Hospitals & Asylums    


Review of the World Health Report 2006: Working Together for Health HA-14-4-06


The World Health Report 2006 - Working together for health contains an expert assessment focusing on all stages of the health workers' career lifespan from entry to health training, to job recruitment through to retirement, the report lays out a ten-year action plan in which countries can build their health workforces, with the support of global partners.  WHO estimates there to be a total of 59.2 million full-time paid health workers worldwide.  Almost all countries suffer from mal-distribution characterized by urban concentration and rural deficits, but these imbalances are perhaps most disturbing from a regional perspective. The WHO Region of the Americas, with 10% of the global burden of disease, has 37% of the world’s health workers spending more than 50% of the world’s health financing, whereas the African Region has 24% of the burden but only 3% of health workers commanding less than 1% of world health expenditure.  Health service providers account for 67% of all health workers globally.  The ratio of nurses to doctors ranges from nearly 8:1 in the African Region to 5:1 in the Western Pacific Region. Among countries, there are approximately four nurses per doctor in Canada and the United States of America, while Chile, Peru, El Salvador and Mexico have fewer than one nurse per doctor.  Typically, more than 70% of doctors are male while more than 70% of nurses are female – a marked gender imbalance. About two thirds of the workers are in the public sector and one third in the private sector.  The report reveals an estimated shortage of almost 4.3 million doctors, midwives, nurses and support workers worldwide. The shortage is most severe in the poorest countries, especially in sub-Saharan Africa, where health workers are most needed and the life expectancy has actually reversed in the past two decades. 57 countries that fall below this threshold and which fail to attain the 80% coverage level are defined as having a critical shortage. Thirty-six of them are in sub-Saharan Africa. Millennium Project assumed salaries would need to double increasing the current annual salary cost by US$ 53 billion in the 57 countries. 

1. In this first decade of the 21st century, immense advances in human well-being coexist with extreme deprivation. In global health we are witnessing the benefits of new medicines and technologies. But there are unprecedented reversals.  What is needed now is political will to implement national plans, together with international cooperation to align resources, harness knowledge and build robust health systems for treating and preventing disease and promoting population health.  At the heart of each and every health system, the workforce is central to advancing health. There is ample evidence that worker numbers and quality are positively associated with immunization coverage, outreach of primary care, and infant, child and maternal survival. The quality of doctors and the density of their distribution have been shown to correlate with positive outcomes in cardiovascular diseases.  Cutting-edge quality improvements of health care are best initiated by workers themselves because they are in the unique position of identifying opportunities for innovation. In health systems, workers function as gatekeepers and navigators for the effective, or wasteful, application of all other resources such as drugs, vaccines and supplies. Health service providers are the personification of a system’s core values – they heal and care for people, ease pain and suffering, prevent disease and mitigate risk – the human link that connects knowledge to health action.  LEE Jong-wook Director General of the WHO at the High-Level Forum, Paris, November 2005 stated, “We have to work together to ensure access to a motivated, skilled, and supported health worker by every person in every village everywhere.”

2. Financing policies, technological advances and consumer expectations can dramatically shift demands on the workforce in health systems. Workers seek opportunities and job security in dynamic health labour markets that are part of the global political economy.  The spreading HIV/AIDS epidemic imposes huge work burdens, risks and threats.  Expanding labour markets have intensified professional concentration in urban areas and accelerated international migration from the poorest to the wealthiest countries. The consequent workforce crisis in many of the poorest countries is characterized by severe shortages, inappropriate skill mixes, and gaps in service coverage.  Based on these estimates, there are currently 57 countries with critical shortages equivalent to a global deficit of 2.4 million doctors, nurses and midwives to achieve the Health related Millennium Development Goals.  This crisis has the potential to deepen in the coming years. Demand for service providers will escalate markedly in all countries – rich and poor. Richer countries face a future of low fertility and large populations of elderly people, which will cause a shift towards chronic and degenerative diseases with high care demands.  In poorer countries, large cohorts of young people (1 billion adolescents) will join an increasingly ageing population, both groups rapidly urbanizing. Many of these countries are dealing with unfinished agendas of infectious disease and the rapid emergence of chronic illness complicated by the magnitude of the HIV/AIDS epidemic. The availability of effective vaccines and drugs to cope with these health threats imposes huge practical and moral imperatives to respond effectively.

3. The workforce must be mobilized to address specific health challenges:


The MDGs target the major poverty-linked diseases devastating poor populations, focusing on maternal and child health care and the control of HIV/AIDS, tuberculosis and malaria. Countries that are experiencing the greatest difficulties in meeting the MDGs, many in sub-Saharan Africa, face absolute shortfalls in their health workforce. Major challenges exist in bringing priority disease programmes into line with primary care provision, deploying workers equitably for universal access to HIV/AIDS treatment, scaling up delegation to community workers, and creating public health strategies for disease prevention.


Chronic diseases, consisting of cardiovascular and metabolic diseases, cancers, injuries, and neurological and psychological disorders, are major burdens affecting rich and poor populations alike. New paradigms of care are driving a shift from acute tertiary hospital care to patient-centred, home-based and team-driven care requiring new skills, disciplinary collaboration and continuity of care – as demonstrated by innovative approaches in Europe and North America. Risk reduction, moreover, depends on measures to protect the environment and the modification of lifestyle factors such as diet, smoking and exercise through behaviour change.


Health crises of epidemics, natural disasters and conflict are sudden, often unexpected, but invariably recurring. Meeting the challenges requires coordinated planning based on sound information, rapid mobilization of workers, commandand- control responses, and intersectoral collaboration with nongovernmental organizations, the military, peacekeepers and the media. Specialized workforce capacities are needed for the surveillance of epidemics or for the reconstruction of societies torn apart by ethnic conflict. The quality of response, ultimately, depends upon workforce preparedness based on local capacity backed by timely international support.


4. From policy and management perspectives, the framework focuses on modulating the roles of both labour markets and state action at key decision-making junctures: 1. Entry: preparing the workforce through strategic investments in education and effective and ethical recruitment practices. 2. Workforce: enhancing worker performance through better management of workers in both the public and private sectors. 3. Exit: managing migration and attrition to reduce wasteful loss of human resources. 4. The world’s 1600 medical schools, 6000 nursing schools and 375 schools of public health in aggregate are not producing sufficient numbers of graduates program.  Education quality is assured through a process of institutional accreditation and professional regulation (licensing, certification, registration and continuing medical education).  Substantial improvements in the availability, competence, responsiveness and productivity of the workforce can be rapidly achieved through an array of low-cost and practical instruments.


Supervision makes a big difference. Supportive yet firm – and fair – supervision is one of the most effective instruments available to improve the competence of individual health workers, especially when coupled with clear job descriptions and feedback on performance. Moreover, supervision can build a practical integration of new skills acquired through on-the-job training.


Fair and reliable compensation. Decent pay that arrives on time is crucial. The way workers are paid, for example salaried or fee-for-service, has effects on productivity and quality of care that require careful monitoring. Financial and non-financial incentives such as study leave or child care are more effective when packaged than provided on their own.


Critical support systems. No matter how motivated and skilled health workers are, they cannot do their jobs properly in facilities that lack clean water, adequate lighting, heating, vehicles, drugs, working equipment and other supplies. Decisions to introduce new technologies – for diagnosis, treatment or communication – should be informed in part by an assessment of their implications for the health workforce.


Lifelong learning should be inculcated in the workplace. This may include short term training, encouraging staff to innovate, and fostering teamwork. Frequently, staff devise simple but effective solutions to improve performance and should be encouraged to share and act on their ideas.


5. Chapter one: Health Workers A Global Profile gives an overview of what is known about them. It describes the size and distribution of the workforce, and some of its characteristics, including how much it costs and then considers how much it would cost to scale up training to meet the perceived shortfall and pay health workers.  The third version of the International Standard Classification of Occupations (ISCO), an international classification system agreed by members of the International Labour Organization, was adopted in 1987 and is known as ISCO-88.  Health workers are distributed unevenly. Countries with the lowest relative need have the highest numbers of health workers, while those with the greatest burden of disease must make do with a much smaller health workforce. In the HIV/AIDS literature, scaling up treatment with anti-retroviral was estimated to require between 20% and 50% of the available health workforce in four African countries, though less than 10% in the other 10 countries surveyed. In more general terms, analysts estimated that in a best case scenario for 2015 the supply of health workers would reach only 60% of the estimated need in the United Republic of Tanzania and the need would be 300% greater than the available supply in Chad. Furthermore,  The world health report 2005 estimated that 334 000 skilled birth attendants would have to be trained globally over the coming years merely to reach 72% coverage of births.


6. To achieve a global assessment of shortfall, the Joint Learning Initiative (JLI), a network of global health leaders, launched by the Rockefeller Foundation, suggested that, on average, countries with fewer than 2.4 health care professionals (counting only doctors, nurses and midwives) per 1000 population failed to achieve an 80% coverage rate for deliveries by skilled birth attendants or for measles immunization.  57 countries that fall below this threshold and which fail to attain the 80% coverage level are defined as having a critical shortage. Thirty-six of them are in sub-Saharan Africa. For all these countries to reach the target levels of health worker availability would require an additional 2.4 million professionals globally.  The largest relative need exists in sub-Saharan Africa, where an increase of almost 140% is necessary to meet the threshold.  The Millennium Project assumed salaries would need to double increasing the current annual salary cost by US$ 53 billion in the 57 countries. To put the figure into perspective, this represents an increase in the annual global wage bill for health workers of less than 5%. It would also require an increase in annual health spending by 2015 of US$ 20 per person in the average country – an increase of over 75% on 2004 levels.  There are 59 million health workers in the world with a shortfall of 4.3 million. 


7. Chapter two: Responding to Urgent Health Needs challenges are, first, to scale up interventions to attain the health-related MDGs; second, to shift successfully to community-based and patient-centred paradigms of care for the treatment of chronic diseases; third, to tackle the problems posed by disasters and outbreaks; and fourth, to preserve health services in conflict and post-conflict states.  A shortage of human resources has replaced financial issues as the most serious obstacle to implementing national treatment plans.  National programmes to achieve disease-specific MDGs place many parallel demands

on district health managers and service providers, such as reading documents, filling forms, writing reports, attending meetings and making field visits. In recent years, the traditional focus on acute, inpatient and sub-specialty care has given way to new paradigms of care emphasizing self-management, and community- based patient-centred pre-hospital care. Five core competencies for long-term patient care have been identified: patient-centred care, partnering, quality improvement, information and communication technology and a public health perspective. The challenge is to translate these into practice through the institutions that produce and deploy the health workforce. Changes in the curriculum, new teaching methods, and innovative training models are necessary.   A team approach is required not only in the management of individuals with chronic conditions but in addressing these public health challenges more broadly. In general, care for chronic diseases is best delivered with a collaborative effort involving public health specialists, policy and service planners, researchers, information technology designers, and support personnel. The multidisciplinary team in mental health includes psychiatrists, psychologists, nurses, general practitioners, occupational therapists and community/social workers who can share their expertise and collaborate with each other. 


8. Thailand is a middle income country (with a per capita GDP of US$ 2000) that in recent years has been affected by SARS, the tsunami of December 2004 and avian influenza. In the avian influenza  epidemic, 60 million chickens were killed and the government paid US$ 120 million to farmers in compensation. A vertical plan for avian influenza was approved by the cabinet in January 2005, for US$ 120 million for three years, with an intensive human resources component.  In the recent epidemic, Thailand called on its 800 000 village health volunteers to assist in bird surveillance. These volunteers have existed in Thailand’s villages since the era of primary health care. The country also used its network of 100 000 health centres, 750 public hospitals, 95 provincial hospitals and 1330 teams in every district, who were on call 24 hours a day.  For the theme of this report, the imperative of working together emerges repeatedly. Collaboration across sectors for chronic diseases and emergencies, striking synergies across programmes for the MDGs, and bringing stakeholders together to reach consensus on strategies to protect what works in the context of conflicts makes the case for working together abundantly clear.


9. Uses and misuses of biomedical and public health knowledge during time of war or armed conflict are commonplace.  Public health and medical crimes such as diverting medical supplies and human resources, abuse and torture, medical killing in the name of science, and eugenics for social goals, have been perpetrated with the complicity of health and medical professionals in countries such as Bosnia and Herzegovina, Cambodia, Nazi Germany and Rwanda. Much more frequent, though, are cases in which health professionals are victims themselves. The attack against Vukovar Hospital on the eve of the war in the former Yugoslavia, in 1991, underscores the extreme vulnerability of health facilities and medical personnel operating in war zones.  Since the Nuremberg Code in 1947 concluded the judgement of the Doctors Trial – the Medical Case of the subsequent Nuremberg Proceedings – and founded bioethics as an independent discipline, dozens of binding treaties, declarations and other texts have drawn up very specific provisions that protect the public and biomedical practitioners from harm (and from doing harm) both in peacetime and in times of conflict. In June 1977, for example, 27 articles, which are known as the “principles of medical neutrality” in times of war, were added to the body of International Humanitarian Law, the Protocols Additional to the Geneva Conventions. The most recent reformulation of aid workers’ competencies and responsibilities in times of conflict and man-made disasters appears in the Sphere Handbook, a document that aims to improve the quality and the accountability of the humanitarian system.  The protection of health systems and biomedical practice from harm requires a universal commitment.  As prerequisites to such a commitment, formal education curricula for health professionals should gradually incorporate studies in bioethics, human rights and humanitarian law.


10. Chapter 3: Preparing the Health Workforce is about preparation: getting it right at the beginning; giving the right training to the right people to create an effective workforce for the delivery of health care. It focuses on the entry of health workers into the workforce and on the health training institutions – schools, universities and training colleges – which provide them with the knowledge and competencies for the jobs they will be required to do.  “Academic medicine” is often defined as a triad of research, clinical service, and medical education. It might also be de- fined as the capacity to study, discover, evaluate, teach, and improve health systems.  The specific priorities related to the number, range and quality of health training institutions are: the disciplinary mix of institutions, accreditation to maintain standards, management of the applicant pool, and retention of students through to graduation.  Globally, educational establishments training health workers are heavily tipped towards the production of physicians and nurses: 1691 and 5492, respectively, in contrast to 914 schools of pharmacy, 773 schools of dentistry and 375 schools of public health. The WHO Eastern Mediterranean and South-East Asia regions have remarkably fewer schools of public health.  Accreditation is an essential mechanism not only for assessing institutional performance but, more fundamentally, for securing public trust.  In low income countries where trained health service providers are scarce, the public sector often competes to recruit workers with the private sector, international nongovernmental organizations and other donors, and multilateral entities offering attractive local or international employment packages. Dr Elizabeth Madraa, manager of Uganda’s AIDS Control Programme, laments, “We keep training them and they go to NGOs or abroad, where they can get better money; then we have to train [more people] again.”


11. Lifelong learning and develop relevant workplace competencies that can adapt to diverse challenges and populations.  New trends in education aim to improve the health of the public by implementing this idea in training methods practice-based teaching aims to: bridge the gap between academia and practice; benefit students, schools, agencies and communities; involve and develop critical thinking and problem solving skills; be interdisciplinary, multidisciplinary and multidimensional; develop learning partnerships among academic staff, practitioners and students, to educate teachers, practitioners and researchers; incorporate experiential education, including critical reflection, observation and learning by doing.  Problem-based learning complements practice-based teaching through: identifying the problem; exploring pre-existing knowledge; generating hypotheses and possible mechanisms; identifying learning issues and objectives; self study and group learning; re-evaluation and application of new knowledge to the problem; assessment and reflection on learning.  Patient-focused practice: integrates teaching and learning with clinical practice; shares experiences of illness, disease and recovery with patients; understands varying needs for care; observes and participates in the ways in which different service providers work together to meet the needs of patients. training pharmacy students.  For example the clinical partners programme at the Ohio state university college of pharmacy provides an active learning environment, offers a patient-focused model based on pharmaceutical care principles, and is an arena for applied research in pharmacy practice.  Over 3200 full-text journals and other resources are now available free to health institutions in 69 countries, and for very low cost in a further 44 countries


12. The Integrated Case Management Process for the outpatient health facility is to Check for danger signs such as Convulsions, Lethargy/unconsciousness, Inability to drink/breastfeed or Vomiting.  Then to assess the main symptoms such as Cough/difficulty breathing, Diarrhoea, Fever or  Ear problems.  Then to Assess nutrition, immunization status and potential feeding problems.  Then to Check for other Problems, Classify conditions and identify treatment actions According to coded treatment methods.  Outpatient health facilities are responsible for Urgent referral, Pre-referral treatments, Advise parents and Refer child.  The physician is also responsible for the treatment at outpatient health facility, treating local infection, Giving oral drugs, Advising and teaching caretakers, Follow-up.  Home based care involves, Home management whereby the Caretaker is counseled on how to: Give oral drugs, Treat local infections at home, Continue feeding, When to return immediately, Follow-up.  Referrals to hospital facilities occur for: Emergency triage and treatment (ETAT), Diagnosis, Treatment and Monitoring and follow-up.


13. Chapter four: Making the Most of Existing Health Workers.  A country’s health workforce is made up of health workers who are at many different stages of their working lives; they work in many different organizations and under changing conditions and pressures. Whatever the circumstances, an effective workforce strategy has to focus on three core challenges: improving recruitment, helping the existing workforce to perform better, and slowing the rate at which workers leave the health workforce.  Strategies to boost worker performance are critical for four reasons: 1.They will be likely to show results sooner than strategies to increase numbers. 2. The possibilities of increasing the supply of health workers will always be limited. 3. A motivated and productive workforce will encourage recruitment and retention. 4. Governments have an obligation to society to ensure that limited human and financial resources are used as fairly and as efficiently as possible.


14. For many years it was assumed that poor health worker performance was primarily caused by a lack of knowledge and skills.  In recent years this perception has changed, and three broad groups of factors are now recognized. 1. Characteristics of the population being served: it is simpler to increase immunization coverage or adherence to treatment for tuberculosis or HIV infection where the population understands the benefits and has the motivation and resources to seek services.  2. Characteristics of health workers themselves, including their own socio-cultural background, knowledge, experience and motivation.  3. Characteristics of the health system, and the wider environment, that determine the conditions under which health workers work. These include the inputs available to them to do their jobs, how the health system is organized, how the workers are paid, supervised and managed, and factors such as their personal safety.


15. The performance of health workers, in terms of both competence and responsiveness, is also influenced by their sense of professional identity, vocation and work ethic.  The notion of “professionalism” and vocation in health has a long history. Almost every doctor and patient has heard of the Hippocratic Oath, which is the longest surviving ethical code of conduct. It is still sworn by many medical graduates. Health workers are expected to conduct themselves with integrity, selflessly to apply technical know-how and to put the interests of the patient above their own.  Supervision, especially coupled with audit and feedback to staff, has been consistently found to improve the performance of many types of health workers, from providers to managers.   Supervision must be supportive, educational and consistent and helps to solve specific problems, can improve performance, job satisfaction and motivation.


16. The way people are paid makes a major difference to what they deliver. Individual health workers, and the facilities in which they work, can be paid in many different ways. For each, pay may be time-based (salaries or fixed budgets), service-based (fee for service) or population-based (per capita payments or block contracts).  No matter how motivated and skilled health workers are, they cannot do their jobs properly in facilities that lack clean water, adequate lighting, heating, vehicles, drugs, working equipment and other supplies.  Two examples illustrate the consequences. In Niger, nurses at health centres were reported to be reluctant to refer patients to district hospitals because only three of the 33 hospitals provided surgical care, most of them could not give blood transfusions or oxygen, and laboratory and X-ray facilities were rudimentary. In Kyrgyzstan, health professionals in primary care providing diabetes care said that their job was hampered by a lack of testing strips, machines to measure blood sugar, weak laboratories and irregular supplies of insulin. Drugs being out of stock is a familiar problem to many health workers. 


17. Health workers are more motivated to perform well when their organization and managers: provide a clear sense of vision and mission; make people feel recognized and valued whatever their job; listen to staff and increase their participation in decisions – they often have solutions; encourage teamwork, mentoring and coaching; encourage innovation and appropriate independence; create a culture of benchmarking and comparison; provide career structures and opportunities for promotion that are transparent and fair; give feedback on, and reward, good performance – even with token benefits; use available sanctions for poor performance in ways that are fair and consistent.  Good managers reward their staff. Some examples of non-financial rewards that may be used are: tea during night duty, holidays and days off, flexible working hours, access to and support for training and education, sabbaticals, study leave, and planned career breaks. Some examples of management and leadership


18. This chapter has described the levers that can influence workforce performance. An inevitable tension exists between the perspectives and goals of individuals and the organizations to which they belong. Organizations have to perform well and deploy their staff to the greatest advantage, while also providing places for individuals to thrive. This tension must be continually monitored and managed. Moreover, managing any change is a subtle and often difficult process, for several reasons. Changes may be needed at several levels. Legal and regulatory frameworks may need to be changed, which can be complex and slow. Resources are often needed to support change. Probably most importantly, local stakeholders must be brought “on board” as they can facilitate or equally effectively block a reform that has been carefully negotiated at central level. However difficult, without changes to support improved performance of existing health workers, any recruitment and retention strategies will have limited effect.


19. Chapter five: Managing Exits from the Workforce.  Each year, substantial numbers of health workers leave the health workforce, either temporarily or permanently. These exits can provoke shortages if workers who leave are not replaced, and such shortages compromise the delivery and quality of health services.  The main reasons people leave the health workforce are depicted in migration; risk of violence, illness or death; change of occupation or work status; child birth and retirement.  High turnover rates in the health workforce may lead to higher provider costs. They are also a threat to the quality of care, because they may disrupt organizational function, reduce team efficiency, and cause a loss of institutional knowledge. Studies show that the costs associated with retention problems are often substantial. Turnover can have potential benefits, however, as it may provide an opportunity to match personnel skills better to workplace needs, facilitate the introduction of new ideas into well established organizations, and increase organizational flexibility. In this context, it is important for policy-makers to manage exits from the health workforce to ensure the least possible disruption of services.


20. Concerns about the adverse impact of the flows of skilled professionals from poorer to richer countries have thrust the migration of health workers to the forefront of the policy agenda in recent years. However, statistics on global flows of health workers remain far from complete.  Each year, 3 million health workers worldwide are exposed through the percutaneous route to bloodborne pathogens: 2 million are exposed to hepatitis B, 900 000 to hepatitis C and 170 000 to HIV. These injuries result in 15 000, 70 000 and 1000 infections, respectively. More than 90% of these infections occur in developing countries.  In areas where rates of HIV/AIDS are high, attrition rates of health workers due to illness and death are alarming. In Zambia, deaths among female nurses in two hospitals increased from 2 per 1000 in 1980 to 26.7 per 1000 in 1991. Estimates show that Botswana lost 17% of its health workforce to AIDS between 1999 and 2005. If health workers infected with HIV are not treated, the proportion of those dying as a result of AIDS may reach 40% by 2010. In Lesotho and Malawi, death is the largest cause of attrition.  Absenteeism in the HIV/AIDS workforce can represent up to 50% of staff time in a health worker’s final year of life.  The age distribution of the workforce in many richer countries discloses a “greying” trend that will result in accelerated attrition through retirement in the medium term.


21. Chapter six: Formulating national health workforce strategies.  The ultimate goal of health workforce strategies is a delivery system that can guarantee universal access to health care and social protection to all citizens in every country.  To the general public, the term “health workers” evokes doctors and nurses. While this does not do justice to the multitude of people who make a health care system work, it does reflect the public’s expectations: encounters with knowledgeable, skilled – and trustworthy – doctors and nurses who will help them to get better and who will act in their best interests. Trust is not automatic: it has to be actively produced and negotiated. It is “slowly gained but easily lost in the face of confounded expectations”.  In many countries, professional organizations decide who can provide care and how providers should behave. Self-regulation can indeed be effective and positive: professional associations can promote professional ethics and positive role models, sanction inappropriate behaviour, and maintain the technical competence of their members. The way health workers balance their own interests and those of their patients depends to a large extent on what is considered “good professional behaviour” by their teachers and peers. Professional associations can play an active role in shaping that image.


22. Even where regulations exist, governments may have major problems enforcing them. There are three results: first, each year approximately 44 million households worldwide are faced with catastrophic health expenditures; second, many more people are excluded from access to care; and third, this situation favours supply induced over-medicalization.. One example is the high incidence of caesarean sections around the world. Within a single country, mothers with the financial means may be subject to an unnecessary and potentially dangerous intervention, while the same procedure is denied to another who needs it to save her life or that of her baby but who cannot mobilize the funds.  In order to ensure public safety and good governance of health care providers, capacity building requires investment in the overall regulatory architecture outlined in. Simultaneous efforts are needed to reinforce the potential contributions of the state and social insurance institutions, as well as those of professional and civil society organizations. This means that, along with the creation of the specific technical bodies for licensing, accreditation and so on, forums must be established that allow for interaction among these various groups, which in turn implies the recognition and support, including financial, of their contributions. National health workforce strategies must move beyond salary and training in the public sector to strategies for the entire work cycle of entry–workforce–exit in both the public and private sectors. Workforce development is both a technical and political exercise, requiring the building of trust among stakeholders and linking people’s expectations with health worker performance.


23. Chapter seven: Working together, Within and Across Countries.  There are five broad areas of concern that impel countries to look beyond their borders and work together with others in order to address issues of human resources for health more effectively: 1. The profound lack of information, tools and measures, the limited amount of evidence on what works, and the absence of shared standards, technical frameworks and research methodologies are all imperatives for regional and international collaboration. 2. The scarcity of technical expertise available to develop better metrics, monitor performance, set standards, identify research priorities, and validate methodologies means that a collective global effort is the only way to accelerate progress in these areas. 3. The changes in demographics, demand for care, and technological advances cut across borders and are manifested in increasingly global labour markets. Cooperative arrangements and agreements between countries are essential to manage these flows and minimize adverse effects. 4. The reality that a violent conflict, an outbreak of an infectious disease, or an unexpected catastrophic event can lay waste even to the most well-prepared national health system demonstrates that no country will ever have the human resource capacity to be able always to mount an effective response entirely on its own 5. The enormous workforce crisis that constrains health development so profoundly in the world’s poorest countries requires an international response. This chapter focuses on the rationale for working together and concludes with a plan of action that is based on national leadership and global solidarity.

24. In planning their health workforce strategies, countries cannot overlook the dynamics of the global labour markets affecting health workers. Pushed by population trends towards ageing, changes in consumer expectations and technological innovations, the health sector globally continues to defy expectations in terms of its rate of growth. Demand for service providers will escalate markedly in all countries – rich and poor.  The dire situation provoked by the global health workforce crisis requires nothing short of an outstanding global response. International action necessitates: coalitions around emergency national plans for health care providers; health worker-friendly practices among global partners; and sufficient and sustained financing of the health workforce.  National strategies on their own, however well conceived, are insufficient to deal with the realities of health workforce challenges today and in the future. Strategies across countries are similarly constrained by patchy evidence, limited planning tools and a scarcity of technical expertise. Outbreaks of disease and labour market inflections transcend national boundaries, and the depth of the workforce crisis in a significant group of countries requires international assistance. National leadership must therefore be complemented by global solidarity.  National leadership and global solidarity can result in significant structural improvements of the workforce in all countries, especially those with the most severe crises. Such advances would be characterized by universal access to a motivated, competent and supported health workforce, greater worker, employer and public satisfaction, and more effective stewardship of the workforce by the state, civil society and professional associations.

World Health Report 2006: Working Together for Health.