOX 1. (continued)
Social accountability within health workforce education

Common health workforce education strategies practised by socially

accountable partner schools of the Training for Health Equity Network
1. Education, research and service programmes are designed to
meet the health and social needs of the communities the school
serves, identified in collaboration with communities and other
stakeholders.
2. Students are selected from communities with the greatest health
needs or those deemed most likely to be willing to work in
underserved areas.
3. Programmes are located within or near the communities the school serves.
4. Much of the learning takes place in the settings in which graduates are
expected to work – in communities, instead of mainly in university
classrooms and teaching hospitals.
5. The curriculum integrates basic and clinical sciences with population
health and social sciences and includes the social determinants of health.
Early contact with patients increases the relevance and value of theoretical
learning.
6. Learning methodologies are learner centred (including service learning),
emphasize teamwork, and are supported by information technology.
7. Community-based practitioners are recruited and trained as educators
and mentors.
8. Educators and programmes model commitment to public service.
9. Social accountability is reflected across all departments and in the
commitment from the leadership.
10. Schools collaborate with health system partners to produce locally
relevant competencies and evaluate the impact of their strategies.
Source: Pálsdóttir and Neusy (22).

PART III: Education and Production | CHAPTER 13 311

 The example of Brazil shows that positive change also requires investment and
reform at system level. Brazil’s comprehensive approach doubled the number of
interprofessional primary care-oriented health teams in 10 years. During that
period, under-5 mortality dropped from 58 to 15.6 per 1000 live births, and neonatal
mortality fell from 26.8 to 9.7 per 1000 births (20).

The remainder of this chapter considers the existing social accountability education
strategies that are taking place across countries, as well as emerging evidence of their
impacts. Evidence on current reforms at the education institution level is presented
first. This includes a focus on transforming curricula; community engagement to better
address needs; targeting student admissions; and the recruitment, development and
promotion of community-based faculty. The chapter then discusses reforms under
way and needed at government and system levels, including a focus on integrated and
participatory policy development and planning and prioritization of investments in
rural and primary care settings. Evidence is then presented on the reforms required to
ensure a health workforce that is of good quality and accountable to those it serves.

This chapter offers as substantive a literature review as possible within the given
time frame, including published articles, grey literature, and relevant global reports
and guidelines, as required to provide input to the deliberations of the High-Level
Commission on Health Employment and Economic Growth. Available evidence
on the effect of system- and governance-level reforms, often in their early stages, is
scarce. Current research on the impact of education strategies and programmes being
conducted in high-income countries tends to focus on medical (and to a lesser extent
nursing) education, and on the impact on learners rather than on communities or
patient outcomes, thus limiting the available evidence. The evidence presented in the
chapter was reviewed by an interdisciplinary panel of health workforce education
experts. The panel jointly selected the policy options that are being put forward.

312 Health Employment and Economic Growth: An Evidence Base

2. Reforms at education institution level

2.1 Transforming what, where and how students learn

to better address needs

Curriculum reform must be viewed in terms of what is being taught, how the
curriculum is developed and implemented, and where the learning takes place.

In many countries there is a lack of alignment between health workforce education

and changing health and health service needs (5, 8). Traditional education
approaches have focused more on curing disease than keeping people healthy, and
often fail to provide learners with an understanding on the importance of addressing
the social determinants of health. For example, the University of New Mexico
screens patients for challenges related to the social determinants of health at its
primary care clinics. It also trains community health workers to help patients obtain
the social services that address the needs that the screening identifies. Identifying
and addressing social determinants of health of high-need and high-cost patients
resulted in a fourfold return on investment, due to a decrease in emergency room
visits, hospitalization, and medication use, and an increase in the use of primary care
services (23).

How needs are defined and curricula are developed is also of importance, and
community engagement is a key approach of social accountability education.
Schools work with community representatives and other stakeholders to design
their curricula in line with the needs of the regions they serve. Communities can
be involved in selecting students, acting as simulated patients, and evaluating
programme impact. Community-engaged education builds social capital1 (24, 25).
Social capital encompasses interdependent and mutually beneficial relationships
between education institutions and the communities they serve. Coupled with
equitable provision of health services, partnerships involving communities,
education institutions, and the health and social service sectors can increase human
security and reduce costs by tapping into social capital, local human resources and
community assets (25).

1 Defined by Robert Putnam as “connections among individuals in social networks and norms of reciprocity and trust-
worthiness that arise from them” (24).

PART III: Education and Production | CHAPTER 13 313

 Learning locally relevant competencies is also enhanced by expanding the learning
environment beyond university classrooms and hospitals to secondary and
primary care settings. Hence, the dental education programme of the University of
Tromsø, which focuses on increasing the dental workforce in northern Norway and
developing competencies related to the public dental health services in the region,
does so through a community-oriented and decentralized education model (26).

At the Ateneo de Zamboanga University School of Medicine in the Philippines,

the curriculum incorporates 12 priority health needs in the region it services, and
students spend 50% of their time in rural and remote communities, where needs are
the greatest. There students gain an understanding of the cross-sectoral nature of
health (16).

While sceptics have suggested that moving training away from hospital settings
compromises the quality of the education, studies show positive impacts on student
competencies and performance in national licensure exams, with rurally based
students doing as well as, and many doing better than, their urban counterparts
(16, 27, 28).

Moreover, there is evidence that aligning curricula to local needs and training
students in the context in which they are expected to work not only prepares a more
fit-for-purpose workforce but also increases the likelihood that graduates choose to
work in primary care and rural settings (8, 26, 29).

By focusing on needs as well as patient- and community-centred care, social

accountability innately calls for building team-oriented competencies. Training in rural
and resource-constrained settings, where there is frequently a shortage of health workers
and resources, provides students with excellent opportunities to learn how to work in
effective interprofessional teams, a strategy deemed by WHO to play an important role
in mitigating the global health workforce crisis (Box 2) (8).

In addition, community-engaged learning adds value when students increase the

quantity and quality of services in underserved communities (30). A recent study
indicates that the presence of students and graduates from social accountability
schools in poor rural communities in the Philippines is associated with significant

314 Health Employment and Economic Growth: An Evidence Base

Box 2

Interprofessional education and collaborative practice

There is now evidence to show that effective interprofessional education enables

effective collaborative practice, which has a direct impact on quality of care (33). The
term “Interprofessional” recognizes the indivisible and mutually reinforcing work of
the health and social sectors in health systems and improving health outcomes, which
aligns with the WHO definition of health as “a state of complete physical, mental and
social well-being and not merely the absence of disease or infirmity”.2 Interprofessional
education – when two or more students from the broad continuum of health or social
care occupations learn about, from and with each other – is a key recommendation for
transforming health workforce education (8) and reorienting the health workforce for
integrated people-centred health services (34).

Collaborative practice as defined by WHO empowers and engages people and

communities to take charge of their own health. A fit-for-purpose worker in
the health and social sector is someone who has learned how to work in an
interprofessional team for collaborative practice and is competent to do so.
Interprofessional education and collaborative practice support the skills mix of the
health workforce, and allow health system planners to engage individuals whose
skills can help achieve population and community health goals (35, 36). It has
been shown in Australia, Canada, Denmark, New Zealand, Sweden, the United
Kingdom, the United States of America and other countries that integrated health
and education policies can promote effective interprofessional education and
collaborative practice and facilitate acquisition of broader skills and competencies
for intersectoral action to promote health equity (37). Interprofessional education
and collaborative practice support achieving SDG 3 targets, notably universal health
coverage, and contribute to other SDGs, particularly SDG 4 (promote lifelong
learning opportunities). Interprofessional education has been shown to provide a
strong curricular framework within which to situate the teaching and learning of the
social determinants of health, as called for in the WHO Global Strategy on Human
Resources for Health. The inclusion of interprofessional education in accreditation
mechanisms will guide the implementation of World Health Assembly resolution
WHA66.23 on transforming the health workforce in support of universal health
coverage (38).

PART III: Education and Production | CHAPTER 13 315

 differences in the level of care infants receive in their first five years and with an
increased utilization rate of local health services as compared to communities served
by graduates of traditional schools (31). Community-based service learning can
yield important returns on investment. An Australian study found that a relatively
small community-based nursing education programme increased access to care for
a previously underserved community. Through immediate action and referrals for
life-threatening conditions, students’ presence resulted in cost savings of 437,000
Australian dollars to the health system (32).

2.2 Putting in place recruitment strategies to increase retention in

underserved areas

With academic performance as the major conventional criterion, recruitment

policies, particularly at medical schools, tend to favour students from urban areas
and higher economic strata, who are less likely to want to work in rural regions.
Underserved populations are frequently underrepresented, particularly in higher-
paid professions such as the medicine health sector (28, 39). In upholding such
recruitment policies, higher education institutions can perpetuate current inequities.
This in turn might undermine the empowerment of rural and marginalized
populations and hamper inclusive socioeconomic growth and development in
disadvantaged regions.

There is convincing evidence that targeted admission criteria – that is, criteria aimed
at selecting students deemed to be most likely to address specific health workforce
needs or increasing the socioeconomic, ethnic and geographical diversity of students
– have positive effects on the distribution and career choices of health workers
(40–43). One study of rehabilitation graduates shows that a graduate is 3.3 times
more likely to choose to work in a rural or remote community if the student was
raised in such a community (44). A study of socially accountable schools identified
four distinct strategies that positively influenced students’ intentions to practise in
underserved areas: quota systems prioritizing rural or underrepresented populations;
community involvement; school marketing strategies; and selection based on
personal attributes (39). All participating schools offered extra academic support
for students from underrepresented groups, and several schools used outreach

2 Preamble to the World Health Organization Constitution, 1946: see http://www.who.int/about/definition/en/print.html.

316 Health Employment and Economic Growth: An Evidence Base

programmes to secondary schools to encourage youths from underrepresented
groups to pursue careers in health. With adequate support, students coming from
lower-quality secondary schools perform just as well in exams, particularly in the
later stages of education or in national licensing exams (28, 39).

In some cases, recruitment strategies focus on mobilizing marginalized populations.

Tekove Katu School of Health in the El Chaco region of Bolivia prepares public
health professionals, mid-level nursing technicians, environmental health technicians
and community social workers for future careers. Students are selected from
indigenous youths who have limited opportunities for professional development. The
selection, training and support of these health workers resulted in expanded and
improved health care to marginalized indigenous populations, along with higher
retention of health practitioners. The empowerment of this group further contributes
to social inclusion and human security (45).

Who the graduates are, combined with where and how students learn, is clearly
important both to retain them as practitioners in underserved areas and to prepare
fit-for-practice workers. For example, results for medical graduates from NOSM are
impressive, with 92% of all NOSM students coming from Northern Ontario, and
with substantial inclusion of underrepresented populations in Northern Ontario
indigenous (7%) and francophone (22%) students. In 2015, 62% of NOSM graduates
chose to pursue careers in family practice, and 94% of the doctors who completed
undergraduate and postgraduate education with NOSM are practising in Northern
Ontario (46).

2.3 Recruiting, developing and promoting community-based

faculty from across professional cadres

Many schools and regions suffer from a shortage of trained clinical and academic
faculty members, who are essential to the training of a fit-for-purpose workforce.
Several schools are using innovative approaches to recruit, train and reward
community-based clinicians and other health workers to become faculty (12, 41).
Many regions also lack trained clinical preceptors whose expertise is needed to
maximize learning outcomes and assure the consistent quality of patient services in
community and small hospital settings.

PART III: Education and Production | CHAPTER 13 317

 For example, NOSM recruits local community-based health professionals
from different cadres and appoints them as faculty members with equal status
and academic promotion opportunities compared to specialists in tertiary
care hospitals. Faculty development opportunities are provided locally in
rural communities via distributed learning, distance education and faculty
development conferences. NOSM also celebrates the contribution of distributed
faculty members through awards for excellence, recognition of promotion, and
acknowledgement of other achievements (41).

Several health workforce education institutions, including Walter Sisulu University

in Eastern Cape in South Africa and the University of Nairobi in Kenya, train
community members and a spectrum of health workers to facilitate learning (47,
48). Recruitment and training of staff committed to social accountability is key to
transforming and implementing a social accountability curriculum.

3. Reforms at government and system levels

3.1 Integrated and participatory policy development and

planning

Ensuring that socially accountable health workforce education is transformative

and actively contributes to the SDGs will also require reforms at government and
system levels. Governments must work across sectors and ministries (49) and
collaborate with key stakeholders, including communities and the full range of
education and service providers.

Systemwide transformation will also necessitate a broader view of who constitutes

the health and care workforce. Education is increasingly viewed within a lifelong
learning framework – that is, from primary to higher education levels and beyond
to in-service education and training (50). This includes technical and vocational
education and training (TVET) (51). The United Nations Educational, Scientific
and Cultural Organization (UNESCO) argues that incorporating a TVET
framework could facilitate the coordination of education for the health workforce

318 Health Employment and Economic Growth: An Evidence Base

within larger national educationwide policies, strategies and plans. Such an
approach supports the harmonization and alignment of social accountability
mechanisms for the health professions with those used in TVET programmes,
supporting the education of all workers for the health and human services
sector (50, 52).

Joint and inclusive health and education sector planning can help stakeholders
to identify opportunities for cost savings and efficiencies and to coordinate
education plans for all cadres. Such coordinated planning will also equip the
health workforce with the optimal skills mix in line with local needs and national
development priorities.

Countries such as Brazil, Cuba and Thailand, which have demonstrated sustained
improvement towards achieving universal health coverage, have adopted more
integrated, equitable and primary care-oriented approaches to policy-making and
resource allocation (20, 40). For example, in Brazil, the government works with
partners at all levels to reduce inequity through a series of integrated strategies
(Box 3).

Australia has made strides in addressing shortages in the rural workforce using
collaborative approaches, albeit with most investment in physician education. The
success of the approach has been due to “passionate leadership of rural medical
and community leaders, government seed funding to encourage rural medicine
as an academic discipline, rigorous research and consultation that underpinned
each step of the innovation pathway, and a political campaign to invest in rural
medical education as a form of rural social capital” (55).

PART III: Education and Production | CHAPTER 13 319

 Box 3

Participatory planning to integrate education and health services

in Brazil

While challenges remain, Brazil has made significant progress towards

universal health coverage over the past two decades through the processes of
decentralization and regionalization of the Unified Health System (Sistema
Único de Saúde, SUS). Brazil has become a “stellar performer, with nearly
universal coverage and limited geographic disparities” (53). The country
has expanded community primary health services and strengthened human
resource management capacities; implemented a multidisciplinary family
health team model of care; scaled up, updated and streamlined health
worker education; and matched deployment with health needs. Initially,
the family health team included a physician, a nurse, a nurse assistant, and
between four and six full-time community health workers; now some teams
include nutritionists, psychologists, social workers, psychiatrists, community
pharmacists, physical education specialists, speech and hearing therapists,
occupational therapists, gynaecologists, obstetricians, geriatricians, general
internists, public health specialists and others. Initially, the 2000 primary
care teams provided services to 7 million people; as of 2014, they covered
120 million people. Strategies include increased pre-service and in-service
training for less skilled front-line health workers, incentives for curricular
reform and the creation of new rurally based medical schools. The massive
scale-up of service delivery in marginalized communities included temporary
incorporation of foreign physicians into the rural workforce in collaboration
with the Pan American Health Organization.
Sources: Campbell et al. (20); Macinko and Harris (54).

320 Health Employment and Economic Growth: An Evidence Base

3.2 Priority investments in rural and primary care settings,
including new or adapting workforce roles
The Governments of Australia, Brazil, Canada, Cuba and Thailand, aiming to
increase deployment and retention of health workers in rural and remote areas,
are learning that success requires investment in health workforce education in
these settings. Investment often includes support for clinical sites and information
technology infrastructure, incentives for rural clinicians, training these clinicians
for faculty positions, and accommodation for students. Already, these investments
are beginning to show returns in terms of recruitment and retention in rural areas,
thanks to increased professional development opportunities and improved quality
of services at clinical training sites (40, 56, 57).

In Canada, a study was carried out of the social and economic impact of
NOSM’s rurally based, community-engaged education model aimed at
producing health professionals for Northern Ontario, after only four years of
operation. The direct, indirect and induced economic impact of the operation
of the social accountability school is estimated at Can$ 67 million, excluding
construction and renovation. By 2009, each of the 70 communities where
students had been placed received a return on investment of Can$ 7300 to
Can$ 103 900 per pair of learners per placement. The lower amount reflects
learner spending during short rotation in rural communities, and the
higher amount is spending in larger communities with several programmes
for different cadres and up to 30 week-long comprehensive community
clerkships, requiring substantial school investment. In the same period,
the school generated between 185 and 280 new full-time jobs in the rural
and remote regions of Northern Ontario (14). With respect to community
engagement, according to a 2015 NOSM report, 1300 trained clinicians
served as teachers, preceptors, and members of various committees in over
90 communities (58).

Creating career tracks and stepladder programmes in underserved and rural

regions is another important strategy to better address health workforce needs.
For example, the School of Health Sciences, University of the Philippines Manila
(UPM-SHS), partnered with marginalized communities and health authorities
to create a stepladder programme starting with midwives and then training them

PART III: Education and Production | CHAPTER 13 321

 as nurses and ultimately as physicians. Decades later, the impact of this approach on
retention in underserved regions is impressive (Box 4).

To equip the health workforce in Queensland, Australia, with the skills it needs to
address local challenges and create opportunities to pursue a career track in rural
and remote health, regional authorities work with rural medical schools to create a
rural generalist training pathway for physicians. Early evidence indicates that this
strategy generates high returns on investment and creates a training pipeline for
rural communities. For example, employing rural generalists with advanced skills
in anaesthesiology and obstetrics allowed for a 120% return on the government’s

Box 4

Building a career in rural and remote areas: the stepladder

programme in the Philippines

Physicians Licensure Examination

Doctor of Medicine (MD)

Service leave

Bachelor of Science in Community Health (BSCH)

Service Leave & National Licensure Examination

Bachelor of Science in Nursing (BSN)

Service Leave & National Licensure Examination

Certificate in Community Health Work (Midwifery)

Source: J.L. Siega-Sur, with permission.

The socially accountable “stepladder” programme of the School of Health

Sciences, University of the Philippines Manila (UPM-SHS), was developed in
1976 to educate a broad range of the health workforce, including midwives
with a Certificate in Community Health Work, nurses with a Bachelor of
Science in Nursing, and Doctors of Medicine, in one sequential and

(continued on page 323)

322 Health Employment and Economic Growth: An Evidence Base

BOX 4. (continued)
Building a career in rural and remote areas: the stepladder programme in the
Philippines

continuous community-based curriculum. At least 50% of their training takes

place in primary care settings, and between each programme level the students
return home to their sponsoring communities to render service leaves. The
model aims to counteract brain drain from and inadequate health care in rural
communities of the Philippines by ensuring students are community oriented,
clinically competent and socially conscious.

Five areas of competency are woven throughout the midwifery, nursing and medicine
curricula, each building on the previous level. The first area stresses the competencies
that students require to become health care providers; the second trains them to
become community mobilizers to improve health-seeking behaviours; the third
focuses on programme management and supervision; the fourth centres on research
skills; and the fifth trains them to become educators.

UPM-SHS builds local capacity by implementing a one-year, two-module

programme for mayors and municipal health officers. Municipalities are selected
in collaboration with the Department of Health and require the commitment
of the mayor to support health reforms. The programme offers training and
coaching in local health system development, with a focus on the six building
blocks of the WHO Health Systems Framework – leadership/governance, health
care financing, health workforce, medical products and technologies, information
and research, and service delivery (62).

The targeted recruitment strategies, needs-based curriculum, partnerships with

communities and health system authorities, and extensive community-based
service learning have significantly contributed to increased recruitment of
UPM-SHS graduates to and their retention in rural areas and areas of economic
disadvantage. One recent study shows UPM-SHS medical graduates are 10
times more likely to practise in towns of below 50 000 population than medical
graduates of more traditional medical schools in the same region, and 8 times
more likely to practise in lower-income towns (2–5 income categories), and more
than 80% remain in underserved regions (63).

PART III: Education and Production | CHAPTER 13 323

 investment, as fewer patients had to be flown out to large cities (59). Thailand
also invests in its district health system workforce pipeline, including the creation
of advanced practice training programmes for nursing cadres. Between 1991
and 2009, the number of nurses increased by 210%, and workforce deployment
differences between the poorest and the most affluent areas were substantially
reduced (40).

To address specific health challenges, some countries have created new

professional cadres. As an example, to reduce maternal and infant mortality,
Bangladesh created a community-based midwifery diploma programme that
yielded a return on investment 16.2 times the total education cost, assessed using
only the number of caesarean sections avoided as the measure (60). Ethiopia
trained more than 30 000 health extension workers for underserved communities;
programme evaluations suggest that they have made a substantial impact on key
aspects of health and well-being (61).

According to a recent survey, 46 nations responded to critical physician shortages

by scaling up the training of advanced/accelerated medically trained clinicians
(AMTCs) (64). The term AMTC covers several cadres, including clinical officers,
physician assistants and clinical associates. AMTCs are trained in regionally
specific, compressed medical models that are less costly than the traditional
training of physicians. They have become critical contributors to service delivery
in several countries, including in sub-Saharan Africa. Evidence is mounting
that they produce impressive patient outcomes and are more likely to remain in
rural areas than physicians. Also, their services can be less costly. For example,
in Mozambique the cost of a caesarean section is US$ 513 if performed by an
obstetrician, US$ 207 if performed by a generalist physician, and US$ 193 if
performed by a clinical officer (65). A recent United States study reported that
employing a primary care physician assistant or nurse practitioner in a rural
clinic had significant economic impact in rural communities. The employment
impact showed an increase of 4.4 local jobs and an estimated labour income of
US$ 280 476 in communities without a hospital. For a rural community with a
hospital, the total effect increased to 18.5 local jobs and an estimated US$ 940 892
of labour income (66).

324 Health Employment and Economic Growth: An Evidence Base

4. Quality assurance and accountability

4.1 Strengthening the regulation of the health workforce

In many countries, there is an urgent need to strengthen both regulations and

regulating bodies to ensure that health workforce education standards are
developed and enforced through accountability and quality assurance mechanisms.
Regulations ensure that health workers receive the quality of training needed for
them to acquire the right competencies and qualifications to practise safely and
effectively, and to be eligible to obtain a job in the health sector. For patients and
communities, regulations ensure that education programmes for health workers
meet quality standards, and that the health practitioners who serve them have the
appropriate competencies to provide quality service.

There is also a need to clearly define the roles of each cadre in the health workforce
and their relationships to each other (3, 67, 68). In many countries, efforts to track
and regulate the AMTC cadre have been slow. For example, Ghana’s physician
assistant-medical cadre, which serves the primary care needs of 70% of the
population living in the most remote parts of the country, was established in 1969, but
registration, standards and regulations did not become official until May 2011, when
they came under the Ghana Medical and Dental Council (68). A lack of regulations
and clearly defined roles and responsibilities can create discord, undermine
implementation of health policies, and compromise the quality of services (69).
However, there are highly divergent approaches to regulation, and cost is certainly a
factor. The Professional Standards Authority for Health and Social Care in the United
Kingdom advocates “right-touch regulation”, an approach that is influencing global
discussions (Box 5).

4.2 Increasing accountability through accreditation and

participatory evaluation
Ensuring that health workers provide high-quality, patient-centred care requires
some form of continuous quality improvement processes, including oversight of
professional development and service delivery organizations (71, 72). Continuous
quality improvement approaches focus on organizations, processes and systems

PART III: Education and Production | CHAPTER 13 325

 Box 5

Right-touch regulation

Right-touch regulation should aim to be:

• Proportionate: regulators should only intervene when necessary.

Remedies should be appropriate to the risk posed, and costs identified and
minimized.

• Consistent: rules and standards must be joined up and implemented

fairly.

• Targeted: regulation should be focused on the problem, and minimize

side-effects.

• Transparent: regulators should be open, and keep regulations simple and

user friendly.

• Accountable: regulators must be able to justify decisions, and be subject

to public scrutiny.

• Agile: regulation must look forward and be able to adapt to and anticipate
change.
Source: Professional Standards Authority for Health and Social Care, United Kingdom (70).

rather than the individual, and capture objective data to analyse and improve
processes. Frequently, there is no formal authority that ensures a smooth progression
through the various stages of quality assurance, including accreditation of education
institutions, certification and licensing of health workers, and continuous professional
development and recertification (71). While there is general agreement on the need
to strengthen and link quality assurance efforts in both education and care (5, 8, 47),
there is less agreement on the most efficient ways to do it. Different approaches are
emerging, including multicountry and interprofessional or intercadre oversight, and

326 Health Employment and Economic Growth: An Evidence Base

establishment of independent interprofessional bodies that are tasked with regulating
the regulators (73).

Social accountability in accreditation is recommended both in WHO’s Global

Strategy on Human Resources for Health and in national health workforce accounts
(3, 52). Direct references to social accountability in accreditation standards are more
prominent in medicine than in other professional cadres. The World Federation for
Medical Education has already integrated social accountability into its standards.
WHO Member States in the Eastern Mediterranean Region are expected to adopt
social accountability in the near future (74), and social accountability values are
being applied to national standards in Canada, Japan and the Republic of Korea.32
In some countries, standards are not defined specifically through the lens of
social accountability, but are based on the same basic principles. For example, the
Australian Medical Council requires schools to have formal agreements with health-
related sectors, organizations and communities for educational purposes; to put in
place arrangements to recruit, train and support Indigenous staff, including specific
recruitment and retention policies for Indigenous Australians; and to provide
clinical experiences across urban and rural health settings (75).

The values associated with social accountability – equity, quality, relevance and
cost-effectiveness – and interprofessional practice require strong alignment between
education and health systems. Hence, accreditation and evaluation of programme
outcomes should be interlinked. The results of programme evaluation should
inform the accreditation process and support continuous quality improvement of
the education process. Evaluation should include tracking of graduates’ practice
locations and career choices, along with their continued professional development
and performance. Training and service delivery sites should also be evaluated
and the health, social and economic impact of education programmes should
be regularly assessed to guide policy and strategy development. Such actions are
aligned with global recommendations to strengthen and streamline data collection.

3 Personal communication with David Gordon, President of the World Federation for Medical Education, 19 June
2016.

PART III: Education and Production | CHAPTER 13 327

 To help institutions become more socially accountable, frameworks are available
to help them identify the needs they should address; assess governance as well as
education, research, and service programmes; and evaluate the impact of their
strategies on health services, career choices and retention of graduates. One such
framework is built on the successful strategies of socially accountable member
institutions of the Training for Health Equity Network (18). The framework is a
comprehensive, context-sensitive tool for designing, reforming and evaluating an
institution’s programmes in collaboration with stakeholders, including communities
(Figure 1).

Figure 1

THEnet social accountability framework

SECTION 1: WHAT NEEDS ARE WE ADDRESSING?

Who do we serve?
What are their needs?
What are the needs of the health system?

SECTION 2: HOW DO SECTION 3: HOW DO WE DO? SECTION 4: WHAT DIFFERENCE

WE WORK? How do we manage resources? DO WE MAKE?
What do we believe in? Who are the educators and how are Where are our graduates?
they trained? What are our graduates doing?
How do we work
with others? Who are our learners? How do we support our graduates
What do our learners learn? and other health workers?
How do we make
How do our learners learn? How have we shared our ideas and
decisions? influenced others?
Where do our learners learn?
What impact have we made with
How does our research program
other schools?
relate to the mission and values of
our school? What difference have we made to
the health of the communities and
What contributions do we make to
regions that we serve?
the delivery of health care?

Source: Training for Health Equity Network (www.thenetcommunity.org).

328 Health Employment and Economic Growth: An Evidence Base

5. Policy options to transform education to
better meet needs

Based on the review of emerging evidence and promising practice described above, this
chapter advances the specific policy options below.

To ensure that health workforce education strategies address population needs, using
models that embrace interprofessional education and practice and that maximize
recruitment and retention in underserved areas, education providers in collaboration
with all stakeholders should:

• ensure that curricula incorporate local patient and population needs, including the
social determinants of health, and that a significant portion of the curriculum is
delivered in the primary care contexts in which graduates are expected work;

• design policies to recruit students from underrepresented populations, along with

others deemed likely to choose to work in underserved regions;

• recruit, train and promote faculty across cadres to build competencies that are
relevant to evolving health care needs;

• support community-based health practitioners as active faculty members and

promote their academic career development.

To ensure that policies are evidence-based, and to maintain high standards for education
and service provision and at clinical training sites, governments and other relevant
independent authorities in collaboration with stakeholders should:

• support national bodies to develop appropriate regulations for health workforce

education in a systematic and integrated manner and enforce these regulations
across all programmes and training sites;

• build the capacity and quality of education institutions through accreditation

mechanisms that include social accountability as an element of the accreditation
standards used at national or regional levels;

PART III: Education and Production | CHAPTER 13 329

 • support streamlined data collection, implementation research and evaluation of
graduate outcomes;

• support the assessment of social, economic, and health returns on investment in

health workforce education strategies.

To reduce fragmentation, increase efficiencies and create an enabling policy

environment, governments should work across sectors and ministries and
collaborate with key stakeholders, including the full range of education and service
providers and communities, to:

• plan, implement and evaluate a broad continuum of socially accountable

workforce education and training programmes that are intrinsically linked to
service delivery;

• support implementation research as well as cost-effectiveness and cost-benefit

analysis of education investments;

• invest in the infrastructure and strengthening of the provision of health services

in rural and primary care settings where needs are the greatest.

6. Key considerations for implementation of

social accountability
Implementing the policy suggestions mentioned above requires interlinked reform,
sustained efforts, and investments at all levels.

For education providers, changing the way established institutions work, coupled
with changing what, how and where students learn, will be a significant challenge in
a context where small changes in curricular content can be a turf battle. Hence the
processes of education reform need to be participatory and carefully designed and
implemented. Those who deliver education services need to work with a broader range
of stakeholders to ensure programmes are aligned with local contexts and address root
causes, and to create a sense of co-ownership of reforms. Key building blocks to foster
socially accountable health workforce education institutions at macro, meso and micro
levels have been identified (Figure 2) (76).

330 Health Employment and Economic Growth: An Evidence Base

Figure 2

Building blocks for socially accountable health workforce education

institutions

Environmental School People

(macro) (meso) (micro)

An explicit policy of
community participation
Responding to and informal linkages with
workforce and a defined community
health needs

Leadership and An explicit

champions with shared and shared
values, political onfluence understanding of
and willingness to social accountability
Responsive challenge dominant that is continually
and appropriate paradigms critically appraised,
International, debated and refined
national and local
government policy Membership of a
with funding and coalition of institutions
resourcing aspiring to be socially
accountable

The bedrock: Shared values and asirations congruent with social accountability
“Talking the talk and walking the walk”

Source: Preston et al. (76).

Governments, and other relevant independent authorities, need to support change

efforts at education institutions with clear vision, enabling policies, planning, incentives
and investments in implementing education reform. This includes support for research
that continues to examine what works, how it works, and in what context, which in
turn should inform policy and action. Accountability and enforcement mechanisms
are of utmost importance to spur reform at education institutions. Hence standards
and processes at oversight organizations, such as quality assurance and accreditation
organizations, need to lead the way.

How we define return on investment in health workforce education should be

expanded to include what communities value, the cost of maldistribution and brain

PART III: Education and Production | CHAPTER 13 331

 drain, and the value added by recruiting women and youths from marginalized
populations into health sector jobs.

Fragmentation, power differentials and vested interests will pose formidable

challenges to the consensus-building process among a broad range of national
stakeholders. However, if the process is inclusive, resources are equitably distributed
across cadres, and focus is kept on needs, such a national dialogue can reduce
fragmentation, achieve stakeholder buy-in, maximize the use of scarce resources, and
identify potential bottlenecks.

7. Conclusions
Socially accountable health workforce education can and should be interprofessional
and cross-cadre; incorporated into all levels of the health system; and supported
by enabling policies, strong regulatory frameworks, and robust quality assurance
processes. All of these factors promise to optimize the impact of investment in
education.

As highlighted above, for maximum benefit, governments and education institutions

need to engage in cross-sectoral participatory planning, increase their investment in
underserved regions, and ensure that remuneration and support for health workers are
adequate. To optimize impact, curricula should reflect the evolving needs of patients and
communities, including the social determinants of health. Significant portions of the
curriculum should be delivered in the settings where graduates are expected to work.
Education providers ought to recruit students from underrepresented populations and
recruit, train and promote community-based health workers and academic faculty with
competencies relevant to evolving health care needs.

A growing body of evidence suggests that such investments will yield returns in
the form of increased availability and distribution of health workers who have the

332 Health Employment and Economic Growth: An Evidence Base

skills and the commitment to provide care where it is most needed. This approach
can also increase the integration of youths and individuals from underserved
and marginalized populations into the health sector, enabling inclusive growth in
disadvantaged regions. In addition, social accountability strategies contribute to
increased economic activity due to the presence and contributions of students and
faculty, an associated investment in infrastructure, the upgrading of clinical training
sites, professional development for local clinicians, and new job creation. A resulting
sense of community empowerment also feeds collective confidence and furthers
economic growth.

However, to address the needs of underserved populations, education providers need

to have the leadership, institutional capacity and resources to do so. The process
will also entail a careful review of the national and regional policy and operational
environment to determine whether current policies enable or hinder the ability of
service providers to deliver the desired results. Ongoing programme evaluation and
implementation research will also be needed to determine what works, how it works,
and in what context.

While more research will be needed to understand these complex interventions,

investing in health workforce education that engages with stakeholders, is results
oriented, monitors progress, and is accountable for addressing collectively identified
needs represents an important milestone in delivering on the promise of universal
health coverage and inclusive growth.

Acknowledgements

The authors would like to acknowledge the assistance of the following reviewers:
Andreia Bruno, David Clarke, Sandra MacDonald-Rencz, and André-Jacques Neusy.

PART III: Education and Production | CHAPTER 13 333

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and coverage for the rural poor. In: Chuhan-Pole P, and do not do, and what they could do. In: Institute of
Angwafo M, editors. Yes Africa can: success stories Medicine (US) Committee on the Health Professions
from a dynamic continent. Washington (DC): World Education Summit; Greiner AC, Knebel E, editors.
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62. Health services development: the WHO Health 2003: Chapter 5 (http://www.ncbi.nlm.nih.gov/books/
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Organization (http://www.wpro.who.int/health_
services/health_systems_framework/en/, accessed
6 December 2016).

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 72. Barzansky B, Hunt D, Moineau G, Ahn D, Lai CW, 75. Standards for assessment and accreditation
Humphrey H et al. Continuous quality improvement of primary medical programs by the Australian
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Teacher. 2015;37(11):1032–8. doi:10.3109/014215 d0ffcecda9608cf49c66c93a79a4ad549638bea0_
9X.2015.1031735. original.pdf, accessed 7 December 2016).

73. McKimm J, Newton PM, Da Silva A, Campbell J, 76. Preston R, Larkins S, Taylor J, Judd J. Building blocks
Condon R, Kafoa B et al. Regulating on and licensing for social accountability: a conceptual framework
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countries. Sydney, Australia: Human Resources for
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accessed 7 December 2016).

338 Health Employment and Economic Growth: An Evidence Base

 PART IV
Addressing Inefficiencies

339
CHAPTER 14

Equipping health workers with the

right skills, in the right mix and in the
right numbers, in OECD countries
Liliane Moreira, Gaétan Lafortune

Abstract
This chapter identifies the education, training and service delivery reforms
required to transform the health workforce in countries of the Organisation
for Economic Co-operation and Development (OECD). While results focus on
doctors and nurses, the chapter stresses the need to move beyond traditional
professional boundaries.

The chapter identifies policies that support the creation of a health workforce
with the right skills, in the right mix and in the right numbers. Skills mismatches
waste human capital when health workers are overskilled, and harm quality of
care when they are underskilled. Countries need to adapt health professional
education and training to better match the skills acquired in training with
the skills required at work, and make more effective use of skills through
interprofessional collaboration and engagement with digital technology.
Moreover, to respond to population health needs, countries will need to train
a sufficient number of generalists, prepare non-physician providers to deliver
primary health services and make better use of technology to reach underserved
populations. Finally, the chapter calls for all countries, particularly countries of
the OECD, to educate and train the right number of health workers to respond
to their domestic needs. This requires more robust labour market information
and health workforce planning models, incorporating impacts of changes in
technology and models of care, to guide decision-making.

PART IV: Addressing Inefficiencies | CHAPTER 14 341

 1. Introduction

Health care provision needs to continuously adapt to respond to new needs driven by
demographic changes, the shifting burden of disease, and new opportunities driven
by technological changes.

Population demographics are changing rapidly. In the Organisation for Economic

Cooperation and Development (OECD) countries, the share of population aged 65 years
and older increased from 12% in 1990 to 16% in 2015, and is expected to continue to
grow to reach 21% in 2030 and 27% in 2050. This trend has been accompanied by an
increased share of the population affected by one or more chronic conditions.

New technologies – such as telemedicine, mobile health, electronic health records, big
data analytics and wearable diagnostic and therapeutic devices – are transforming, and
often disrupting, health care delivery. Smartphone software applications (apps) are now
being used for the diagnosis of health conditions in a cheaper and timelier way than
the traditional face-to-face consultation. Wearable devices and sensors are enabling the
continuous transmission of a person’s vital signs to his or her primary care practitioner
in real time, permitting more effective and tailored management of health problems.
Telemedicine is also becoming available to an increasing number of patients. Along
with these innovations come heightened expectations from citizens and communities,
who now have greater access to information than ever before.

Technology is beginning to encroach on professions previously thought immune

to disruption. “Deep learning” computer programmes are now able to interpret
radiological images and diagnose potential pathology in some cases more accurately
and more quickly than trained radiologists. Robotic anaesthesia and sedation is
now available for routine surgical procedures. These technologies will not make
radiologists and anaesthetists obsolete, but will require a transformation in their
skills and competencies, mainly related to their ability to interact with patients and
colleagues. Anaesthetists will be able to concentrate their efforts on more complex
interventions that require intense collaboration with the surgical team. In the case of
radiology, algorithms cannot converse empathically with patients about the meaning
and implications of the findings they have detected; knowledgeable and compassionate
health professionals will continue to be required in this role into the foreseeable future.

342 Health Employment and Economic Growth: An Evidence Base

A new policy landscape is emerging, offering tremendous opportunities to deliver
better, more effective and more efficient health services. But this evolution challenges
the organization of health service delivery and the skills mix required for different
categories of health workers. What are the new skills needed in the primary care
workforce to better respond to the health care needs of ageing populations? How can
health workforce planning methodologies be adjusted to provide better guidance on
education and training requirements and the skills mix, in light of rapidly changing
technologies and population health needs?

This chapter addresses these questions, shedding light on current challenges and
needed reforms in education and training programmes and health service delivery to
transform the health workforce. While the chapter focuses on doctors and nurses –
due to their predominant role in health service delivery in OECD countries – it also
stresses the need to move beyond traditional professional boundaries to optimize the
training and scope of practice of different health care providers to better respond to
population health needs.

2. The right skills

Health workforce skills can be broadly defined as a bundle of knowledge, attributes
and capacities that enable professionals to successfully perform different tasks. These
skills include technical, communication, management and other general skills (1),
which can be acquired through initial education and training programmes as well as
through continuous learning.

For both clinical and economic reasons, OECD countries tightly regulate the
acquisition, certification and use of skills of health professionals. Entry into medical,
nursing and other health-related education programmes is often implemented through
numerus clausus policies, which limit access to education to a given number of
students. Certification is usually achieved by issuing licences to practise in regulated
professions, through exams at the end of education or training programmes, and
increasingly also through reregistration procedures throughout the professional’s
life. The use of skills and scope of practice of different health care providers is usually
defined by laws and regulations (1).

PART IV: Addressing Inefficiencies | CHAPTER 14 343

 Nonetheless, despite all these regulations, there is evidence of a considerable skills
mismatch in the health sector as in other sectors of the economy, which is wasting
human capital when health workers are overskilled (that is, they have skills above
those required in their jobs) and threatening quality of care when health workers are
underskilled (that is, their skills are below those required for their jobs). Evidence
from the 2011/2012 OECD Programme for the International Assessment of Adult
Competencies (PIAAC) survey shows that a large proportion of doctors and nurses
reported being either overskilled or underskilled for some of the tasks they need to
perform. In this survey, around 70% of doctors and 80% of nurses reported being
overskilled for some aspects of their work, while about 50% of doctors and 40% of
nurses reported being underskilled for other tasks (Figures 1 and 2).1

Figure 1

Reported overskilling by physicians, nurses and other occupations,

PIAAC survey, 2011/2012

100%

80%

60%

40%

20%

0%
Physicians Nurses Others

Note: “Others” means workers in other technical and professional occupations (ISCO 2 and 3). The figure depicts
percentage responses with the associated 95% confidence interval.
Source: OECD (1).

1 The OECD PIAAC survey is a comprehensive survey of workers in all sectors of the economy that provides information
on the use of workers’ skills and skills mismatch. It includes 23 countries, with responses obtained from 500 doctors
and more than 2000 nurses. The survey questionnaire was designed to be fairly general, so it does not allow identifying
precisely the specific tasks for which the health professionals report being either overskilled or underskilled. Therefore,
self-reports of underskilling do not necessarily mean that health professionals are not able to fulfil their clinical tasks.
Rather, it implies that for some aspects of their work, these health workers think that they could benefit from more
training.

344 Health Employment and Economic Growth: An Evidence Base

Figure 2

Reported underskilling by physicians, nurses and other occupations,

PIAAC survey, 2011/2012

60%

50%

40%

30%

20%

10%

0%
Physicians Nurses Others

Note: “Others” stands for workers in other technical and professional occupations (ISCO 2 and 3). The figure
depicts percentage responses with the associated 95% confidence interval.
Source: OECD (1).

Addressing skills mismatches in the health sector is crucial to ensure high quality in
health service delivery while promoting greater return on the substantial investment
of time and money in educating and training health professionals. A recent report
by the United Kingdom’s National Audit Office indicates that it takes three years
and costs an estimated £79 0002 to train a new nurse, 10 years and £485 000 to train
a general practitioner (GP), and 14 years and £727 000 to train a senior specialist
doctor (consultant) (2).

2.1 Addressing issues of overskilling

Policies to address issues related to overskilling involve, first and foremost, reviewing
the scope of practice of different health care providers to promote a more efficient
use of their skills. Too many high-skilled health professionals are reporting that they
spend a large amount of time doing work that could be delegated to non-physician
providers (in the case of doctors) or health care

2 Current exchange rate: £1.00 = US$ 1.23 (November 2016).

PART IV: Addressing Inefficiencies | CHAPTER 14 345

 assistants (in the case of nurses). The results from the PIAAC survey reveal that
nurses with an advanced university degree are particularly likely to report being
overskilled for the job they do (almost twice as likely as those with a bachelor’s or
lower degree). This raises concerns over the value of providing more education
and training if a large proportion of nurses are not using these additional skills in
their jobs.

To overcome this challenge, OECD countries are introducing or expanding the role
of non-physician providers, including more advanced roles for nurses (for example,
nurse practitioners), pharmacists and other categories of health workers. In
2012/2013, at least one third of OECD countries reported having used this strategy
in the previous five years. In Canada, the Nordic countries and the United States of
America, advanced practice nurses and other non-physician providers have often
been deployed initially to address the needs of populations living in rural or remote
areas that are underserved by doctors (3). They then spread out more widely across
the health system as their role and the quality and safety of their work become
more broadly accepted by physicians and patients.

However, expanding the scope of practice of non-physician providers alone might

not be a productive strategy. As new technologies are subsumed into health service
delivery, policy-makers will need to consider the technologies’ impact on the
current overskilled workforce and adapt the strategy accordingly. One may even
dare to ask: does the introduction of ehealth in health service delivery lead to an
accentuation of overskilling issues by substituting health workers in certain tasks?
If so – taking this possibility to the extreme – could this mean that some health job
categories might even become superfluous?

To ensure health workers are fit for purpose in the 21st century context,
policy-makers ought to conduct an in-depth review of skills indispensable
for the new generation of health workers, and adapt education and training
models accordingly. At the same time, as new technologies start facilitating the
performance of certain tasks, a range of skills become expendable, and should
therefore be discarded from health professionals’ curricula.

346 Health Employment and Economic Growth: An Evidence Base

2.2 Addressing issues of underskilling
Three key reforms or policy levers can be used when addressing an underskilled
health workforce: modify education and training programmes, strengthen continuous
professional development (CPD), and reap the benefits of technology innovation.

Reforming the initial education and training programmes of health professionals is

crucial. It is during these formative years that health professionals acquire important
skills that will be required throughout their professional lives. Supporting this argument
is the strategy proposed in 2010 by the Global Independent Commission on Education of
Health Professionals for the 21st Century. The Commission called for 10 major reforms
to transform the education of health workers and strengthen health systems. Six of these
reforms concern health professional training, including the need to develop competency-
based curricula that are more responsive to rapidly changing needs and the promotion of
interprofessional and transprofessional education that breaks down professional silos and
enhances collaborative and effective teamwork. Four other reforms relate to actions that
institutions could take, such as establishing joint planning mechanisms and nurturing
a culture of critical inquiry within universities and institutions of higher learning. The
Commission also identified four long-term enabling actions to create an environment
conducive to implementing these specific reforms (Figure 3).

Figure 3

Recommendations for reforms and enabling actions

REFORMS

Instructional
• Competency-driven GOAL
ENABLING ACTIONS
• Interrofessional and
transprofessional education
• IT-empowered • Mobilise leadership Transformative
• Local-global • Enhance investments and interdependent
• Educational resources • Align accreditation professional
• New professionalism • Strengthen global education for
learning equity in health
Institutional
• Joint planning
• Academic systems
• Global networks
• Culture of critical inquiry Source: Reprinted from Frenk et. al. with permission from Elsevier (4).

PART IV: Addressing Inefficiencies | CHAPTER 14 347

 CPD can ensure that the skills of actively practising doctors and nurses are
kept up to date during their professional lives. Awarding a licence to practise
at the end of medical or nursing education is no longer sufficient to ensure the
delivery of high quality of care throughout a professional’s career. With the
speed at which new technologies are being incorporated into health service
delivery, certain skills will become more relevant. For instance, communication
skills are increasingly important as modern health care provision moves from
an individual pursuit to a team effort, driven partly by an increasing range and
complexity of interventions and the growing number of patients with unique
and complex needs.

Policies and regulations concerning CPD vary greatly across OECD countries.
There are variations regarding whether participation in CPD activities is
mandatory and whether relicensing requirements are in place. Where there are
relicensing requirements in place, there is variation in whether (and how much)
CPD is a mandatory part of the relicensing or reregistration process. In at least a
dozen OECD countries, participation in CPD activities for doctors is combined
with relicensing or reregistration requirements. In the United Kingdom, CPD is
linked to relicensing or reregistration procedures, although CPD provisions for
doctors do not follow a uniform nationwide system (1).

Regardless of whether mandatory or voluntary systems are in place, some

key common barriers to greater participation in CPD activities for doctors,
nurses and other health professionals are lack of time and related cost (5).
Hence there is a need for more systematic and organizational support that
will allow professionals to take time off for CPD, to ensure that the costs are
not prohibitive and that CPD activities are well designed to address important
skills gaps. CPD should thus be designed and aligned with identified needs
and delivered in effective ways. Evidence suggests that certain types of CPD
are more effective than others. In particular, when compared with more
traditional learning forms, interactive forms of improving medical knowledge
seem to be more effective in terms of changing physician care and patient
outcomes (6).

348 Health Employment and Economic Growth: An Evidence Base

Digital technology can be used to tackle an underskilled health workforce.
Digital technology refers to generating, storing and processing data in a fast and
efficient way. It enables much more efficient transfer of information between
two or more parties than older forms of data sharing. Given that health care
is an information-intensive industry, the use of digital technology in health
service delivery can help manage the complexity and uncertainty associated
with health and illness. By providing necessary information and permitting fast,
reliable communication, this technology can complement health workers’ skills
and enable health professionals to make more accurate and timely decisions in
otherwise uncertain situations. For instance, evidence suggests that diabetes
health workers (or community health workers in low-income countries) – when
supported with information and communication technology (ICT) and clear
protocols about what to do when symptoms are not within a prescribed range
– can be trained to ensure that treatment regimes are followed correctly, leaving
health professionals with more expertise to focus their attention on more
problematic cases.

3. The right mix

Across OECD countries, addressing current and future health care needs –
characterized by an increased burden of chronic diseases, ageing populations
and quicker discharges from hospitals – will require building stronger primary
care systems. Current demographic and epidemiological shifts are rapidly
increasing the demand for an adequate supply of generalists3 who were properly
trained to work in multidisciplinary teams and make smart use of technology to
connect with people, providers and places. However, over the past two decades,
the share of generalists has declined in nearly all OECD countries. On average
across OECD countries, in 2014, only one in three doctors were generalists
(Figure 4).

3 For the purpose of this paper, the term “generalists” refers to general practitioners or family doctors.

PART IV: Addressing Inefficiencies | CHAPTER 14 349

 Figure 4

Generalists as a share of all physicians, selected OECD countries,

1995–2014
60

55

50

45

40

35

30

25 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Australia Belgium France Germany Netherlands United Kingdom OECD

Note: Generalists include general practitioners (“family doctors”) and other generalists (non-specialists).
Source: OECD (1).

To address this challenge, a few OECD countries have started to train more
generalists or use other health professionals to fill the gaps in primary care.
In Canada, France and the United Kingdom, the number of postgraduate
training places in general medicine has been increased. In Canada, the
proportion of medical students admitted to postgraduate training in general
medicine is 44% of the total entrants, while this proportion is 40% in England
and 48% in France (Figure 5). However, it has not always been easy to attract
a sufficient number of new medical graduates to fill these places. Numerous
factors affect the choice of medical specialization training beyond increasing
the number of posts available. Complementary actions are needed to make
general medicine a more attractive option for new doctors, including
narrowing the remuneration gap with other medical specialties and reducing
time on duty by promoting group practices (1).

350 Health Employment and Economic Growth: An Evidence Base

Figure 5

Share of students admitted in general medicine versus other

specializations, selected OECD countries, 2013 (or nearest year)

General medicine Other specialisations

100
90
80
52% 56%
70 60% 63% 73%
60 73%
50
40
30
48% 44% 40%
20 37%
27% 27%
10
0
ce

da

es

s
nd
an

ai
an

na

at

Sp
gl

rla
St
Fr

Ca

En

he
d
te

et
ni

N
U

Note: In the United States, general medicine includes students admitted to both family medicine and internal
medicine.
Source: OECD (1).

OECD countries are also expanding nurses’ roles as a way to strengthen primary
care services. Evaluations have shown that properly trained advanced practice nurses
working in primary care can improve access to services and deliver the same quality of
care as GPs for various patient groups (for example, those with minor illnesses or those
requiring routine follow-up for chronic conditions). When advanced practice nurses
take on some of the tasks previously performed by doctors, it helps free up the time of
GPs and provides these services at a lower cost (3).

In Canada, the Netherlands and the United States, the number of students admitted
to nurse practitioner (NP) programmes has expanded and increased the supply of
these mid-level providers in primary care and other settings. In the United States, the

PART IV: Addressing Inefficiencies | CHAPTER 14 351

 number of graduates from NP programmes more than doubled between 2001 and 2012,
rising from around 7000 in 2001 to over 14 000 in 2012 (Figure 6), and this number
increased further to 15 000 in 2013 (7).4

While training more generalists or expanding the scope of nurses’ roles requires
substantial resources, digital technology and ICT can offer countries cost-effective
means to expand access to primary care services. For instance, telemedicine or mobile
health (m-health) – both already being used in OECD countries – can be accessed
through smartphone apps, wearable monitors and portable devices.

Figure 6

Graduates from nurse practitioners programmes, United States, 2001–

2012

16,000
14,000
12,000
10,000
8,000
6,000
4,000
2,000
0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Nurse pratitioner (graduates)

Source: OECD (1).

The potential of telemedicine – clinical services, mostly medical consultations, that are
provided remotely – is undeniable. Not only can it bring high-quality and specialized
care to underserved populations by connecting patients to providers, it can also

4 For the past 20 years, a master’s degree has been required to become an NP, or any other recognized advanced
practice nurse (APN), in the United States. However, in 2004, the American Association of Colleges of Nursing and the
National Council of State Boards of Nursing proposed that the minimum requirement for advanced practice nursing (to
be imposed from 2015 onwards) be raised to a “Doctor of Nursing Practice” degree. While this change will not have
any consequence on current NPs and other APNs with a master’s degree (they will still be able to practise), this will add
more years of education and training for the new generation of advanced practice nurses and further delay their entry
into practice.

352 Health Employment and Economic Growth: An Evidence Base

connect local nurses and paramedical staff with GPs, who offer advice and support
for diagnoses and prescriptions as needed.

The cost-effectiveness of telemedicine has sometimes been questioned and the

infrastructure around using this technology is going through significant change.
While consultations used to require complex videoconferencing equipment, they
can now be done via smartphones. In addition, the cost of high-speed Internet is
also decreasing, making telemedicine more affordable. Across OECD countries, the
number of initiatives using telemedicine is growing.

Governments can also strengthen the investment and incentive structure around
the use of mhealth. Giving people more control to manage their own health
decreases the need for medical or nursing consultations. Wearable devices and
sensors can continuously transmit a person’s vital signs to his or her primary care
practitioner in real time, permitting more effective and tailored management of
health problems. According to one estimate, more than 165 000 health apps were
available in 2015, a figure that has doubled since 2013 (8). These apps perform a
wide range of functions, such as medication reminders, tracking movement and
activity, and monitoring progress in pregnancy. For example, diabetes management
apps allow glucometers to be plugged into the smartphone to track insulin levels
and send alerts if necessary.

However, a greater use of these technologies does not necessarily guarantee

improvements in access to health services for all the population. As with any
technology, potential benefits should be considered against possible risks or
limitations. Users must be competent and possess a minimum level of digital
literacy to navigate the new mobile tools correctly. Risks include unequal access to
these tools driven by cost and lack of awareness, which may discriminate against
the very people who stand to benefit from them the most.

PART IV: Addressing Inefficiencies | CHAPTER 14 353

 4. The right numbers

As health needs continue to change and technologies become a more integral part of
health service delivery, policy-makers will need to carefully consider the number and
types of health workers needed in the system.

In OECD countries, one of the most powerful policy levers governments use to
adjust the supply of doctors, nurses and other health professionals is through
numerus clausus policies,5 which regulate the number of students admitted to
medical and nursing education programmes each year. While limiting student
intakes is clearly a powerful tool, the effects are not felt immediately, as it takes
several years to train new health professionals.

Since 2000, most OECD countries have increased, often quite substantially, the
number of students admitted to medical and nursing education, in response to
concerns about current or future shortages. Increased intakes have led to growing
numbers of medical and nursing graduates entering the labour market, contributing
to the continued rise in the number of doctors and nurses that has been observed in
nearly all OECD countries over the past decade, both in absolute number and on a
per capita basis (9).

The number of medical graduates has increased particularly rapidly in English-

speaking countries such as Australia (increasing by 150% since 2000), Canada
(increasing by 75% between 2000 and 2012) and the United Kingdom (doubling
during that period) (Figure 7).

5 Ever since numerus clausus policies were introduced to control entry into medical education in the 1970s, both
their legitimacy and management have been questioned. Numerus clausus policies have often been characterized
by increases or decreases in the number of students admitted, as a response to concerns over future shortages or
surpluses of health care providers. Determining what may be the right number of students to admit each year has
proven to be challenging for governments, given the wide range of factors that affect the future demand for and
supply of health workers and political pressures from different interest groups. At least one country, Australia, has
recently decided to abandon numerus clausus policies for most health-related university studies (with the exception
of medical education) in an effort to open up entry into university education.

354 Health Employment and Economic Growth: An Evidence Base

Figure 7

Rising number of medical graduates, selected OECD countries, 2000–

2013

Non-European countries
Australia Canada Japan United States
250
Index (2000=100)

200

150

100

50
2000 2003 2006 2009 2012 2013

European countries
France Germany Netherlands United Kingdom
250
Index (2000=100)

200

150

100

50
2000 2003 2006 2009 2012 2013

Nordic countries
Finland Norway Sweden
250
Index (2000=100)

200

150

100

50
2000 2003 2006 2009 2012 2013

Central and Eastern European countries

Czech Republic Poland Hungary Slovak Republic
250
Index (2000=100)

200

150

100

50
2000 2003 2006 2009 2012 2013

Source: OECD (9).

PART IV: Addressing Inefficiencies | CHAPTER 14 355

 The number of students admitted to and graduating from nursing education
programmes has also increased strongly since 2000, particularly in Australia and the
United States, but also in European countries such as Finland (although a reduction
occurred in the years following the economic crisis) and France (most of this
increase occurred in the early 2000s) (Figure 8).

Figure 8

Rising number of nursing student intakes (or graduates), selected OECD

countries, 2000–2013 (index: baseline year = 100)

Australia United States

250 250

225 225

200 200

175 175

150 150

125 125

100 100

75 75
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

France Finland
250 250
225 225
200 200
175 175
150 150
125 125
100 100
75 75
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Note: For the United States, the number of graduates is used as a proxy for the number of students admitted
to nursing education. For France, the annual quotas established by the government are used as a proxy for the
number of students admitted to nursing education.
Source: OECD (1).

356 Health Employment and Economic Growth: An Evidence Base

In the United States, the number of graduates from registered nurse (RN)
programmes nearly doubled between 2001 and 2013, rising from around 100 000 to
200 000 per year. This strong and steady rise was a response to former projections
pointing towards expected RN shortages by 2020 (10). As a consequence, around
100 000 additional RN graduates are now graduating from United States universities
each year compared to the early 2000s. There is concern that the supply of nurses
may soon exceed the demand if student admission rates remain at their 2013 level
(11). The recent sharp increase in the number of domestically trained nurses in
the United States has been accompanied by a sharp drop in the number of foreign-
trained nurses who pass the exam to work in the United States (1).

The above example illustrates the need to conduct regular assessments of labour
market prospects based on more robust health workforce planning models that do
not overreact to cyclical fluctuations, given the time that it takes to train new health
professionals.

In addition, health workforce planning models will undergo substantial changes as

digital technologies become a more integral part of health service delivery. Digital
technology is currently changing health service delivery (and will continue to do so
in future), with a consequent shift in the number and types of health workers needed.
For instance, digital technologies are prompting the emergence of coordinators
liaising across teams of health and social care providers and coaches that empower
people to manage their conditions effectively. More health professionals will be
needed to promote healthy lifestyles and disease prevention among individuals and
populations; more generalists and nurse practitioners will be needed to manage
multiple chronic conditions. As the role of ICT and data analytics grows with the
use of digital technology, so will the necessity to add professionals specializing in
bioinformatics as key members of care teams.

Box 1 summarizes some of the main recommendations that arose from a 2013
OECD review of health workforce planning models to improve the management
of numerus clausus policies based on more robust health workforce data and
sophisticated health workforce planning models.

PART IV: Addressing Inefficiencies | CHAPTER 14 357

 Box 1

Recommendations to improve health workforce planning in OECD

countries

Health workforce planning is not an exact science and needs regular

updating. Assessing the future supply of and demand for doctors, nurses or
other health professionals 10 or 15 years down the road is a complex task, fraught
with uncertainties on the supply side and even more so on the demand side.
Projections are inevitably based on a set of assumptions about the future; these
assumptions need to be regularly reassessed in light of changing circumstances,
new data and the effect of new policies.

We need to know where we are before we can know where we are heading. The
first step of any good health workforce projection is gathering comprehensive
data about the current situation. One of the main benefits of strengthening health
workforce planning efforts is that it often triggers improvements in this crucial
first step.

Health workforce projections should help avoid a “yo-yo” approach to

student intakes and entry into medical and nursing occupations. Available
evidence shows that employment in the health sector tends to be less sensitive to
economic cycles than employment in other sectors, and there is also a long time
lag between decisions about medical student intakes and the actual entry of those
students into the labour market. Hence, health workforce planning should keep
an eye on long-term structural factors and avoid being overly sensitive to cyclical
fluctuations.

5. Conclusions
Ensuring that the health workforce becomes fit for purpose for 21st century health
needs will require that policy-makers, professional associations and educational
institutions support the necessary transformations in education and training
programmes and in health service delivery models. The need to adapt is driven by

358 Health Employment and Economic Growth: An Evidence Base

Supply-side improvements need to focus more on retirement patterns. Most
health workforce projection models have focused their attention on new entry
into different professions, but have paid less attention to exit through retirement.
There is a need to consider more closely the complex issue of work-to-retirement
patterns, particularly for doctors but also for other professions, as a large number
of health care providers are approaching retirement age and their retirement
decisions will have a major impact on supply in the coming years.

Health workforce planning requires a multiprofessional approach. Health

workforce projection models need to be able to assess in a more integrated way
the impact of different health care delivery models, as many countries are looking
at ways to reorganize the delivery of services to better respond to population
ageing and the growing burden of chronic diseases. Moving from uniprofessional
to multiprofessional approaches to health workforce planning is particularly
important in the primary care sector, where the roles and responsibilities of
different providers (doctors, nurses and other providers) are rapidly evolving in
an increasing number of countries.

Health workforce planning models need to adequately address the geographical

distribution of health workers. Any nationwide balance of health workers does
not necessarily mean that regional shortages or surpluses do not exist. A proper
assessment of gaps between supply and demand needs to go below the national
level to assess the geographical distribution of health workers and how this might
evolve over time under different scenarios.
Source: Ono, Lafortune and Schoenstein (12).

changing population health needs as well as a rapidly transforming technological

landscape, particularly in the area of digital innovation.

So far, OECD countries have focused mainly on ensuring there will be sufficient
health care providers (notably doctors and nurses) to replace those who will be

PART IV: Addressing Inefficiencies | CHAPTER 14 359

 retiring in the coming years. This has often been done without taking into account
two longer-term objectives: first, promoting the transformations needed in education
programmes and health service delivery to better respond to changing health needs
of the population and new technologies; and second, making fuller use of the skills of
different providers at all levels. In responding to pressures to achieve the short-term
replacement goal, policy-makers need to make sure that their decisions will not make
it more difficult to achieve the longer-term strategic objectives.

Policies around education and training of health professionals in OECD and

non-OECD countries need to be adapted to achieve the goal of providing the right
skills and competencies to a more diverse workforce, with a particular focus on
promoting greater access to primary care based on teamwork. Policies also need
to promote greater support for continuous professional development and skills
reassessment to ensure that health care providers remain fit for purpose throughout
their professional lives. To achieve this ambitious agenda, four key objectives are
proposed:

1. adapt education and training programmes to more competency-based

curricula, and optimize the scope of practice of different categories of
health professionals to ensure effective use of their skills;

2. ensure an efficient supply of primary care providers, and provide sufficient

incentives to attract and retain general practitioners and other health workers in
primary care;

3. develop more robust health workforce planning models – including the potential
impact of new technologies in changing the roles of and requirement for different
health professionals – to guide the decisions of prospective students and public
investments in education and training programmes;

4. provide greater support for continuous professional development activities and

implement regular skills reassessment to ensure that the skills of health care
providers are kept up to date throughout their professional lives.

360 Health Employment and Economic Growth: An Evidence Base

The opinions expressed and arguments employed herein are solely those of the authors
and do not necessarily reflect the official views of the OECD or of its member countries.

Acknowledgements

The authors gratefully acknowledge contributions from Francesca Colombo

and Luke Slawomirski (from the OECD Health Division) and James Buchan
(from Queen Margaret University).

PART IV: Addressing Inefficiencies | CHAPTER 14 361

 References

1. Health workforce policies in OECD countries: right 7. NP fact sheet. American Association of Nurse
jobs, right mix, right places. Paris: Organisation for Practitioners; 2016 (https://www.aanp.org/all-about-
Economic Co-operation and Development; 2016. nps/np-fact-sheet, accessed 17 January 2017).
doi:10.1787/9789264239517-en.
8. Terry K. Number of health apps soars, but use
2. Managing the supply of NHS clinical staff in England. does not always follow [online]. New York;
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National Audit Office; 2016 (https://www.nao.org.uk/ viewarticle/851226).
report/managing-the-supply-of-nhs-clinical-staff-in-
england/, accessed 20 November 2016). 9. Health at a glance 2015: OECD indicators. Paris:
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3. Delamaire M-L, Lafortune G. Nurses in Development; 2015 (http://www.oecd.org/health/
advanced roles: a description and evaluation of health-systems/health-at-a-glance-19991312.htm,
experiences in 12 developed countries. OECD accessed 17 January 2017).
Health Working Paper No. 54. Paris: Organisation
for Economic Cooperation and Development; 10. Biviano MB, Tise S, Dall TM. What is behind HRSA’s
2010 (http://www.oecd.org/officialdocuments/ projected U.S. supply, demand, and shortages of
publicdisplaydocumentpdf/?cote=DELSA/HEA/ registered nurses? In: Gupta A, Harding A, editors.
WD/HWP(2010)5&doclanguage=en, accessed 20 Modelling our future: population ageing, health
November 2016). and aged care. International Symposia in Economic
Theory and Econometrics, Volume 16. Emerald Group
4. Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Publishing Limited; 2007:343–74.
Evans T et al. Health professionals for a new
century: transforming education to strengthen 11. The future of the nursing workforce: national
health systems in an interdependent world. Lancet. and state level projections, 2012–2025. Rockville
2010;376(9756):1923–58. doi:10.1016/S0140- (Maryland): U.S. Department of Health and Human
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Administration; 2014 (https://www.nh.gov/nursing/
5. Study concerning the review and mapping of forms/documents/hrsa-report-nursing-projections.pdf,
continuous professional development and lifelong accessed 20 November 2016).
learning for health professionals in the EU. European
Commission, DG Health and Food Safety; 2014 12. Ono T, Lafortune G, Schoenstein M. Health
(http://ec.europa.eu/health/workforce/key_documents/ workforce planning in OECD countries. OECD
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2013 (http://www.aacp.org/resources/research/
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2014-9789264225428-en.htm, accessed
20 November 2016).

362 Health Employment and Economic Growth: An Evidence Base

CHAPTER 15

The role of decent work in the

health sector
Christiane Wiskow

Abstract
This chapter focuses on the importance of decent work in the health sector for
the achievement of Sustainable Development Goals 3, 5 and 8. It considers all
workers in or contributing to the health sector as part of the health workforce,
including a broad range of skill levels and occupational groups. Referencing the
normative work of the International Labour Organization and recent literature,
the chapter summarizes decent work challenges and opportunities, and suggests
strategies to create quality jobs in the health sector.

The chapter emphasizes the need for and value of investment in decent work
in the health sector, as related to attracting and retaining health workers and
enabling the provision of quality health care. Core issues addressed include
secure employment, safe and healthy work environments, fair pay and benefits,
social protection, and education and professional development, with particular
attention paid to the gender dimensions of each issue. The chapter calls for
a rights-based approach to health employment, with collective bargaining,
organizing, and freedom of association rights as fundamental. It additionally
highlights the positive contribution of social dialogue, as an integral part of
decent work, to health sector development and reforms; and consensus-based
responses to health sector challenges, resulting in policies that are more effective
and sustainable.

PART IV: Addressing Inefficiencies | CHAPTER 15 363

 1. Introduction
The Sustainable Development Goals (SDGs) underscore the critical role of decent
work in ensuring inclusive economic growth and its contribution to social progress.
SDG 8, on promoting full and productive employment and decent work for all,
is closely linked to the part of SDG 3 that calls for increasing the recruitment,
development, training and retention of the health workforce to ensure healthy lives
for all, and to SDG 5 on gender equality (1).1

The health and social work sector2 has remained a relatively stable employment
sector, with annual growth rates even in times of slowing economic growth and
increasing levels of unemployment, particularly for women, who constitute more
than 70% of the workforce (2).

Notwithstanding the global growth trends in health employment, significant health

workforce shortages exist in many countries. These shortages, which are most
pronounced in rural areas and in low-income economies, constrain the ability of
countries to achieve universal access to essential health services for all in need,
especially as they primarily affect the poorest and most vulnerable populations by
excluding them from access to health services, thereby exacerbating a country’s
health inequities (3–5).

While the care economy has been identified as a source of future job growth due
to ageing populations, many existing needs for care go unmet because of financial
constraints on the individual in need, or because the care needs are met by
underpaid or unpaid carers (6).

The Ebola outbreak in western Africa demonstrated the harsh consequences that
inadequate investments in public health systems and their workforce can have on
societies, economic development and international health security (7). The high

1 SDG 8: Promote sustained, inclusive and sustainable economic growth, full and productive employment and decent
work for all. SDG 3: Ensure healthy lives and promote well-being for all at all ages (target 3.c: Substantially increase
health financing and the recruitment, development, training and retention of the health workforce in developing
countries, especially in least developed countries and small island developing States). SDG 5: Achieve gender equality
and empower all women and girls.
2 The health and social work activities sector is defined according to ISIC Rev.4, section Q: Human health and social
work activities.

364 Health Employment and Economic Growth: An Evidence Base

death toll among health workers3 sheds further light on the lack of protection against
exposure to occupational hazards and the poor conditions of work that confront
health workers in their daily tasks (8, 9).

Workforce shortages, high staff turnover, increasing health worker migration

and early exits from health professions are symptoms of decent work deficits and
dysfunctional health systems. Investments in health need to provide for employment
with decent working conditions if they are to yield the intended result of effective
and sustainable health care systems.

This chapter focuses on the importance of decent work in the health sector for the
achievement of SDGs 3, 5 and 8. It considers all workers in or contributing to the
health sector as part of the health workforce, including a broad range of skill levels
and occupational groups. New estimates suggest that a significant number of workers
in non-health occupations4 are contributing to the provision of health care (10 ).
With reference to International Labour Organization (ILO) normative work and
recent literature, the chapter summarizes decent work challenges and opportunities,
and suggests strategies to create quality jobs in the health sector.

2. Importance of decent work

Health workers are the backbone of health systems. To perform effectively they
need secure jobs, fair pay, safe and healthy working conditions, adequate education,
continuing professional development, career opportunities, equal treatment and
social protection for themselves and their families (Box 1).

3 WHO reported the deaths of 513 Ebola-infected health workers (as of October 2015) in the course of the outbreak in
the three most affected countries – Guinea, Liberia and Sierra Leone (8).
4 Examples of workers in non-health occupations in the health sector include information technology workers, cleaners,
catering and maintenance personnel, and accountants. For a more detailed definition of workers in health occupations
and workers in non-health occupations in the context of estimating the size of the workforce contributing to the
health economy, see Scheil-Adlung and Nove (10).

PART IV: Addressing Inefficiencies | CHAPTER 15 365

 Box 1

What is decent work?

Decent work is productive work for women and men in conditions of

freedom, equality, security and human dignity. It involves:
• opportunities for work that is productive and delivers a fair income;
• security in the workplace and social protection for families;
• better prospects for personal development and social integration;
• freedom for people to express their concerns, organize and participate in
the decisions that affect their lives;
• equality of opportunity and treatment for all women and men.

Source: International Labour Office (11).

Yet, in the face of reforms focused on cost containment, policy-makers face major
and growing challenges in responding to the increasing demand for health care.
While existing workforce shortages already result in overburdened workers, there is
a risk that extending access to health care without expansion of health employment
will lead to further intensification of workloads and deteriorating working conditions
for the workforce.

Virtually all countries face challenges in recruiting, deploying and retaining

sufficient numbers of well trained and motivated health workers where they are
needed. The reported causes for high turnover and attrition rates of health workers
in many countries are mainly poor employment and working conditions, including
low salaries and weak career prospects. Despite differences across countries and
occupational groups, health workers’ job dissatisfaction is directly linked to
motivations to leave the profession (12, 13).

366 Health Employment and Economic Growth: An Evidence Base

Working conditions and income remain common key motivations for individual
health workers to move abroad. For example, the association between income levels
in origin countries and intentions to migrate was observed in 17 European countries,
where health professionals were attracted to countries offering higher income, while
outflows decreased in countries where salaries were improved (14). Income, however,
is not the only motivation to leave. More important is an overall dissatisfaction with
working conditions, such as excessive workloads, long hours of work, inadequate
infrastructure and medical equipment, lack of control over work, poor work
relations, and lack of professional development and recognition. The search for better
protection against exposure to occupational hazards, such as infectious diseases, is
also a motive to migrate, particularly in Africa (15–17).

Working conditions influence the quality of care. Patient outcome indicators such as
morbidity and mortality are closely associated with appropriately determined staffing
levels, staffing stability and the education levels of health workers (18). Research in
some European countries shows that an increase in a hospital nurse’s workload by
one patient increases the risk of inpatient mortality by 7%; while inversely, each 10%
increase in the proportion of nurses with a bachelor’s degree is associated with a 7%
decrease in patient mortality (19).

Thus, decent work in the health sector has a dual critical role: ensuring both the
sustainability of the health workforce and the provision of quality care. Improving
employment and working conditions will attract and retain health workers while also
enabling them to perform more effectively.

3. The Decent Work Agenda

Job creation and employment, rights at work, social protection and social dialogue
form the pillars of decent work. These main elements build the basis of the
ILO’s Decent Work Agenda and its four strategic objectives, which are equally
important, interrelated and mutually supportive; they are outlined in the following
subsections (20).

PART IV: Addressing Inefficiencies | CHAPTER 15 367

 3.1 Promoting productive employment
Sustainable institutional and economic environments will encourage investments
in health employment. Health employment policies need to consider the specifics
of health labour markets: they have to balance demand and supply with a view to
meeting population health needs for effective access to health care. Policies have
to address the diversification of employment in the health sector. Important in
this context is the transition from informal to formal jobs, for instance in the care
economy, and addressing vulnerable employment in the health sector to ensure
productive employment and inclusive economic growth, in line with SDGs 3 and 8.

3.2 Guaranteeing rights at work

All aspects of decent work have a legal dimension: international labour standards
and national labour laws help to clarify what decent work implies in concrete
terms and are preconditions for its achievement (21). Fundamental rights at work
include freedom of association, the right to organize and collective bargaining, equal
remuneration, the elimination of discrimination in employment and occupation,
and provision of safe and secure working environments for all workers, including
migrant workers.

International labour standards provide guidance for decent work policies. The
Nursing Personnel Convention, 1977 (No. 149) and its Recommendation (No. 157)
outline key standards, also relevant for other occupational groups in the sector,
including standards for education and training appropriate to the exercise of
functions; professional regulation; occupational safety and health legislation adapted
to nursing work; hours of work, leave and social security at least equivalent to other
workers; and voice and participation (22). Box 2 presents ILO Conventions and
standards of relevance to the health sector.

With a view to international recruitment and migration, the protection of migrant

health workers’ rights is important. In line with international standards,5 migrant

5 Notably: Migration for Employment Convention (Revised), 1949 (No. 97); Migrant Workers (Supplementary Provi-
sions) Convention, 1975 (No. 143); Nursing Personnel Recommendation, 1977 (no. 157) (all ILO); and International
Convention on the Protection of the Rights of All Migrant Workers and Members of Their Families, 1990.

368 Health Employment and Economic Growth: An Evidence Base

 Box 2

ILO Conventions and standards relevant to the health sector

• Freedom of Association and Protection of the Right to Organise

Convention, 1948 (No. 87)
• Right to Organise and Collective Bargaining Convention, 1949 (No.98)
• Equal Remuneration Convention, 1951 (No. 100)
• Discrimination (Employment and Occupation) Convention, 1958 (No. 111)
• Nursing Personnel Convention, 1977 (No. 149)
• Nursing Personnel Recommendation, 1977 (No. 157)
• Labour Relations (Public Service) Convention, 1978 (No. 151)
• Social Security (Minimum Standards) Convention, 1952 (No. 102)
• Social Protection Floors Recommendation, 2012 (No. 202)
Source: International Labour Office. NORMLEX: information system on international labour standards
(www.ilo.org/normlex) (22).

health workers should enjoy, without discrimination, equality of treatment with

national workers regarding remuneration and working conditions, social security
and the right to organize. The World Health Organization (WHO) Global Code
of Practice on the International Recruitment of Health Personnel promotes the
protection of health workers’ rights as an integral part of ethical international
recruitment practices (23).

Appropriately applied and enforced in national legislation, according to country

situations, these international labour standards protect workers as well as supporting
the effectiveness of health services. This rights-based approach to decent work is
anchored in the Universal Declaration of Human Rights (24).

PART IV: Addressing Inefficiencies | CHAPTER 15 369

 3.3 Extending social protection
The implementation of national social protection floors with basic social security
guarantees aims to ensure universal access to essential health care and income
security for all in need, at a nationally defined level.6 It is based on the human right
to health and social protection (24). Because health workforce shortages constrain
access to health care, an effective social health protection system is important in
providing fiscal space for investing in decent health employment to ensure universal
access to health care (4). It is important to include the protection of health workers
when extending labour protection measures that address wages, working hours,
occupational safety and health, and maternity protection (25).

3.4 Promoting social dialogue

Social dialogue may include all types of negotiation and consultation, ranging
from exchange of information to collective bargaining and mechanisms for dispute
settlement. It operates at various levels, from national institutions, through regional
coverage to individual workplaces. Effective social dialogue requires strong,
representative and independent social partners who recognize the legitimate roles of
each other. Social partners in health services are public authorities as regulators or
as employers, and employers’ and workers’ organizations in the sector. Increasingly,
other stakeholders within and beyond the health sector have been involved in
dialogue on health policy development, while matters concerning negotiating and
collective bargaining remain a prerogative of the social partners (26).

Social dialogue contributes positively to the development and reform of health

services, and is particularly important in times of structural change. Based on values
and principles, including patients’ needs, professional ethics and affordable and
universal access to health care, social dialogue facilitates consensus building on
issues such as health reforms, social protection, financing, quality of health services,
working conditions, skills, career development and pay systems (26–28).

The freedom to participate and to express their concerns are critical for enabling
health workers to actively contribute to enhancing positive work environments

6 In line with the Social Protection Floors Recommendation, 2012 (No. 202) and the Social Security (Minimum
Standards) Convention, 1952 (No. 102) (22).

370 Health Employment and Economic Growth: An Evidence Base

and shaping quality health services, and are guaranteed in fundamental rights at
work. Social dialogue plays an important role in promoting decent work and better
health care. For example, the European Sectoral Social Dialogue Committee for the
Hospital and Healthcare Sector was established in 2006 (29). The social partners
– the European Public Services Union and European Hospital and Healthcare
Employers’ Association – have adopted a range of joint documents and agreed on
joint work programmes for their implementation.7 Another example is from South
Africa, where the Public Sector Coordinating Bargaining Council’s Resolution 2012
sets out to review working time schemes and rearrange working time organization to
facilitate improvement of health service delivery (30).

4. Major challenges to decent work and responses

4.1 Changing patterns of employment relationships

Health sector reforms, in response to cost and efficiency concerns, have resulted
in growing diversification in forms of employment. The sector increasingly uses
non-standard forms of employment, including fixed-term work, temporary work,
temporary agency work, dependent self-employment and part-time work (31).

Across countries, a common trend in public health services is to replace permanent

employment with fixed-term contracts for all employees, and to use outsourcing.
Agency workers often have no employment security, are excluded from collective
bargaining coverage, and may not receive the same pay as their permanently
employed colleagues (32). The use of zero-hour contracts8 has increased. In 2013,
for instance, an estimated 27% of United Kingdom health care employers were using
zero-hour contracts, and 307 000 workers in the care sector were on such terms of
employment in England alone (33).

In South Africa, the use of agency staff and related different contractual
arrangements within the same institutions has been identified as a growing problem,

7 Such as: Guidelines and good practice examples “ageing workforce healthcare sector” (2013); Framework of action
on recruitment and retention (2010); Multi-sectoral guidelines to tackle third-party violence and harassment related
to work (2010); Framework agreement on the prevention from sharp injuries in the hospital and healthcare sector
(2009); Code of conduct on ethical cross-border recruitment and retention (2008). All documents available from www.
epsu.org and www.hospeem.eu.
8 Zero-hour contracts are employment arrangements without guarantee of a minimum number of work hours.

PART IV: Addressing Inefficiencies | CHAPTER 15 371

 compromising service delivery, continuity of care, and health and safety, and
contributing to greater inequality (Figure 1). Outsourced ancillary services jobs
are mostly temporary, part time and insecure, with agencies supplying workers on
demand to the public health service (34).

Figure 1

Subcontracting of ancillary services in all public hospitals in

South Africa, 2011
Source: Kisting and Dalvie (34).

Cleaning % own
87% 13%
% contracted

Catering 72% 28%

Maintenance 36% 64%

Technology
25% 75%
services

Security 19% 81%

0 20 40 60 80 100

While well regulated non-standard forms of employment can allow organizations

to respond to changing demands, and workers to reconcile work, life and family
responsibilities, workers in such employment tend to be more exposed to deficits in
decent work, including job insecurity, lower pay, gaps in access to social protection,
higher risks of safety and health, and limited power for organizing and collective
bargaining (31). Employment policies have to provide protection for workers in such
vulnerable contractual arrangements.

The case of the Brazilian Unified Health System – Sistema Único de Saúde
(SUS) – provides an example of how institutional openness to dialogue and
negotiation can create a way to decrease the instability of outsourced work through

372 Health Employment and Economic Growth: An Evidence Base

the development of ways to guarantee the rights of these workers or by the adoption
of policies to replace outsourced workers with public servants through public
selection (Box 3) (35).

Box 3

Examples of improving conditions of work and organizing

care work

In Brazil, in response to the concern of the “precarization” (increasingly

precarious work status) of the workforce in the Unified Health System
(Sistema Único de Saúde, SUS), the Ministry of Health created the National
Interinstitutional Committee on Deprecarization of Work in the SUS,
composed of government representatives (federal, provincial and local)
and trade union leaders. It aims to promote the creation of employment
relationships that guarantee rights and job stability to workers as well as
the quality of the health services. Today, due to these efforts, there is an
institutional plan to regulate labour relations in the health sector and to
substitute outsourced and informal temporary workers for permanent
public servants.
Source: Verma and Gomes (35).

Cooperatives are emerging as a type of care provider, generating access to

better terms and conditions of work for the largely informal care workers. In
addition, cooperatives foster integrative, participatory and people-centred
care by privileging equitable inclusion and democratic decision-making
across the care chain. As a result, care workers, care beneficiaries and their
families, and other stakeholders have a voice in the nature of service provided
and the operations of the care provision enterprise. In Rwanda, for example,
community health workers have been organized in cooperatives.
Sources: International Labour Office (36); Condo et al. (37).

PART IV: Addressing Inefficiencies | CHAPTER 15 373

 4.2 Safe and healthy workplaces
Health workplaces can be dangerous. Workers in the health sector face a range
of occupational risks related to biological, chemical, physical, ergonomic and
psychosocial hazards.

In the European Union, health workers had the fourth-highest rate of serious work-
related problems across economic sectors. The sector ranked highest with regard
to exposure to biological and chemical hazards and work-related stress, violence
and harassment (38). Of concern to health workers are needlestick and sharps
injuries as sources of infection of hepatitis B, hepatitis C and HIV (39).9 Violence
and harassment are persistently high in the sector in both developed and developing
countries (40–42). Discrimination against health workers related to their status with
regard to HIV, Ebola or other infections, their gender or other reasons is a concern.

During the Ebola crisis in western Africa, the infection and mortality rates among
the national health and emergency workforces were exacerbated (8) due to lack of
personal protective equipment, supplies for hygiene, infection prevention and control,
and occupational safety and health measures.10 Once those measures were in place, the
infection rate among health workers dropped significantly (9).11

Health workers are increasingly under attack in emergencies and situations of

conflict: 159 workers were killed or wounded between 2008 and 2010; between
2012 and 2014, 760 health workers were affected by violence, including those killed,
wounded or beaten, threatened or subjected to arrest (43, 44). The number of victims
may be higher as there is no global system for documenting and reporting these
attacks (45).

The complexity of ensuring 24-hour services seven days a week, involving shift work,
night work and weekend work, poses enormous challenges for workers’ health and
organizational performance. Excessive workloads, long hours, sleep-disruptive shifts,
night work, overtime, short rest periods and work–life conflicts are associated with

9 In 2003, WHO estimated 3 million needlestick accidental injuries in health workers, leading to 37% of all new
hepatitis B cases in health workers, 39% of new hepatitis C cases and around 5.5% of new HIV cases (39).
10 WHO reported 881 confirmed or probable cases of Ebola-infected health workers, of which 513 had died, as of
October 2015 (8).
11 Health workers’ risk of infection was between 21 and 32 times higher than in the general population at the beginning
of the outbreak (9).

374 Health Employment and Economic Growth: An Evidence Base

staff health problems and chronic fatigue, leading to poorer individual performance,
including risks of medical errors and accidents. Resulting absenteeism and high
turnover are costly for health services.

Improving how working time is organized can lead to a better reconciliation of

workers’ well-being with individual and organizational performance requirements,
when inputs from all parties are integrated into the design of working time
arrangements. More flexible schedules and participatory approaches improve staff
control over their working time, and help them better balance work and family
responsibilities. Promising examples include compressed work weeks, flexitime
schemes, time banking systems, part-time work, job sharing and matching shift
schedules to circadian rhythms (30, 38).

Employers have overall responsibility to ensure that all practicable measures

are taken to ensure occupational safety and health. Health-care workers are
responsible for following established occupational safety and health procedures.
National legislation on occupational safety and health should be adapted to health
workplaces.12 Effective labour inspection is necessary for ensuring compliance with
standards protecting workers.

In non-health sectors, the economic return on prevention has been estimated at 2.2,
supporting the business case for investment in occupational safety and health in the
health sector as well (46).

4.3 Remuneration

Over the first decade of this century, the remuneration of salaried health workers
as a proportion of gross domestic product (GDP) remained nearly unchanged
globally and decreased in terms of total health expenditure (Figure 2). In some
countries, for example Egypt, Myanmar and Sudan, workers in the lowest paid
categories received wages on average 1% above the poverty line (47). To make up for
low wages, health workers often resort to working multiple jobs or increasing shifts
or overtime (30, 48).

12 In line with ILO Convention No. 149 and Recommendation No. 157.

PART IV: Addressing Inefficiencies | CHAPTER 15 375

 Figure 2

Yearly change of health workers’ remuneration compared to

total health expenditure and GDP by country income level,
2000–2010 (%)

0.03 Global Average yearly change

-0.51 in remuneration of
salaried workers as
-1.41 Low-income countries
-0.09 % of GDP

0.3 Lower-middle Average yearly change

-0.27 income countries of remuneration of
salaried health workers
0.25 Upper-middle- as % of total health
-0.64 income countries expenditure
-0.08 High-income countries
-0.56
-1.5 -1.0 -0.5 0.0 0.5

Average yearly change

Source: International Labour Office (47).

In response to the global economic crisis, some European countries reduced salaries
drastically or froze them, also affecting benefits such as pensions. These measures
contributed to increasing wage disparities, further stimulating health worker
outflows from some countries. Austerity measures induced a radical transformation
in the hierarchy of wage levels between the public and the private sector, resulting in
wage penalties for public service workers in some countries of the region (49–51).

Wage levels across occupations vary widely: among 16 health occupational groups
across 20 countries, medical doctors were paid the highest and personal care workers
the lowest wages, while the nursing and midwifery groups ranked in the middle.
Wage differentials between countries were also significant (52).

Pay is a major factor for recruitment, retention and motivation. As remuneration

reflects the level of recognition and value attached to a person’s work, the level of
pay for health workers should be comparative to and competitive with occupational
groups of similar skill levels and responsibilities in other economic sectors. Adequate
pay is important for the independence of health workers in exercising their
responsibilities according to their professional ethics.

376 Health Employment and Economic Growth: An Evidence Base

4.4 Gender aspects

While around 70% of the global health workforce is female (Figure 3), paradoxically
women in the health and social sector tend to remain in lower-skilled jobs, with less
pay and at the bottom end of professional hierarchies (53). In the United Kingdom,
female employment in care is mostly related to direct care work, while managerial
jobs tend to be held by men (54). In particular, long-term care is mainly performed
by women (90% in Organisation for Economic Co-operation and Development
(OECD) countries), often in part-time arrangements, while the training and skills
development of formal long-term care workers is often at very low levels compared
to other health workers (54).

Figure 3

Female share of employment in the health and social services sector by

region, 2013

Arab States 38.4%

Africa 54.1%

Asia and the Pacific 63.5%

Americas 74.0%

Europe and Central Asia 76.8%

Overall 70.3%

0 10 20 30 40 50 60 70 80 90

Source: ILO (2).

The number of informal long-term care workers in care of the elderly, often unpaid
female family members, by far exceeds that of formal long-term care workers (55).
Informal carers, including migrant workers, have less favourable working conditions,
lack social security and receive lower wages (38).

Because care work involves tasks that women have traditionally performed without
pay, the skills required for it and care provision in general are undervalued or

PART IV: Addressing Inefficiencies | CHAPTER 15 377

 overlooked in national measures of the economy (56). It has been argued that the
labour market devalues so-called “female” tasks and skills, as shown by the fact that
when women’s participation in the workforce in an occupation increases, wages
often are lowered (52). Women’s contribution to health care has been estimated to
account for nearly 5% of global GDP, equivalent to over US$ 3 trillion, but nearly
half of this is unpaid and unrecognized. This informal and volunteer work in families
and communities is considered a hidden subsidy to health systems and societies that
should be recognized and compensated (53).

The gender pay gap,13 globally estimated at an average of more than 20% in the
overall economy (6), appears even more marked in the human health and social
work sector, where the unadjusted wage gap has been estimated at an average 26% in
high-income countries and 29% in upper middle-income countries.14

Employment and social policies conducive to women’s participation in the labour

market, including measures to ensure equal pay for work of equal value, as well as
equal opportunities in professional development, career progression, and balancing
work with family responsibilities, are particularly important for the health sector.
Strategies to attract young people to care professions should address the needs
of both women and men in adequate ways.

4.5 Professional development

Education, vocational training and lifelong learning, as central pillars of

employability15 and productive employment, are indispensable for ensuring
decent work and inclusive economic growth (57). Rapid technological changes,

13 The gender pay gap refers to differentials in earnings between women and men. While being explained by a number
of factors, such as level of education, hours worked, and type of occupation, these factors are consequences of
broader gender inequalities in labour markets, including occupational segregation, hours spent in unpaid care and
household work, and part-time work due to family responsibilities (56).
14 This refers to an unadjusted gender wage gap, that is, the simple difference in average wages, not taking into
account the different characteristics of male and female employees. The reasons for the unadjusted wage gap need
to be further studied. Data available from 40 countries (27 high-income; eight upper middle-income; four lower mid-
dle-income; one low-income); latest available 2011–2013. Source: ILOSTAT, based on national labour force surveys
and official estimates of each country (http://www.ilo.org/ilostat/).
15 The term “employability” relates to portable competencies and qualifications that enhance an individual’s capacity to
make use of the education and training opportunities available in order to secure and retain decent work, to progress
within the organization and between jobs, and to cope with changing technology and labour market conditions. See ILO
Recommendation concerning Human Resources Development: Education, Training and Lifelong Learning, 2004 (No.
195) (22) .

378 Health Employment and Economic Growth: An Evidence Base

demographic transitions, epidemiological developments and scientific advancement
require continuous health workforce development to meet current and future
health needs.

Fragmented professional health education inadequately prepares young people for

practice as members of interprofessional teams delivering people-centred integrated
care. Entry-level employment at lower skill levels is particularly important for
addressing youth unemployment. Recruitment and retention of young people in
health occupations are improved when career development paths are well designed
through technical and vocational education and training (TVET), in-service
training and continuing training. Collaboration of education and health sectors,
academia, regulatory bodies, and employers’ and workers’ organizations is essential
to develop up-to-date curricula that result in the required skills and competencies,
to promote professional development and to open career paths beyond traditional
roles. Sustainable skills development systems are able to anticipate skill needs; engage
social partners in decisions about training provisions; maintain quality and relevance
of training; make it accessible to all in need; ensure viable and equitable financing
mechanisms; and evaluate the economic and social outcomes (57).

Education and professional development opportunities are major factors for

recruitment and retention as well as motivators for health worker migration (15,
17, 18). To mitigate the adverse impact on source countries of the loss of their
skilled health workforce, international standards, including the WHO Global
Code of Practice on International Recruitment of Health Personnel, suggest that
mechanisms of international cooperation be established to help strengthen health
workforce development systems in countries of origin (23).16 Recognition of skills,
competencies and qualifications in the context of negotiated agreements can be
beneficial by facilitating skills transfer to source countries as part of fair migration
policies.17 Timely information is vital for raising awareness on health workers’ rights
during the migration process (Box 4).

16 See also ILO Human Resources Development Recommendation, 2004 (No. 195), article 21.
17 See also ILO Nursing Personnel Recommendation, 1977 (No. 157), articles 62–67; ILO Human Resources Develop-
ment Recommendation, 2004 (No. 195), article 21(f); and WHO Global Code of Practice, article 5.3.

PART IV: Addressing Inefficiencies | CHAPTER 15 379

 Box 4

Raising awareness on labour rights for prospective migrant

nurses in the Philippines

Spearheaded by the Philippines Commission on Higher Education, a course

on migration and decent work has been developed for inclusion in the
country’s nursing and health science curriculum. The course consists of seven
context-specific modules covering the health care system in the Philippines,
decent work for Filipino health professionals, international agreements for
the mobility of health professionals, migration and ethical recruitment issues
and multiculturalism in the health sector. As prospective migrant health
professionals, students learn how to protect and exercise their labour rights,
and are thus better prepared to avoid the pitfalls of international migration.
Source: ILO (58).

5. Policy options

Policy option 1
Invest in decent work in the health sector so as to attract and retain health
workers and enable the provision of quality care

• To attract and retain skilled personnel where they are needed, investment in
health employment must be founded on decent work. Core issues to be addressed
include secure employment, safe and healthy work environments, fair pay and
benefits, social protection, education and professional development, and a voice
for health workers and their organizations.

• It is important to take into account gender dimensions when developing strategies for
health care to address the challenges for women in health work, including measures
reconciling work with family responsibilities, equal opportunities and pay, career
paths for women and the recognition and compensation of unpaid care work.

380 Health Employment and Economic Growth: An Evidence Base

• Conducive work environments enable and support the provision of quality
health care. Participatory approaches to improving workplaces and practices,
involving management and worker collaboration, have proven their
effectiveness.

Policy option 2
Promote a rights-based approach in health employment and social
dialogue in the health sector

• International labour standards incorporated in national legislation set the

legal frame for implementing decent work. At the health sector level, general
standards need to be adapted to the nature of work in the sector with means
for effective regulation or collective agreements. The protection of all health
workers, particularly those in vulnerable employment situations, is critical.

• Migrant health workers should have equal treatment with nationals.

Agreements between origin and destination countries should cover such
issues as social security entitlements, recognition of qualifications and funding
of training.

• Promoting social dialogue is a means to facilitating consensus building

among governments and social partners on relevant economic and social
policies affecting the health sector. The use of social dialogue with a view
to negotiating terms and conditions of employment by means of collective
agreements should be encouraged and promoted.

• Recognizing and respecting the rights to freedom of association, to organize

and to collective bargaining are fundamental to enabling health workers to
express their views and participate in the development of decent work in the
health sector.

• Intersectoral collaboration is indispensable for effective health care. All

relevant stakeholders should be involved in social dialogue, taking account of
the context and issues to be addressed.

PART IV: Addressing Inefficiencies | CHAPTER 15 381

 6. Implementation considerations

The decent work approach to health employment puts an emphasis on social

dialogue and on respect for rights at work. Based on these principles, successful
recruitment and retention policies consist of comprehensive interventions
addressing interrelated health workforce challenges. Combining financial incentives
with improved working conditions has proven to meet health worker aspirations for
decent work. Strategies have to be context specific according to country situations
and local needs, informed by evidence and lessons learned and backed by political
commitment through involvement of all stakeholders (59, 60).

Box 5

Brazil: Decent Work Agenda in the health sector

In November 2015, the Brazilian Ministry of Health and social partners

signed a protocol for the Permanent National Negotiation Table of the SUS
(Mesa Nacional de Negociação Permanente do SUS) to establish a Decent
Work Agenda for Health Workers in the National Health System (Agenda
Nacional do Trabalho Decente para Trabalhadores e Trabalhadoras do SUS,
Protocolo No. 009/2015). It builds on four priority action areas:

• generate more and better jobs in the national Unified Health System (SUS);

• strengthen health workforce management;

• strengthen dialogue and negotiation of working conditions and labour

relations in the SUS;

• combat all forms of discrimination at work, with special attention to

gender, race and ethnicity.
Sources: International Labour Office (61); text of the Protocol available from Ministério da
Saúde, Secretaria de Gestão do Trabalho e da Educação na Saúde Mesa Nacional de Negociação
Permanente do SUS (http://u.saude.gov.br/images/pdf/2015/dezembro/02/protocolo-mesa009.pdf).

382 Health Employment and Economic Growth: An Evidence Base

In Brazil, for example, the Ministry of Health and the social partners engaged in
dialogue on decent work for workers in the national health system, resulting in the
adoption of the National Decent Work Agenda in the health sector, setting out an
action plan for implementation (Box 5) (61).

Monitoring the impact of policies on the health workforce with a view to improving
work quality, access to health care and health outcomes is a next step requiring the
development of assessment tools adapted to the health sector.

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PMID:23541059. on the migration of health professionals. Manila:
International Labour Office; 2014 (http://www.ilo.org/
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gaps in rural areas: country examples. Geneva:
52. Tijdens K, de Vries DH, Steinmetz S. Health workforce International Labour Office; [forthcoming].
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dispersion of 16 occupational groups in 20 countries. 60. Barriball L, Bremner J, Buchan J, Craveiro I,
Human Resources for Health. 2013;11(1):11. Dielemann M, Dix O et al. Recruitment and retention
doi:10.1186/1478-4491-11-11. PMID:23448429. of the health workforce in Europe: final report.
Brussels: European Union; 2015 (http://ec.europa.
53. Langer A, Meleis A, Knaul FM, Atun R, Aran eu/health/workforce/docs/2015_healthworkforce_
M, Arreola-Ornelas H et al. Women and health: recruitment_retention_frep_en.pdf, accessed 22
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pdf, accessed 22 November 2016).

386 Health Employment and Economic Growth: An Evidence Base

CHAPTER 16

A hidden human resources for health

challenge: personnel posting and
transfer
Marta Schaaf, Kabir Sheikh, Lynn Freedman, Arielle Juberga

Abstract
Posting and transfer (P&T) encompasses initial health worker deployment
and subsequent transfers. Irrational P&T refers to deployment and transfer
that is inconsistent with population health needs. This chapter is based on a
comprehensive literature review to uncover the actual practices and informal
regulations characterizing P&T in low- and middle-income countries.

Irrational P&T in the health sector is described in many diverse low- and middle-
income countries. Existing data suggest that irrational P&T affects many cadres
of health care workers and administrators, from specialist doctors to outreach
workers. P&T is intimately related to the distribution of power at multiple levels
of governance. Negotiations often occur in a context of official and informal
regulations and incentives, lack of adequate human resources for health, political
patronage and networks, personal networks and corruption. Irrational P&T can
contribute to maldistribution and absenteeism, undercutting efficiency and health
worker morale. Often, the poorest regions are the most affected.

Despite its relevance to global health goals, P&T remains a largely unnamed
health system governance function. The chapter calls on policy-makers to
improve health worker deployment as a core system function; to introduce
direct accountability to communities around health workforce deployment;
and to improve collaboration between health-specific and broader public
administration actors.

PART IV: Addressing Inefficiencies | CHAPTER 16 387

 1. Introduction and outline of methods

Achieving universal health coverage requires adequate numbers of skilled health care
workers in functioning health facilities. However, in many countries there are too
few skilled personnel in the public sector, and the existing public sector workforce is
inequitably distributed. This maldistribution results in part from poor posting and
transfer (P&T) practice (Box 1).

Box 1

Irrational posting and transfer

Posting and transfer (P&T) encompasses initial health worker and
administrator deployment, and subsequent transfers. In general, “irrational
P&T” refers to P&T that is inconsistent with population health needs. While
a provider obtaining a post in a more desirable area may be rational from
the provider’s point of view, it is not rational from the perspective of health
system requirements for meeting health goals.

Even when governments have P&T policies that are intended to guide the
distribution and movement of health personnel, these policies are not always
followed. This may be because the policies are unknown to those tasked
with implementing them, because of management and communication
challenges or because their enforcement would interfere with entrenched
informal practices.

While further research is required, existing quantitative and qualitative

data suggest that irrational P&T practices contribute to maldistribution and
absenteeism, undercutting efficiency and the morale of health workers as well as
governmental efforts to improve access and quality. Often, the poorest regions
are the most affected by irrational P&T. These challenges are widespread;
irrational P&T is prevalent among different cadres of health workers in many
different countries (1, 2).

388 Health Employment and Economic Growth: An Evidence Base

Given its determinative role in reaching universal health coverage, P&T is a
fundamental health systems governance function, necessitating political and
resource commitment among stakeholders at subnational, national and global levels.
Providers and patients on the front lines of the health system attest to the relevance
of P&T. Yet, perhaps due to the fact that actual P&T practice often comprises a
“parallel system” (2), and because national-level data often fail to capture the actual
distribution of health workers, P&T remains largely below the radar in research
regarding human resources for health (HRH). Consequently, the informal rules and
patterned practices that constitute such a parallel system – although well known and
intimately understood by those workers who participate in it – are rarely seriously
considered when opportunities to develop new strategies and policies arise. As the
Sustainable Development Goal (SDG) era begins and the Global Strategy on Human
Resources for Health: Workforce 2030 takes shape, this chapter aims to consolidate
and synthesize existing data about irrational P&T practice and to propose ways
to promote P&T as a crucial element of health systems and health workforce
stewardship.

This chapter is based on a comprehensive literature review conducted to uncover

the actual practices and the informal regulations characterizing P&T in low- and
middle-income countries. We searched Google Scholar and PubMed for terms
related to posting and transfer in the health sector, including “posting”, “deployment”,
“turnover” and “transfer”. We started with a broader review that some of us had
conducted in 2012 (1) and then added resources that had been published in the
subsequent four years. We consulted both peer-reviewed and “grey” literature, as
many of the existing data and conceptual studies on P&T and related issues have not
been published in peer-reviewed journals. We also consulted relevant global health
strategies, particularly the Global Strategy on Human Resources for Health. Though
our findings refer to related phenomena, such as maldistribution and absenteeism,
we did not conduct separate reviews on these topics; these phenomena have
determinants and implications well beyond the scope of the discussion here.

We also conducted limited academic and grey literature reviews of policy

interventions that emerged in the initial review or that were identified as part of an
ongoing transnational discussion among researchers and policy-makers on P&T. We
looked at approximately 10 peer-reviewed articles related to each area; we did not

PART IV: Addressing Inefficiencies | CHAPTER 16 389

 conduct systematic reviews. These areas included transparency in deployment and
transfers; public service reform; civil society engagement and social accountability;
and the creation of new human resource processes, such as those related to recruiting
new cadres and emergency hiring.

2. Findings
HRH-related studies suggest that there may be significant gaps between policy and
practice. Actual P&T of health providers and administrators is shaped by factors at
individual and health system levels. Some of these factors, such as urban preference,
are well explicated in the retention and HRH distribution literature; others are not.
On the individual level, health providers and administrators may have locational
preferences for several reasons, including standard of living, proximity to family,
access to further education, access to promotion opportunities, opportunities to use
one’s skills, opportunities to generate additional licit or illicit income, and access
to development projects or other activities that might entail additional income or
professional support (1–8). Several studies report that providers fear being posted
to a rural area, where they can be “forgotten” and overlooked for transfers or
promotions. Thus, while some of these workers might be willing to spend two years
in a rural area, they may be wary of posts that are theoretically two years, but much
longer in reality (5, 8–10). The World Health Organization (WHO) has developed
global policy recommendations on how to address these challenges by increasing
retention of health providers in rural areas (11). For their part, actual decision-
makers (who may or may not be the persons with decision-making authority as per
official policy) may have preferences about P&T related, for example, to a desire to
punish a particular worker, to make a dysfunctional system function better or to
ensure that an ally is well placed (1, 4, 5, 12).

P&T as it occurs on the ground goes well beyond the negotiation of individual
preferences. Negotiation can occur in a context of official and informal regulations
and incentives, lack of adequate HRH, political patronage and networks, personal
networks and corruption (1, 2, 4, 5, 8, 10, 12, 13). Thus, P&T is related to the
distribution of power at multiple levels of governance. For example, individuals who
hold power in a certain context, for example when their political party is in power,
may be able to draw upon networks as resources, such as when they pay for a post

390 Health Employment and Economic Growth: An Evidence Base

or rely on a political ally to obtain a desired post (1, 5). Indeed, in contexts where
political figures exert considerable control over the public sector, the distribution of
posts and transfers may actually be used as a tool in political contests. Harris et al.
describe how, during the constitutional crisis in Nepal, political parties essentially
sold posts to generate income. Professional unions were associated with political
parties, and they systematically interfered with P&T (5). On the other hand,
individuals lacking power in a certain context may have little room to negotiate
their own or others’ placement, as they are arbitrarily moved to make room for
someone else or because they are “forgotten” in a rural area where they were officially
supposed to serve for only a limited duration (1, 8).

Irrational P&T in the health sector has been described in many diverse low- and
middle-income countries, including the Dominican Republic (2), Ethiopia (9),
Ghana (6), Guatemala (13), India (2, 4, 10), Indonesia (3), Nepal (5), Niger (13),
Nigeria (12), Sierra Leone (8) and the United Republic of Tanzania (7). National
perception surveys conducted by the World Bank with households, businesses and
public officials revealed that significant percentages of public officials – ranging from
9% in Benin to 50% in Zambia – report that purchasing posts in the health sector
is relatively common (14). The scope and breadth of the challenge is probably large,
with articles from many other countries obliquely referring to irrational P&T.

Research in non-health domains of the public sector has described irrational

P&T, some of which has contributed to the understanding of how P&T may
function in the health sector. For example, Wade illuminated the system for
purchasing posts in India’s irrigation sector, with the price of posts being based
on opportunities to generate income, with an adjustment for the standard of
living (15). There are some anecdotal data suggesting that the dynamics of P&T
may be different for women. First, women may experience different personal and
social expectations around proximity to family (8); second, they may face greater
threats to their physical security in rural areas (5, 7, 8, 16, 17); and third, they
are often concentrated among lower-level work cadres. Existing data suggest that
the deployment of many cadres of health care workers and administrators – from
specialist doctors to outreach workers – is affected by irrational P&T, with some
indications that there are fewer transfers among the lowest level cadres, who are
often hired locally (5, 7, 18, 19).

PART IV: Addressing Inefficiencies | CHAPTER 16 391

 While there are sufficient peer-reviewed articles that describe irrational P&T, there
are no studies or reports that purport to provide prevalence figures for irrational
P&T. Moreover, there are few articles that discuss informal P&T practice as a
palliative practice of “making do” or as a way to correct staffing problems so that
services function better (for example, ensuring that a surgeon is posted with an
anaesthetist so that they can work as a team to ensure that safe surgery can happen).
One recent article suggests that palliative practice may be significant in certain
contexts; qualitative research in Nigeria shows that primary health care managers
may redistribute existing human resources to put strong clinicians in sites that are in
need (12). Lack of analysis stems in part from poor-quality data. The system in reality
may bear little resemblance to the system on paper, with people at posts who do not
appear in formal statistics, the widespread use of public infrastructure and human
resources for private services, and extensive absenteeism (20).

It is also important to highlight that P&T practice is overlaid on an official system

that may not be capable of addressing population health needs for at least two
reasons. First, in many countries, even if all health care workers were equitably
distributed, the health system would still suffer from inadequate numbers of these
workers. Second, the number and distribution of “sanctioned” or “established”
positions may not correspond to population health needs. Thus, P&T can be both
a means of exacerbating, or of “making do” with, inefficient HRH governance and
workforce planning (4, 12).

Within the global health community, P&T is a largely unnamed health system
governance function, though P&T more broadly is frequently discussed within the
public administration world. Given its links to retention, equitable distribution,
public administration reform and corruption, P&T relates to many global and
national strategies and policy-setting priorities. The fact that actual practice is often
tacit, and the fact that irrational P&T is not yet high on policy agendas, means that
P&T is rarely explicitly addressed in these forums. Yet, given the increasing focus on
HRH governance, health systems, universal health coverage and delivery of quality
care in the SDG era, there is ample opportunity to address P&T.

392 Health Employment and Economic Growth: An Evidence Base

3. Discussion

3.1 Challenges

The following subsections outline the challenges faced in addressing the gaps
between P&T policy and practice.

3.1.1 Deeply ingrained nature of P&T practices

As a health systems governance function that is shaped by individual preferences and

health system attributes, actual P&T practice is deeply embedded and not amenable
to “quick fixes” (13). For example, if obtaining better postings is tied to ability to pay
(illicitly) for them, then providers may realign their efforts away from their public
sector jobs towards the private practice that can generate revenue (2). In this context,
attempts to better regulate absenteeism or dual practice are unlikely to be successful.
Indeed, some researchers describe P&T as a “collective action problem” (5), that is,
in situations where irrational P&T practices prevail, there is little incentive for an
individual to follow the official rules and refrain from participating in the informal,
“irrational” system. The person who follows the formal rules will suffer by being
assigned to the most undesirable posts, while those who continue to “play the game”
will do better.

In these contexts, mechanisms for supervision and accountability might perpetuate

irrational practice, rather than disrupt it. For example, personnel evaluations may be
perfunctory or biased (1, 5), or they may even be predetermined by a P&T decision
that has already been made (1). Similarly, actors in the system may utilize policies
and procedures to their advantage, for example by taking medical leave to avoid an
unwanted post (2).

This is not to say that the system is so ossified that there is no subnational variation
or that informal P&T is never positive. There are scattered examples of both,
although the peer-reviewed literature in this area is slim (2, 5). For example, P&T
practice may vary significantly among different states in India, perhaps determined
in part by degree of health worker scarcity, state-level laws and regulations, and the
political party in power (2). Research in some contexts has found that health workers

PART IV: Addressing Inefficiencies | CHAPTER 16 393

 may ignore official deployment orders to work at adequately staffed facilities to instead
work at a facility where they know they are needed. Recent, unpublished, research
conducted by the Averting Maternal Death and Disability programme at Columbia
University has found that particular cadres may be more likely to make these
“prosocial” choices, even in a context where the majority of health providers overall
are part of the P&T “game” (21).

3.1.2 Linkage of P&T to sensitive questions of political power and possible

corruption

Irrational P&T is often linked to broader dynamics of political competition and

professional power (1, 2, 5, 13). Thus, there are powerful interests in maintaining the status
quo, as well as potential stigma or fear for people who might reveal corrupt and illegal
practices. This undermines reform as well as research and learning.

3.1.3 Balancing individual preferences with community needs

Individual health workers and administrators have preferences about where they live.
In the context of significant human resource shortages, these preferences frequently
clash with the needs of underserved communities. Health workers who lack power
can end up languishing in posts they do not want, or be arbitrarily transferred,
undermining their morale, professional satisfaction, sense of organizational justice
and, ultimately, their retention in the workforce (13). Though it may make short-term
rural postings more feasible, increasing the absolute number of health workers is
probably insufficient to remedy the clash between individual preferences and
system needs.

394 Health Employment and Economic Growth: An Evidence Base

3.2 Action under way and previous efforts: lessons learned

3.2.1 Broad public sector reform

As a cross-cutting issue, efforts to address P&T can be part of a larger reform effort.

Starting in the 1980s, many countries implemented broad public sector reforms
that aimed to promote better public sector governance, administrative devolution,
enhanced management, customer service and efficiency (22). These reforms were
often guided by New Public Management (NPM), a philosophy and set of policies
developed in the 1970s and 1980s in Nordic and Organisation for Economic Co-
operation and Development (OECD) nations. A common theme was the transfer of
responsibility from the core public sector to “agencies”.

Key components of “agencification” include the creation of mission-specific agencies,

performance-based contracting and deregulation (23). NPM was hypothesized
to reduce political influence by distancing an agency from ministries, increasing
decision-making autonomy, professionalizing management cadres, using data for
planning, and focusing on results through performance contracts. Results have
been mixed. For example, in 1997, the United Republic of Tanzania undertook
NPM-inspired reforms in order “to create a smaller, affordable, efficient and effective
civil service” (24). However, evaluations highlight the lack of performance-based
accountability, weak evaluation systems and continuing presence of the traditional
civil service system. A lack of political will and commitment and weak public
demand for better public services may explain, in part, this hybrid system (24).
On the other hand, more recently, global budget support in the United Republic of
Tanzania was conditioned on the improved distribution of nurses and midwives.
Over the period assessed, the proportion of districts with three or more midwives or
nurses per 10 000 people improved (25, 26).

Beyond NPM, policy-makers have focused on reforming the governmental

organizations that are usually charged with designing and implementing P&T
across the public sector (often called public service commissions or civil service
commissions). These bodies were generally created to ensure fair and consistent
recruitment, posting and transfers. For example, in 2001, Sri Lanka’s Constitution
was amended to halt the ruling party’s influence in the Public Service Commission

PART IV: Addressing Inefficiencies | CHAPTER 16 395

 and permit involvement from opposition political parties (27). In Namibia,
government posts are publicly advertised, and the Public Service Commission
oversees appeals from individuals denied civil service appointments (28). In
Mauritius, civil sector employment decisions focus more on merit than on
ethnic group representation (29). These reforms suggest that there are a variety
of policy options that may distance a public service commission from political
interference.

As is contextually appropriate, other labour and auditing authorities might be

engaged to promote accountability across government agencies for stronger
HRH governance (2). In some countries, labour ministries, local governments
or auditing institutions might be engaged productively to improve the P&T
oversight process, particularly when the public civil service commissions
are functioning poorly. For example, civil servants in the United Republic of
Tanzania have brought disciplinary appeals to the Ombudsman (30).

3.2.2 Transparency

Given that whole system public sector reform is an ambitious and politically
challenging undertaking, many propose “within-system” solutions. For example,
health care providers and administrators, researchers, and international
agencies, including the World Bank, have advocated transparent recruitment and
deployment (1, 14, 31–33). The WHO Global Strategy on Human Resources for
Health: Workforce 2030 recommends transparent HRH regulatory mechanisms
(34). Indeed, transparency is widely considered to be an integral attribute of
robust health systems governance (15, 35), and essential to development more
broadly (36). Some countries and states, particularly some states in India, have
tried to introduce greater transparency into the process.

In the Indian state of Tamil Nadu, a “counselling” procedure has replaced

many mechanisms of the traditional P&T process. Under the revised system
promotions are largely based upon seniority, and there is a transparent process of
advertising vacant positions and explaining transfers (1). Eligibility for transfers
is determined by a transparent, detailed set of personal and district-specific
characteristics. Counselling appears to have undermined parallel systems, due

396 Health Employment and Economic Growth: An Evidence Base

in part to strong leadership in the Health and Family Welfare Department and a
committed and powerful physicians’ association (2). Yet, to some extent, health
care worker maldistribution continues. In 2011, a division bench of the High
Court ordered the government to repeat the counselling and transfer process for
over 100 physicians, citing shortages in some areas (37). La Forgia et al. studied a
reform in a different – unnamed – Indian state, and found that “the incidence of
de facto parallel HRM practices … where there is more specification of rules and
processes … and special units to enforce disciplinary practices … displays only
marginal differences from a pre-reform context” (2). It appears that high-level
commitment and capacity to implement this within-system reform is key.

3.2.3 Civil society monitoring

Civil society engagement in monitoring the delivery of government services is

often recommended as one way of improving health systems governance (2, 14,
38). In regard to health care worker P&T, community monitoring most frequently
entails tracking and reporting the related phenomenon of absenteeism and, in one
example, transfers.

Several programmes in India and Uganda have equipped citizens to monitor

health centres and report provider absences. A variety of outcomes – ranging
from lower absenteeism to no change – have been reported. Community
members in Rajasthan, India, were compensated for monitoring nurse and
midwife attendance at a government health clinic. While individuals accurately
recorded the absence rate, communities did not implement sanctions for absent
workers, and absenteeism, relative to a comparison area, did not decrease (39).

Similarly, in Udaipur, India, a nongovernmental organization (NGO) monitored

nurse attendance through unannounced visits and time/date stamping
machines. While the programme initially reduced absenteeism (compared to a
control group), administrative changes from the local government weakened the
programme, leading to a rebound of absenteeism (40). In both instances, health
care worker behaviour was characterized by seemingly random, non-predictable
patterns of attendance and absence, as opposed to rejection of the assignment
and total absence from the post. The sporadic presence of a health care worker

PART IV: Addressing Inefficiencies | CHAPTER 16 397

 may be more easily monitored by a community. However, if they have data
on the number of providers who have been posted to a facility, communities
should be able to monitor and report the complete non-appearance of workers
as well.

In Uganda, similar programmes had somewhat positive outcomes. A

randomized field experiment enabled communities to determine priority
health issues and monitor local facilities based on these priorities; compared
to control facilities, absences decreased, utilization of health services
increased, and a wide variety of health outcomes improved (41). In northern
Uganda, citizens used a toll-free number to report health centre issues,
including staff absences and “uncoordinated health workers transfers
without replacement”. An evaluation conducted by the implementing
agency concluded that the programme led to a 30% decrease in staff absence
compared to pre-programme figures (42).

While it would be quite difficult to envision a community monitoring programme

addressing P&T in its entirety, the examples above addressed important
manifestations of irrational posting. These community monitoring programmes
are consistent with the participatory principles of the SDGs (specifically,
targets 16.6 and 16.7). However, they have to contend with several challenges
that undercut citizen participation and programme effectiveness, including
citizen distrust and reluctance to engage with the health system, lack of citizen
ability to levy sanctions, and lack of adequate knowledge about health system
standards (43, 44). For their part, health providers may feel that the community
is inappropriately policing them (8). Integrating opportunities for trust and
relationship building between communities and providers may be crucial to
enabling accountability (45, 46). Moreover, transparency programmes are argued
to be more effective when integrated into existing decision-making structures
(47). As such, programmes that streamline data into a functioning monitoring or
supervisory system may be more successful.

398 Health Employment and Economic Growth: An Evidence Base

3.2.4 Routine and extraordinary human resource interventions
Conventional best practices in human resource management have sometimes
effected improvements in HRH. Such practices may include improving human
resource information systems, audits to identify ghost workers, supportive
supervision, performance management, streamlined recruitment procedures,
and career and development reviews (48–51). While these techniques are widely
regarded as necessary for overall organizational success, their ability to counter
irrational P&T practices depends upon multiple factors.

First, the techniques need to be fully implemented and integrated into existing
decision-making routines. A systematic review of human resource information
systems found that few countries actively used the information systems for staffing
decisions (51).

Second, existing political support and receptive staff are necessary for reforms to take
root. This can be a challenge in contexts where there is interest among both political
actors and health providers to maintain the status quo of irrational P&T. Unions
may present a formidable obstacle to reform (5). On the other hand, it has been
argued that some human resource reforms (particularly supportive supervision) can
garner effective political support, as politicians can easily understand the impact
of supervision on organizational function (52). Qualitative research in Benin and
Kenya found that weak or non-functioning management structures (particularly
supervision structures) were related to staff motivation and self-efficacy. Thus, if
management reforms respond to the perceived needs of staff on the ground, then
staff may embrace such reforms (33).

Due, in part, to the challenges in fully implementing best practices in human

resource management, some countries have opted for special or emergency
staffing procedures. The intent is to circumvent challenges inherent in national
hiring protocols. Kenya, Malawi, Namibia and Senegal have implemented unique
programmes characterized by financial incentives, greater staff flexibility and the use
of foreign-trained health care workers (53–56). There have been varying degrees of
sustained success within these programmes.

PART IV: Addressing Inefficiencies | CHAPTER 16 399

 Beginning in 2005, an Emergency Hiring Plan was instituted in Kenya to quickly
hire, train and deploy previously unemployed nurses to areas experiencing a high
disease burden and reduced workforce (53). Working with the Kenyan Ministry
of Health, Deloitte Kenya supervised recruitment, deployment and payroll
responsibilities, while Amref Health Africa, the Kenya Medical Training College
and the Kenya Institute of Administration assisted with training (53). Nurses were
recruited from geographical areas experiencing staff shortages, thus reducing
long-distance deployments (57). After one to three years of donor-funded contracts,
nurses were integrated into the Kenyan health ministry system. The average
recruitment time decreased from approximately 12 months to less than 3 months.
After three years, 94% of the Emergency Hiring Plan nursing staff were retained in
the programme; qualitative interviews suggest that nurses recruited locally were
motivated to remain at their posts (58). Facility data demonstrate that following
implementation of the Emergency Hiring Plan, family planning, HIV and child
health services were offered more frequently in health clinics, as compared to the
pre-deployment period (58).

Emergency and special hiring procedures address health care worker postings in
rural areas without modifying existing legislation on hiring and transfer. These
temporary programmes have clear policy implications, as they have focused national
attention on professional human resource departments, routine HRH planning
and leadership development (58). Successful elements from the hiring programmes
(recruitment from rural areas, special financial incentives) may be incorporated into
permanent policies.

4. Policy options
The following policy options are suggested to address the challenges surrounding
P&T, particularly irrational P&T.

Policy option 1
Improve health worker deployment as a core system function

Improving health worker deployment, particularly in the context of strengthening

public sector health systems, involves advancing norms for effective and accountable

400 Health Employment and Economic Growth: An Evidence Base

workforce deployment that build on promising practices on the ground and on
professionalism among providers. In other words, rather than creating new policies
that may encounter fierce resistance and implementation challenges, reformers might
seek to identify and expand promising practices and professional norms. These could
be expanded using problem-driven iterative approaches, which entail learning by
doing and local-level experimentation (59). For example, empirical evidence suggests
that commitment to serving patients and the community can be – though is not
always – widespread among health workers (7, 8, 10, 60). The pervasiveness of these
sentiments suggests that health workers would be willing to serve in rural areas if
they knew the assignment was time bound. Working with unions and health care
workers to leverage these values for reliably short-term rural postings might dilute
the resistance to rural postings.

Policy option 2
Introduce direct accountability to communities around the deployment
of health workers

Rather than looking at deployment only as a top-down function, this policy option
aims to engage existing decentralized and local governance mechanisms that are
accountable to local communities in the local deployment and, where relevant,
monitoring of health workers. As described, many of the top-down efforts to reform
P&T and the public sector more broadly have faced significant resistance. Bottom-up
community monitoring and accountability approaches address some of the intractable
determinants of irrational P&T. For example, village health committees, facility
committees, locally elected officials and other entities can be engaged in addressing
absenteeism and other P&T-related concerns. Health systems should be accountable to
people for the delivery of responsive, equitable services, and communities should have
a say in who serves them.

Policy option 3
Work with national and provincial/state labour departments, public or civil
service commissions and other related bodies

As noted, policies regarding public sector recruitment and P&T are often made
by labour authorities. In general, however, there is inadequate expertise about

PART IV: Addressing Inefficiencies | CHAPTER 16 401

 the particularities of the health sector among those formulating guidelines on
public sector recruitment and P&T, and inadequate expertise about public sector
recruitment and P&T among some key health sector stakeholders (22). Health actors,
such as health ministry officials, international organizations and NGOs, may not
engage broader authorities in public administration. Yet, P&T practices should be fit
for purpose for the health sector. Issues such as skills mix, retention in rural areas,
gender-specific security concerns, and access to further education may be considered
in revised P&T guidelines. In brief, collaboration across health-specific and broader
public administration actors could improve P&T-related policies and practice.

5. Implementation considerations
There are few data about actual P&T practice, and in some cases, little transparency
about formal P&T policies. Effective HRH information systems would be the
most effective way of learning about the actual distribution of the workforce and
informing reforms. In the absence of such systems, national and subnational data
gathering may be advised in certain contexts. Data collection is challenging due
to the hidden nature of prevailing practices. Partly for this reason, bottom-up
approaches may be particularly appropriate.

In some contexts, actual P&T practice may be linked to political factors and not
openly discussed. Any efforts at assessing the situation and proposing reform will
need to navigate these challenges.

HRH-related strategies and programmes are important areas for addressing P&T.
Depending on the context, anticorruption strategies, community participation
strategies, broad public sector reform efforts and other development initiatives may
need to explicitly engage the actual dynamics of P&T practice.

Acknowledgements

James Buchan provided helpful peer review comments.

402 Health Employment and Economic Growth: An Evidence Base

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PART IV: Addressing Inefficiencies | CHAPTER 16 405

406 Health Employment and Economic Growth: An Evidence Base
CHAPTER 17

Geographical variations in outpatient

physician supply in Germany:
Encouraging a more even distribution of outpatient
health care services in rural and urban areas
Stefan Scholz, Wolfgang Greiner

Abstract
This chapter provides empirical evidence on factors associated with spatial
variations in the supply of and demand for outpatient physicians in Germany.
There are substantial district-level differences in physician–population ratios
within the country, with higher physician densities evident in urban areas
and other favoured locations, for example close to the Alps. Statistical links to
both demand-side factors (population, morbidity and financial incentives) and
supply-side factors (health care system, cultural variety, labour and economy,
attractiveness, and infrastructure) are examined.

Among the demand-side factors, physician–population ratio evidenced the

strongest association, positively for specialists and negatively for general
practitioners, with the population density of a district. No significant association
was found between physician–population ratio and morbidity. Supply-side
factors – as listed above – show significant correlations with both general
practitioner and specialist densities.

The results presented in this chapter could only be achieved due to the
availability and accessibility of a broad range of data in Germany. A further
and essential improvement of evidence is possible if more disaggregated data
on physicians (for example, geographical or demographic data) were made
accessible in the public domain.

PART IV: Addressing Inefficiencies | CHAPTER 17 407

 1. Introduction and outline of methods

1.1 Problem statement

Spatial variations in the physician–population ratio are a reality in most countries,
even in those with social health insurance or a national health service financing
the health care for a vast majority of the population (1). Those spatial variations
represent the status quo in Germany and are intensified by the fact that many young
physicians prefer entering the labour market in urbanized areas (2). This preference
causes shortages in the health care workforce in the outpatient sector of rural areas
and accelerates demographic changes in the rural health workforce, as ageing
outpatient physicians are not being replaced by younger colleagues. Given a general
trend of urbanization of the general population (3), an urban location preference
among outpatient physicians does not automatically cause problems in the provision
of health care. However, a preference for urban locations among more highly
qualified or skilled workers, such as medical professionals, due to better employment
possibilities (4) may lead to an inequitable distribution of health care professionals
between urban and rural areas. The resulting risk is twofold:

• Financial resources are drawn from the financing system by overfulfilled health
care needs in urban areas (supplier-induced demand; oversupply).

• The corresponding shortage of health care professionals may cause health care
needs to be unmet in rural or remote areas (undersupply).

This may also affect the equity principle of many health care systems, if the rural
population contributes the same share of their income as the urban population to the
financing system but has less access to physicians.

Theoretically, in a free market, spatial variations in the distribution of physicians

could be explained either by differences in population distribution or by differences
in the personal preferences of physicians for certain locations. In the first case, higher
numbers of physicians would simply follow the higher population numbers that
exist in urban areas, in accordance with economic theory, by which greater demand
is met by greater supply. In the second case, physicians choose a certain location
for personal reasons (for example, cultural characteristics or family preferences)

408 Health Employment and Economic Growth: An Evidence Base

and may accept financial losses to have their geographical preferences met. A broad
economic literature applies the concept of supplier-induced demand in this context,
according to which physicians aim to compensate for financial losses by using
information asymmetry to provide patients with unnecessary services (5, 6). Thus,
physicians may choose to practise wherever they please, and the resulting uneven
geographical distribution of physicians may be considered a market failure
calling for government intervention.

From these theoretical findings, two common measures – both adopted in Germany
– are derived that governments or regulatory bodies can take to counteract the
geographical differences in physician–population ratios. One measure is to implement
a regulatory system to control the number of practices, or the establishment of new
practices, in defined locations. If a certain threshold in the physician–population ratio
is reached, no additional practices are allowed in that location. The second measure is
to incentivize physicians to work in areas with low physician–population ratios, either
by reimbursement schemes specific to those areas or by financial support for opening
new offices. (In Germany, these latter measures are not applied nationwide, but are
rather implemented at lower administrative or non-governmental levels.) For both
measures to be properly implemented, it is necessary to know if the extent of spatial
variation in physician numbers corresponds to the variations in population numbers
(“demand-side factors”), and to what extent “supply-side factors” representing
physicians’ geographical preferences shape the spatial distribution of physicians.
Empirical analyses can provide this information, focusing on revealed preferences of
physicians (that is, observing their actual behaviour).

1.2 Methods
The present chapter analyses the association of physician–population ratio with several
factors on both the demand side and the supply side in Germany. The German health
care system is based on the Bismarckian system of compulsory health care insurance.
This statutory insurance covers the health care services of roughly 90% of the German
population. Only persons with higher income, entrepreneurs and federal employees are
allowed to be privately insured. In contrast to most other health care systems, specialized
and general ambulatory health care services in Germany are mainly provided by office-
based physicians. Only emergency and highly specialized ambulatory services (for

PART IV: Addressing Inefficiencies | CHAPTER 17 409

 example, for rare diseases) may be performed by hospital physicians. The statutory
reimbursement system for ambulatory services in Germany is based on a fee-for-service
scheme, but it is restrained by subnational budgets and an increasing number of services
are being reimbursed by lump sums. Fees for privately insured patients follow a higher
reimbursement scheme without restrictions. Most outpatient physicians are self-
employed, although physicians are allowed to employ other physicians. The budget set by
the statutory reimbursement system is not increased for employed physicians.

Following the establishment of a regulatory system in 1993 (the so-called needs-

based planning system, see Box 1), Germany’s current geographical distribution of
physicians is a mixture of unregulated and regulated openings of practice locations,
given that physicians who have settled before 1993 are not subject to restrictions on
their practice location. Population density also plays a major role in the regulatory
system as it affects the geographical differences in physician–population ratio. As
specialists usually tend to have larger catchment areas than general practitioners
(GPs), separate planning systems are deployed for the respective physician groups.
Figure 1 depicts the geographical differences in physician–population ratios at
district level in Germany in 2010. Given that the smaller districts represent major
cities, higher physician densities are found in urban areas and other favoured
locations, for example close to the Alps.

To explain those differences, a statistical (regression) analysis was performed to find

factors besides population density that were associated with a higher or lower density
of GPs and specialists in Germany in 2010. Screening of the scientific literature (2,
8–11) provided a comprehensive list of factors representing physicians’ preferences.
As the literature revealed, income maximization is not exclusively responsible for
physicians’ decisions regarding the location of their practices. Factors such as the
professional environment for physicians, a labour market for their spouses, the
accessibility of cultural and recreational activities and the attractiveness of a district
also contribute to their decision.

In the statistical model, a variety of variables were used to explain the differences
in the geographical distribution of GPs and specialist doctors in 2010. They
were combined with the findings in the literature under the topics “population”,
“morbidity” and “financial incentives” for the demand-side factors; and “health

410 Health Employment and Economic Growth: An Evidence Base

 Box 1

Regulatory planning system in Germany

Since 1993, the permission to open a practice within a certain area has been
regulated by 17 Associations of Statutory Health Insurance Physicians (ASHIPs)1
within each of the 16 states of Germany (North Rhine-Westphalia is covered by
two ASHIPs). For each of the country’s 412 districts (which represent the second
smallest administrative level), a physician supply rate is calculated as the current
physician–population ratio in relation to the baseline ratio in 1990 (specialists)
or 1995 (general physicians). A time constant ratio between physicians and
population therefore corresponds to a supply rate of 100%.

Physicians are only allowed to open a new practice within a district

whose supply rate lies below 110%. Following new legislation (GKV-
Versorgungsstrukturgesetz) in 2012, this planning procedure is not only
based on the absolute number of persons living in the planning area, but is
also supplemented by its demographic structure (share of persons aged over
65 years) to calculate the number of physicians allowed to practise in the
area. Nevertheless, there are still significant, historically derived geographical
differences in physician supply.

The average supply rate in Germany was 126.5% for all groups of
physicians in 2010, with a minimum of 93.0% for general practitioners in
Saxony-Anhalt, and a maximum of 266.2% for surgeons in Mecklenburg,
Western Pomerania (7).

1. In German, Kassenärztliche Vereinigungen.

care system”, “culture”, “labour/economy”, “attractiveness” and “infrastructure” for

the supply-side factors (Box 2). The data sources were the federal ASHIP for the
number of GPs and specialists in 412 German districts in 2010; the German Federal

PART IV: Addressing Inefficiencies | CHAPTER 17 411

 Figure 1

Physician–population ratio as physicians per 100 000 inhabitants at

district level in Germany, 2010

Physician–population ratio (physician density)

in 412 German districts in 2010

Physicians per 100 000 persons

st
74 to 106 ( 1 quintile)
nd
106 to 115 ( 2 quintile)
rd
115 to 122 ( 3 quintile)
th
122 to 132 ( 4 quintile)
th
132 to 357 ( 5 quintile)

Source: Author presentation based on data from the federal ASHIP, 2010.

412 Health Employment and Economic Growth: An Evidence Base

Box 2

District factors possibly affecting physicians’ choice

of practice location in Germany
DEMAND-SIDE FACTORS (representing higher need in a district)
Population • Number of inhabitants/population density
(persons/km2)
Morbidity • Old-age dependency ratio
• Life expectancy
• Age-standardized mortality

Financial • Household income

incentiaves • Rate of privately insured persons

SUPPLY-SIDE FACTORS (representing physicians’ preferences for a district)

Health care • University hospital
system • Number of hospital beds per inhabitant
• Number of nursing home beds per inhabitant
Labour and • Unemployment rate
economy • Rate of highly qualified workers
• Gross domestic product (GDP) per capita
Cultural variety • Number of middle-order centres
• Number of high-order centres
• City in district
• State capital in district
Labour and • Unemployment rate
economy • Rate of highly qualified workers
• Gross domestic product (GDP) per capita
Attractiveness • Touristic attractiveness (overnight stays in hotels)
• Building area attractiveness (price)
• Migration balances
Infrastructure • Travel time to middle-order centre
• Travel time to high-order centre
• Travel time to high-speed train station
• Travel time to airport
• District in former East Germany

PART IV: Addressing Inefficiencies | CHAPTER 17 413

 Statistical Office (12) for the population numbers; literature for the number of
privately insured patients (13); and the INKAR2 data set of the Federal Institute for
Research on Building, Urban Affairs and Spatial Development (14) for all other
variables. Annex 1 presents the data on which the analysis is based.

2. Findings

2.1 Demand-side factors

The following demand-side factors were considered in analysing physicians’ choice of

practice location in Germany.

2.1.1 Population

The population density (defined as persons per km2) is the most basic proxy for the
demand for health care services in a district, as one can assume an increasing need
for health care services with an increasing number of inhabitants in a district. The
respective densities of GPs and specialists show strong associations with the population
density of a district. While the results from the specialist model suggest a positive
correlation with the population density, GP density seems to be negatively associated
with population density, contradicting the theoretical assumption of higher GP density
in more densely populated areas. In all models, significant interactions are changing
the coefficient of the population density substantially. This means that the association
between physician–population ratio and population density differs according to
whether a city is present in a district or not. Where no cities are present, the GP density
decreases while specialist density increases with increasing population density. Where
cities are present, population density has nearly no effect on the physician–population
ratio. These findings might suggest that specialist density and the specialist–GP ratio
increase and GP density decreases with increasing population density until some level
of urbanization is reached.

2. Indikatoren und Karten zur Raum- und Stadtentwicklung.

414 Health Employment and Economic Growth: An Evidence Base

2.1.2 Morbidity
The actual need for health care services is hard to define and hard to measure. But
as a population with higher morbidity is assumed to have a higher need for health
care, proxies for morbidity are often used to represent need in statistical analyses.
The “old-age dependency ratio”, calculated as the share of persons aged over 65 years
divided by the number of persons aged between 15 and 65 years, can be seen as a
proxy for age-related morbidity. Age-standardized mortality and life expectancy are
additional variables capturing morbidity, assuming a relation between morbidity and
mortality. Surprisingly, according to 2010 data, none of the above proxies for morbidity
of the inhabitants is significantly correlated with the density of GPs or specialists.
This might be due to the fact that government regulations did not incorporate the
population age structure as a proxy for morbidity in regulatory planning until 2012
(15). It might also indicate that the differences in health service utilization are not
captured by age, or that the morbidity is more evenly distributed than life expectancy
or mortality.

2.1.3 Financial incentives

Following the categorization by Ono, Schoenstein and Buchan (16), financial

incentives can be introduced as non-wage-related payments (for example, one-time
payments for setting up practices) or wage-related payments (for example, higher
reimbursement schemes in rural areas). Non-wage-related payments in Germany
can be in the form of subsidies for opening a practice in an underserved area. The
conditions under which these subsidies are paid, as well as their amount, vary
markedly. They are provided by states, ASHIPs and small municipalities in a non-
centralized and uncoordinated manner, which made it impossible to include them in
the statistical analysis. However, we controlled for variables in ASHIP areas by using
a random effect model to capture unobserved characteristics of these areas. There are
no official wage-related interventions in Germany, but physicians can charge higher
fees for their services if they are providing them for privately insured patients or
patients who want to be billed directly. Thus, a greater share of private patients can
be seen as a wage-related incentive for physicians. To test this hypothesis, household
income and the share of privately insured persons were used and were found to be
significantly associated with a higher physician–population ratio, although these
proxies of the financial incentives play only a minor role.

PART IV: Addressing Inefficiencies | CHAPTER 17 415

 2.2 Supply-side factors
The supply-side factors represent the different aspects of physicians’ preferences for
certain locations and are therefore more widespread than the demand-side factors.
The coefficients of the supply–side variables indicate that geographical preferences
have an effect other than pure income maximization.

2.2.1 Health care

Health care institutions play different roles in the possible attractiveness of a district
for physicians. Hospitals often serve as education centres in the last stage of medical
training, which coincides for many physicians with the stage in life in which they
start a family. Medical institutions such as hospitals can also serve as centres for
medical networks and collegial exchange of knowledge. It is not possible to separate
the effects of health care institutions, but the number of hospital beds was found
to be highly associated with the number of outpatient physicians in a district.
University hospitals were not significantly associated with a higher density of GPs
and specialists; nor was the number of nursing home beds.

2.2.2 Culture

Other than the higher population density, urban areas tend to offer a broader
spectrum of cultural facilities and activities that might meet the preferences of
physicians. The analysis included the number of middle-order centres (defined
as cities providing specialist doctors, shopping malls, cinemas, hospitals, public
swimming pools and legal counsellors) and high-order centres (defined as
cities additionally providing special shops, specialist hospitals, and cultural,
educational and administrative institutions) as well as state capitals. The results
show an increasing effect of the cultural variables, with the strongest effect for
state capitals. This result is more clearly defined in the model for specialists.
Although the cultural variables are not defined in terms of population density,
there are some correlations.

416 Health Employment and Economic Growth: An Evidence Base

2.2.3 Labour and economy
A strong economy in a district might also correspond to physicians’ preferences. This
may be due to employment possibilities for highly qualified spouses, the higher variety
of cultural and leisure possibilities, and better earning opportunities in economically
strong districts. The analysis shows a positive association between physician–
population ratio and the rate of highly qualified workers in a district, whereas
GDP per capita was not significantly associated with the number of physicians
per 100 000 inhabitants. Surprisingly, the unemployment rate showed a positive
correlation, meaning that a higher unemployment rate coincides with a higher
physician–population ratio. As there is evidence that unemployment causes negative
effects on mental health (17) and physical health (18), the unemployment rate may
serve as a proxy for morbidity.

2.2.4 Attractiveness

Besides the culture and economy of a district, there might be other factors representing
its attractiveness to physicians. For example, a higher touristic attractiveness, measured
by the number of guest-nights in tourist enterprises per capita, might represent the
recreational value of a district. Building area prices and migration balances capture
other aspects of a district’s attractiveness. However, these factors show only minor
associations with the physician–population ratio, with touristic attractiveness being
positively correlated with GP density, and the migration balance of the past five years
positively associated with specialist density. Building area attractiveness and the
migration balance of the past 10 years show no significant effect.

2.2.5 Infrastructure

The final category of supply-side factors representing physicians’ preference for their
practice location consists of variables depicting the infrastructure. The variables
concerning travel times to the nearest high-speed train station, airport, middle-
order centre and high-order centre indicate how well a district is connected to other
districts offering more of the above described characteristics. The travel time to the
nearest middle-order centre is negatively associated with physician–population ratio
(especially for specialists), indicating that a shorter travel time coincides with more
physicians. The travel time to the nearest airport is only significant for the number of

PART IV: Addressing Inefficiencies | CHAPTER 17 417

 GPs and counterintuitively indicates a smaller number of GPs the closer a district
is to an airport. The travel time to the next high-speed train station, the travel
time to the next high-order centre, if a district is in former East Germany and if a
district is considered an urban district do not show a significant correlation with the
physician–population ratio.

2.3 Summary

In summary, the findings provide some evidence that a higher density of physicians
per 100 000 population can be found in districts with a higher population density
per km2. As we have controlled for factors associated with physicians’ geographical
preferences, a relevant part of the differences in physician–population ratios can be
solely explained by differences in patient demand. Compared to the density of GPs,
the density of specialists is generally more strongly associated with the population
density and other variables describing an urbanized district. For example, a higher
household income and a higher travel time to the next middle-order centre indicate a
higher density of specialists in comparison to the population parameters alone. These
results support the hypothesis that a higher density of specialists is associated with
urban districts than is the case for the density of GPs. Box 3 summarizes the factors
showing a significant association with physician–population ratio.

2.4 Limitations and generalizability

There are several limitations that need to be considered when interpreting the results.
Importantly, although the results represent a complete survey of German outpatient
physicians, no causal interpretations can be made, as the analyses were carried out
using cross-sectional data. Not all the data used in the model were available for the
same year. However, the maximum difference is one year, and it is assumed that no
drastic changes of the independent variables occurred within this short period of
time. Finally, districts are politically administered units, and district sizes vary widely
in different states. Therefore, homogeneity of the explaining variables may be smaller
in larger districts, reducing effect sizes and leading to an underestimation of the
coefficient sizes.

418 Health Employment and Economic Growth: An Evidence Base

 Box 3

Factors showing a significant association with physician density

General practitioners
Strong • Population density (–)
• State capital (+)

Moderate • Number of hospital beds (+)

• Travel time to middle-order centre (–)

Weak • Travel time to airport (+)

• Touristic attractiveness (+)
• Share of privately insured patients (+)
• Number of high-order centres (+)

Specialists
Strong • Population density (+)
• Number of hospital beds (+)
• State capital (+)
Moderate • Travel time to middle-order centre (–)
• City in district (+)
• Unemployment rate (+)
• Share of privately insured patients (+)
• Rate of highly qualified employment opportunities (+)
Weak • Household income (+)
• Number of middle-order centres (–)
• Migration balance, five years (+)
• Number of high-order centres (+)

Besides the regulatory planning mechanism, there may be other factors limiting
the transferability of the above results to other countries. In Germany, the health
insurance system leaves the possibility for doctors to provide health care for privately
insured persons, which shows a weak to moderate association with physician–
population ratio. In addition, many explanatory variables may be fundamentally

PART IV: Addressing Inefficiencies | CHAPTER 17 419

 different in other countries (for example, travel times, unemployment rates), raising
the question whether the linear trend found in the German data could be extended
to those countries. Also, the effects of some variables from the supply side might
be correlated with population density. For example, urban areas tend to have more
labour in the tertiary sector, requiring highly qualified workers or generating higher
household income.

3. Discussion

3.1 Measures to counteract the imbalance in physician

distribution

Following the global policy recommendations of the World Health Organization

on improving recruitment and retention of health care workers in rural areas (19),
several measures can be taken to counteract the imbalance in the geographical
distribution of physicians. These are categorized into the fields of education,
regulatory interventions, financial incentives, and personal and professional support.
Using the results of the analysis, potential measures can be evaluated using the
German setting as an example.

3.1.1 Education

The primary institutions for the education of physicians in Germany are university
hospitals and cooperating teaching hospitals. Outpatient training lasts four weeks
for specialists and GPs, and further general practitioner training is optional for
older GPs. As university hospitals did not show a significant association with the
number of physicians per 100 000 inhabitants, bringing those major education
centres closer to rural areas might not be an effective measure to decrease
geographical imbalances in Germany. However, the observed moderate to strong
effect of the number of hospital beds on physician–population ratio might also
be due to the number of beds in teaching hospitals (roughly one third of German
hospitals other than university hospitals), indicating some association between
a higher number of physicians in areas where training takes place. In Germany,
a rural background is not a criterion in medical student selection and there are
no mandatory internships in rural areas as part of the curricula. However, there

420 Health Employment and Economic Growth: An Evidence Base

are financial incentives by some ASHIPs to motivate medical students to do
their internships in rural areas. Unfortunately, there are no data available on the
number of students accepting those internships. Therefore, the results cannot
provide evidence on the effect of recruiting medical students from rural areas,
although this could represent a cost-efficient intervention (16).

3.1.2 Regulatory interventions

There is mixed evidence regarding the effect of the German regulatory system and
planning mechanism. Population density, the main parameter in the first phase
of the planning process, shows the expected positive association with specialist
density, but a negative association with GP density. The old-age dependency
ratio, introduced as an additional parameter when the planning mechanism was
reformed, does not show a significant association with GP and specialist density.
These findings might indicate that the effectiveness of regulatory interventions
can only be measured in the long term, as it takes time for the disparities that have
arisen to disappear.

3.1.3 Financial incentives

The association between the number of privately insured persons and the respective
GP and specialist densities may be interpreted as the effect of financial incentives
on the decision of practice location. As reimbursement of health services for
privately insured persons is higher than for statutory health insurance, this can be
seen as an example of higher income attracting more physicians. Nevertheless, the
association is moderate and weak, indicating that financial incentives in the form
of additional income may need to be very high to overcome physicians’ preferences
for urban areas and attract them to practise in rural areas. This interpretation is
supported by findings from Günther et al. (2). In their study, physicians were given
the choice between a practice location with a monthly income of US$ 6600, two
on-call duties, on-site career opportunities for the partner as well as child care
and leisure activities, and a practice location in the same area but with 30 minutes
travel time to a location providing those opportunities. The results indicate that
physicians would have to be compensated by an additional US$ 11 938 per month
to opt for the second choice.

PART IV: Addressing Inefficiencies | CHAPTER 17 421

 3.1.4 Personal and professional support
Personal and professional support can include a variety of measures influencing
physicians’ preferences for a practice location. The association between hospital
beds and physician–population ratio, for example, can be seen not only in the
context of education but also the access to professional support for outpatient
physicians by hospital doctors. Medical networks surrounding hospitals can also
provide support and contribute to a higher physician–population ratio. But there
are also indications that personal support may be associated with higher GP and
specialist density. For example, the positive association between the rate of highly
qualified workers and specialist density may be triggered by physicians’ partners
finding employment opportunities. Moreover, for both physician types, the travel
time to high-order centres is weakly associated with a higher physician–population
ratio, and the travel time to the nearest middle-order centre is moderately
associated. Thus, infrastructure improvements, bringing rural and remote areas
closer to urban areas, may not only affect the general economy in those areas, but
also allow physicians to practise in rural areas without being deprived of cultural or
leisure activities offered in urban areas.

3.2 Policy options and implementation considerations

The findings of the present analysis indicate that supply-side as well as demand-
side factors are associated with physician–population ratio. The parameters
included in the German planning mechanism for outpatient physicians do not
seem significant. This might be due to the long time it takes newly introduced
regulatory systems to overcome historically derived geographical imbalances,
especially if no relocation of physicians takes place. The findings also indicate that
professional and especially personal support might help to increase the number
of physicians in underserved areas. Education centres such as university hospitals
do not seem to be associated with a higher physician–population ratio, but no
conclusions can be drawn concerning other educational interventions, for example,
choosing a rural background as a selection criterion for medical students, as these
interventions have not been adopted as policies.

However, it is important to recognize that different interventions have varying

cost implications, and that it will take time before effects can be seen. Further

422 Health Employment and Economic Growth: An Evidence Base

study is needed on the appropriate balance of interventions, including regulatory
interventions, financial incentives and infrastructure development. Systematic
evaluation of interventions implemented by subnational planning authorities
could yield a deeper insight into their effectiveness, including their strengths and
weaknesses. Funding of education interventions in different locations and their
evaluation might reveal the most effective and cost-effective interventions, creating
best-practice models to be adopted nationally.

The present analysis was only possible due to the availability of a broad range of
data. Federal ASHIPs were able to provide detailed numbers on GPs and specialists,
and the INKAR data set provided measures from a wide field of variables that are
potentially linked with physician–population ratio. However, the evidence could be
improved substantially if more spatial demographic data on physicians were made
accessible to science and the public. In particular, data on the age of physicians
would allow analysis on future shortages caused by retirement, and potential changes
in retirement patterns could be assessed and influenced by targeted support for older,
pre-retirement doctors.

PART IV: Addressing Inefficiencies | CHAPTER 17 423

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424 Health Employment and Economic Growth: An Evidence Base

ANNEX 1: Presentation of data
Table 1

Dependent and independent variables at district level (n = 412)

Standard
Metric variables by topic Mean deviation Minimum Maximum
Dependent
Density of GPs (per 10 000 inhabitants) 6.32 0.99 1.52 12.58
Density of specialists
3.14 1.35 0.51 8.99
(per 10 000 inhabitants)
Ratio GPs–specialists 2.30 0.99 0.75 12.80
Demand/need factors
Population
Population density (per km2) 518.68 674.91 37.09 4 355.28
Morbidity
Old-age dependency ratio 32.14 4.22 22.03 45.53
Life expectancy women (from 60 years) 25.08 0.63 23.10 27.10
Life expectancy men (from 60 years) 21.56 0.94 19.40 24.60
Mortality (deaths per 1000 inhabitants) 10.91 1.59 6.90 15.40
Financial incentives
Household income (in £, per month) 1 548.93 199.31 1 157.90 2 585.00
Rate of privately insured persons (%) 13.46 4.32 3.53 27.00
Control factors
Health care system
No. of hospital beds
64.49 38.70 0.00 215.90
(per 10 000 inhabitants)
No. of nursing home beds
108.94 28.83 47.10 256.60
(per 10 000 inhabitants)
Cultural
No. of middle-order centres 2.24 2.16 0.00 11.00
No. of high-order centres 0.39 0.56 0.00 4.00

PART IV: Addressing Inefficiencies | CHAPTER 17 425

 Table 1 (continued)

Dependent and independent variables at district level (n = 412)

Standard
Metric variables by topic Mean deviation Minimum Maximum
Labour/economy
Unemployment rate (%) 7.41 3.31 1.90 17.40
Rate of highly qualified workers (%) 8.23 3.80 3.00 26.50
GDP per capita (in 1000£) 27.58 10.24 13.20 83.60
Attractiveness
Touristic attractiveness 5.27 7.56 0.00 90.60
Building area attractiveness 125.47 117.34 0.00 1 031.80
Migration balance (past 10 years) 4.54 46.13 –171.40 100.30
Migration balance (past 5 years) –3.98 21.85 –69.80 61.80
Infrastructure
Travel time to airport 54.41 24.11 7.60 161.50
Travel time to high-speed train station 22.36 14.42 0.00 61.60
Travel time to middle-order centre 8.26 6.40 0.00 36.60
Travel time to high-order centre 26.56 17.83 0.00 76.20
Binary variables Frequency Percentage
Cultural
State capital 16/412 3.88
City > 100 000 inhabitants 68/412 16.50
Health care system
University hospital 33/412 8.01
Infrastructure
District in former East Germany 86/412 20.87
Urban district 206/412 50.00

426 Health Employment and Economic Growth: An Evidence Base

Table 2

Results of the three zero-truncated, negative binomial GLMs

for GP density, specialist density and ratio of GPs–specialists

Ratio
General physicians Specialists GPs–specialists
Coefficients
by topic Estimate p-value Estimate p-value Estimate p-value
Intercept 1.736 0.000*** 1.919 0.000*** –0.178 0.003**
Population
Population density
–0.136 0.005** 0.349 0.000*** –0.453 0.000***
(per km2) (z-score)
Financial incentives
Household income
0.018 0.255 0.093 0.001** –0.088 0.001**
(z-score)
Share of privately
insured persons 0.042 0.008** 0.123 0.000*** –0.063 0.033*
(z-score)
Health care
No. of hospital beds
0.073 0.000*** 0.253 0.000*** –0.206 0.000***
(z-score)
Cultural
No. of middle-order
–0.005 0.703 –0.074 0.004** 0.052 0.038*
centres (z-score)
No. of high-order
0.036 0.003** 0.057 0.022* –0.022 0.336
centres (z-score)
City in district
–0.021 0.476 0.146 0.005** –0.140 0.008**
(binary)
State capital in
0.127 0.000*** 0.278 0.000*** –0.096 0.244
district (binary)
Labour/economy
Rate of highly
qualified workers 0.019 0.264 0.106 0.001** –0.099 0.001**
(z-score)
Unemployment
0.052 0.064 0.139 0.006** –0.073 0.142
rate (z-score)
Attractiveness
Touristic
attractiveness 0.046 0.000*** –0.004 0.861 0.036 0.116
(z-score)
Migration balance
(past 5 years) –0.012 0.478 0.072 0.025* –0.113 0.000***
(z-score)

PART IV: Addressing Inefficiencies | CHAPTER 17 427

 Table 2 (continued)

Results of the three zero-truncated, negative binomial GLMs for GP density,

specialist density and ratio of GPs–specialists

Ratio
General physicians Specialists GPs–specialists
Coefficients
by topic Estimate p-value Estimate p-value Estimate p-value

Infrastructure
Travel time to the
nearest airport 0.049 0.000*** 0.021 0.420 0.016 0.548
(z-score)
Travel time to
middle-order –0.064 0.007** –0.177 0.000*** 0.115 0.004**
centre (z-score)
Interactions
Population density:
0.099 0.044* –0.422 0.000*** 0.464 0.000***
city in district
GoF measures
Sigma (global
–8.177 0.000*** –3.763 0.000*** –3.892 0.000***
deviance)
BIC-score
3 260 4 125 3 979
first model
BIC-score
3 162 3 828 3 751
final model

428 Health Employment and Economic Growth: An Evidence Base

 Health Employment
and Economic Growth

An Evidence Base
Health Employment and Economic Growth
Powerful demographic and economic forces are shaping health The 17 chapters
workforce needs and demands worldwide. in this book, are
grouped into
An Evidence Base
Effectively addressing growing population need and economic four parts:
demand for health workers stands as one of our foremost
global challenges. It also represents an opportunity to secure • Health workforce
a future that is healthy, peaceful, and prosperous. dynamics
Edited by
The contents of this book give direction and detail to a richer • Economic value James Buchan
and more holistic understanding of the health workforce and investment
through the presentation of new evidence and solutions- Ibadat S. Dhillon
focused analysis. It sets out, under one cover, a series of • Education and
production
James Campbell
research studies and papers that were commissioned to
provide evidence for the High-Level Commission on Health
Employment and Economic Growth. • Addressing
inefficiencies

“An essential read that rightfully places investments in health workforce at the heart
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The Lancet

“A resource of fundamental importance. Evidences the socio-economic benefits

that follow from appropriately recognizing, rewarding, and supporting women’s

Campbell
Dhillon
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work in health.”
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Princess of Jordan

“An important book for those who would like to understand the role, relevance
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