Toolkit on monitoring health systems strengthening
 
 
 
 
 
 
 
 
 
 
 

HUMAN RESOURCES
FOR HEALTH
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
 
May 2009
Table of contents

1. Introduction ......................................................................................2

2. Sources of information on the health workforce ..........................3

Population census and surveys ....................................................................... 3
Health facility assessments.............................................................................. 3
Administrative records ..................................................................................... 4
Data comparability and synthesis across multiple information sources ........... 4

3. Core indicators.................................................................................7
Recommended core indicator 1: Number of health workers per 10 000
population ........................................................................................................ 7
Recommended core indicator 2: Distribution of health workers – by
occupation/specialization, region, place of work and sex................................. 8
Recommended core indicator 3: Annual number of graduates of health
professions educational institutions per 100 000 population – by level and field
of education ..................................................................................................... 9

4. Additional considerations for monitoring national workforce

plans and actions .................................................................................10

Selected tools and resources................................................................................ 13

References .............................................................................................................. 14

Annex: Mapping health workforce statistics: relevant codes in selected

international standard classifications for social and economic statistics ........ 16

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1. Introduction
The ability of a country to meet its health goals depends largely on the knowledge, skills, motivation and
deployment of the people responsible for organizing and delivering health services. A number of studies
show evidence of a direct and positive link between numbers of health workers and population health
outcomes (1, 2). Many countries, however, lack the human resources needed to deliver essential health
interventions for a number of reasons, including limited production capacity, migration of health workers
within and across countries, poor mix of skills and demographic imbalances. The formulation of national
policies and plans in pursuit of human resources for health development objectives requires sound
information and evidence. Against the backdrop of increasing demand for information, building
knowledge and databases on the health workforce requires coordination across sectors. WHO is working
with countries and partners to strengthen the global evidence base on the health workforce – including
gaining consensus on a core set of indicators and minimum data set for monitoring the stock, distribution
and production of health workers.

The health workforce can be defined as “all people engaged in actions whose primary intent is to enhance
health” (3). These human resources include clinical staff such as physicians, nurses, pharmacists and
dentists, as well as management and support staff – those who do not deliver services directly but are
essential to the performance of health systems, such as managers, ambulance drivers and accountants (see
Box 1). There are presently no comprehensive and robust methodologies for assessing adequacy of the
health workforce to respond to the health-care needs of a given population. It has been estimated,
however, that countries with fewer than 23 physicians, nurses and midwives per 10 000 population
generally fail to achieve adequate coverage rates for selected primary health-care interventions, as
prioritized by the Millennium Development Goals (3).

Perceived shortages of health workers have many causes and may be a result of inadequate numbers and
skills mix of persons being trained or maldistribution of their deployment, as well as losses caused by
death, retirement, career change or out-migration. The need for comprehensive, reliable and timely
information on human resources for health – including numbers, demographics, skills, services being
provided and factors influencing recruitment and retention – has been widely identified at the
international, regional and national levels among both resource-poor and wealthier countries. This need
has become even more urgent in view of the international effort to scale up education and training of
health workers in 57 countries, mostly in sub-Saharan Africa, which have been identified as having a
critical shortage of highly skilled health professionals (3).

A health information system with a strong human resources component can help to build the evidence
base in order to plan for availability and accessibility of needed health workers in the right place, at the
right time and in the desired quality. Planning
requires knowledge of the numbers of health Box 1 Boundaries of the health workforce
workers who are active in the health sector,
their distribution and characteristics, as well as Various permutations and combinations of what
the numbers and characteristics of those constitutes the health workforce may exist according to
being trained and added to the human each country’s situation and the means of monitoring.
resources pool, and of those leaving the active Human resources for health include individuals working in
workforce and the reasons for leaving (4, 5). the private and public sectors, those working full-time or
A comprehensive human resources part-time, those working at one job or holding jobs at two
or more locations, and those who are paid or provide
information system (HRIS) can also guide
services on a volunteer basis. They include workers in
decision-making to ensure the cultural different domains of health systems, including curative,
appropriateness of the health system, e.g. the preventive and rehabilitative care services as well as health
appropriate sex and ethnic mix of health education, promotion and research. They may also include
workers, especially to encourage utilization of people with the education and training to deliver health
services among underserved or marginalized services but who are not engaged in the national health
communities. For example, in some contexts, labour market (e.g. if they are unemployed or have
access to female providers is an important migrated or withdrawn from the labour force for personal
determinant of women’s health service reasons).

2
utilization patterns (6). A strategy for ensuring the male–female balance of the health workforce should
include promoting the collection and use of sex-disaggregated data in all human resource assessments.

A timely, reliable and relevant HRIS is essential to support the formulation, monitoring and evaluation of
health workforce plans, strategies and policies at the sub-national, national and international levels.
Unfortunately, for most countries, there remains a significant lag between the demand for data and the
availability and usefulness of the information required to support decision-making.

2. Sources of information on the health

workforce
Effective monitoring and evaluation of human resources for health in countries requires the development
of an agreed core set of indicators and their means of measurement to inform decision-making among
national authorities and other stakeholders. Diverse sources that can potentially produce relevant
information exist even in low-income countries – including population-based sources, health facility
assessments and routine administrative records (4, 5, 7–11). Each of these sources has its strengths and
limitations for health workforce analysis (see Table 1). In many countries, comprehensive data on human
resources are not available in any one repository. This means that any attempt to determine the size and
core characteristics of the health workforce requires some level of analysis and synthesis of available
information from multiple sources. The use of information from a variety of sources should, in principle,
increase the options for measuring and validating core health workforce statistics.

Population census and surveys

Many meaningful results pertinent to workforce analysis can be produced through tabulation of
population-based data. All countries collect at least some data on their population, mainly in terms of
periodical demographic censuses and household sample surveys that produce statistical information about
the people, their homes, their socioeconomic conditions and other characteristics. Most censuses and
labour force surveys ask for the occupation and place of work of the respondent (and other adult
household members) along with other demographic characteristics, including age, sex and educational
attainment.

Nationally representative population censuses and labour force surveys with properly designed questions
on occupation, place of work and field of training allow identification of people with education and
training in health, of people with a health-related occupation and of those employed in health services
industries. Enumeration of health workers from census data is a count of the number of people with a
health-related occupation and/or working in the health services industry. A similar method is used for
counting health workers from labour force survey data, with the additional application of a sampling
weight to calibrate for national representation.

Health facility assessments

Health facility assessments can be conducted using different sampling approaches (establishment census
or sample survey) and methodologies (self-administered postal, fax or Internet-based questionnaire, or
telephone or face-to-face interview). Depending on the nature of the data collection procedures and
instruments, in-depth information can be obtained on a range of health workforce variables, for example
in-service training, support supervision and current staffing levels in relation to planned staffing norms.
Using a census-based sampling approach may be better suited for collection of data on the numbers and
distribution of facility-based health workers, whereas an approach that uses sampling and subsequent
extrapolation may be better for collection of data on health worker motivation and productivity. In
addition, the nature of facility-based assessments facilitates the collection of data for numerous other

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indicators pertinent to health systems performance assessment, such as infrastructure, availability of
supplies and costs.

Administrative records
In many countries, the computerization of administrative records – including public expenditure, staffing
and payroll, work permits, health insurance and social security records – is greatly facilitating the
possibilities for analysis. Many skilled health-care providers require formal training, registration and
licensure to practise their professions, so the administrative records of health training institutions and
professional licensing bodies are potentially valuable sources for tracking the health workforce. These
sources offer the advantage of producing continuously updated statistics. In addition, depending on the
characteristics of the registries, notably whether individuals are assigned a unique identifier, it may be
possible to track workers’ labour force entry, career progression and exit.

Data comparability and synthesis across multiple information

sources
Precisely defining and classifying the health workforce remains an important challenge in comparing
information across sources, across countries and over time. Health workers play different roles and often
have different national history, culture and codes of practice. For instance, nursing and midwifery
personnel may be characterized by different educational requirements, legislation and practice regulations,
skills and scope of practice from one country to another (and even within a given country). Second, many
countries, especially ones with critical shortages and maldistribution of highly skilled medical and nursing
professionals, have large numbers of non-physician clinicians (often called clinical officers or surgical
technicians) and/or community health workers (12, 13), for whom the levels of training vary widely.
Comparability of health worker data can be enhanced through the setting and use of common definitions
and classifications for monitoring the labour market (4, 5). The collection, processing and dissemination
of information should follow internationally standardized classifications for social and economic statistics
(or their national equivalent), including the International Standard Classification of Occupations (ISCO),
International Standard Industrial Classification of all Economic Activities (ISIC) and International
Standard Classification of Education (ISCED) (14–16). Details of the uses of these frameworks for
statistical delineation of the health workforce are presented in the Annex to this section.

In particular, the ISCO enables occupations to be arranged into a hierarchical system according to the skill
level and skill specialization required to carry out the tasks and duties of jobs. In the latest 2008 ISCO
revision (known as ISCO-08), most health occupations are expected to fall within two sub-major groups:
group 22 “health professionals” (generally well-trained workers in jobs that normally require a university
degree for competent performance) and group 32 “health associate professionals” (generally requiring
knowledge and skills acquired through advanced formal education but not equivalent to a university
degree). This distinction was designed to reflect differences in tasks and duties that may be a consequence
of differences in work organization as well as in education and training. It must be recognized, however,
that in some countries the possibility of distinguishing between the two typologies of nurses and midwives
remains limited; inadequacies in the reporting system or incomparability of the education systems and
measures of technical capacity may mean that some nursing and midwifery jobs do not fit easily into these
two categories.

The main statistical advantages of ISCO are in the setting of clearly defined occupational groups within
and across countries and in the monitoring of migration of workers between countries. Overall, it is
expected that possibilities for health workforce analysis will be strengthened in the upcoming 2010 round
of population censuses, which will be able to exploit the new ISCO-08 revision (17). Among the
significant improvements in ISCO-08 (compared with the previous version adopted in 1988) is the
creation of new unit codes for identifying more of types of health service providers, including paramedical
practitioners and community health workers, as well as certain categories of health management and
support workers (notably health service managers, health information technicians and medical secretaries).
The March 2008 revision to the WHO Global atlas of the health workforce reflects the improved classification

4
(18) (see Box 2). Ideally, information on these Box 2 Counting health workers: occupational
categories of workers should be available for categories in the Global atlas of the health workforce
all countries where the occupations are
practiced. The classification of health workers used for the WHO
Global atlas of the health workforce
Certain tools also exist that aim at providing (http://www.who.int/globalatlas/autologin/hrh_login.asp)
guidelines on how to develop national is based on criteria for vocational education and training,
classifications and their mapping to regulation of health occupations, and activities and tasks of
international standards. One such manual, jobs, i.e. a framework for categorizing key workforce
developed by the European Centre for the variables according to shared characteristics. The WHO
framework largely draws on the latest revision to the ISCO
Development of Vocational Training and
and other standard classifications for social and economic
Eurostat, is intended to serve as guide in statistics. Data on nine occupational categories are captured
countries where comprehensive national in the main data set:
classifications for vocational education and  Physicians
training are not developed, based on an  Nursing and midwifery personnel
analysis of the descriptions of the content of  Dentistry personnel
training programmes (19).The most up-to-  Pharmaceutical personnel
date information from the International  Laboratory health workers
Labour Organization and latest advice for  Environmental and public health workers
 Community and traditional health workers
countries on how to develop, maintain and
 Other health service providers
revise a national occupation classification and
 Health management and support workers
its mapping to the international standard can
be found on the ISCO web site (14). National-level data are collated from four main sources:
population censuses, labour force surveys, health facility
Given the diversity of information sources for assessments and administrative reporting systems. Where
health workforce monitoring, it is especially available, disaggregated data are presented on up to 18
important that the dissemination of statistics occupational categories as well as on the distribution of the
concerning human resources for health health workforce by age, sex and geographical location
include metadata descriptors for each data (urban/rural).
point, including details on its nature and
coverage. This would be crucial for efforts to synthesize and triangulate figures across multiple sources, in
particular in order to distinguish whether the data include health workers in the private sector, workers
who are unpaid or unregulated but performing health-care tasks, potential double-counts of workers
holding two or more jobs at different locations, or trained health service providers not currently working
at health facilities or other service delivery points.

 
 

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Table 1: Potential data sources for monitoring the health workforce
Source Strengths Limitations
Population  Provides nationally representative data on stock of human resources in all health  Periodicity: usually only once every 10 years
census occupations (including public and private sectors, management and support staff, and  Database management can be computationally cumbersome
health occupations in non-health sectors)  Dissemination of findings often insufficiently precise, but micro-data that would allow for
 Data can be disaggregated for specific subgroups (e.g. by age and sex) and at lowest in-depth analysis are often not released
geographical level  Cross-sectional: does not allow tracking of workforce entry and exit
 Rigorous collection and processing procedures help to ensure data quality  Usually no information on labour productivity or earnings
Labour force  Provides nationally representative data on all occupations  Variable periodicity across countries: from monthly to once every 5 years or more
survey  Provides detailed information on labour force activity (including place of work,  Sample size often too small to permit disaggregation and precise analysis
unemployment and underemployment, earnings)  Cross-sectional: does not allow tracking of workforce entry and exit
 Rigorous collection and processing procedures help ensure data quality
 Requires fewer resources than census
Health facility  Provides data on health facility staff including management and support workers  Usually conducted infrequently and ad hoc
assessment  Data can be disaggregated by type of facility, staff demographics (age, sex) and  Private facilities and practices are often omitted from sampling
geographical area  Community-based workers may be omitted
 Can be used to track wages and compensation, in-service training, provider productivity,  May double-count staff working at more than one facility
presence/absenteeism of health workers on the day of visit, supervision, available skills for  Cross-sectional: does not allow tracking of workforce entry and exit
specific interventions and unfilled posts  No information on unemployment or on health occupations in non-health services (e.g.
 Usually requires fewer resources than household-based assessments health research, teaching)
 Can be complemented with routine reporting (e.g. monthly) of staff returns from each  Variable quality of data across countries and over time
facility (such statistics are frequently cited in official publications)
Civil service  Provides data on stock of public sector employees (in terms of physical persons and full-  Excludes those who work exclusively in the private sector (unless they receive
payroll time equivalents) government compensation)
registries  Data are usually accurately and routinely updated (given strong government financial  Depending on the nature of the registry, may double-count staff with dual employment
incentive for quality information, which can also be validated through periodic personnel and/or exclude locally hired staff not on the central payroll
audits)  Many countries have persistent problems eliminating “ghost workers”a and payments to
 Data can be sometimes be disaggregated by age, sex, place of work and pay grade staff who are no longer active
Registries of  Provides head counts of all registered health professionals  Variable coverage and quality of data across countries and over time, depending on the
professional  Data are routinely updated for entries to the national health labour market characteristics and capacities of the regulatory authorities
regulatory  Data can typically be disaggregated by age, sex and sometimes place of work  Usually limited to highly skilled health professionals
bodies  Depending on the characteristics of the registry, may be possible to track career
progression and exit of health workers
aPersonnel formally on payroll but providing no service (in some cases as a strategy among health personnel to overcome unsatisfactory remuneration or working conditions).
Source: adapted from (4, 5).

6
3. Core indicators

Recommended core indicator 1: Number of health workers per 10 000

population
 
The health worker density – the number of health workers per 10 000 population, by cadre – is the health
workforce indicator that is most commonly reported internationally and represents a critical starting point for
understanding the health system resources situation in a country. When measured systematically, this indicator
provides information on the stock of health workers relative to the population; it can be used to monitor
whether, for example, the size of the current workforce meets a given threshold that should allow the most
basic levels of health-care coverage to be achieved across the country. The advantages include that it is simple
to calculate, may be used for comparative analyses across countries and over time, and is easy to understand
among a wide range of audiences, facilitating its usefulness for advocacy purposes. However it does not
necessarily take into account all of a health system's objectives, particularly with regard to accessibility, equity,
quality and efficiency.

Definition
The number of health workers available in a country relative to the total population.
 Numerator: The absolute number of health workers at a given time in a given country or region (that is,
all persons eligible to participate in the national health labour market by virtue of their skills, age, ability
and physical presence in the country).
 Denominator: The total population for the same geographical area.

Data collection methodology

Ideally assessed through routine administrative records on numbers of active health workers compiled,
updated and submitted regularly (e.g. quarterly) by district health officers, payroll registrars, individual health
facilities (both public and private) and/or health professional regulatory bodies and collated into a centralized
HRIS or database maintained by the ministry of health or other mandated agency. Information on the stock
of health workers and on the total population should be periodically validated and adjusted against data from a
population census or other nationally representative source.

Comparability issues
Data on health occupations should ideally be classified according to the latest ISCO revision (or its national
equivalent).

Periodicity
Monthly, quarterly or annually for routine administrative records. A validation exercise should be conducted
every 3–5 years against a national population- or facility-based assessment.

Complementary dimensions
The most complete and comparable data currently available on the health workforce globally pertain to
physicians, nurses and midwives. However, the health workforce includes a wide range of other categories of
service providers (e.g. dentists, pharmacists, physiotherapists, community health workers) as well as
management and support workers (health service managers, health economists, health information technicians
and others). Information should ideally be captured on all of these categories of human resources for health.

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Recommended core indicator 2: Distribution of health workers – by
occupation/specialization, region, place of work and sex

There is increasing interest globally in equity in health and the pathways by which inequities arise and are
perpetuated or exacerbated. Imbalance (or maldistribution) in the supply, deployment and composition of
human resources for health, leading to inequities in the effective provision of health services, is an issue of
social and political concern in many countries. Drawing on an analytical framework for understanding health
workforce imbalance (20), at least four typologies for monitoring the distribution of health workers should
be considered: imbalances in occupation/specialty, geographical representation, institutions and services, and
demographics. The impact on the health system varies for these different types of imbalances; in consequence,
there is a need to monitor and assess each of these dimensions of workforce distribution. In practical terms,
this implies that the collection, processing and dissemination of health workforce data should enable
disaggregation by occupation (and within a given occupation, for example by medical specialization), by
geographical typology (e.g. urban or rural, within or outside the capital city, by province/state or district), by
place of work (e.g. hospital or primary health-care facility, public or private), by main work activities (e.g.
preventive/curative/rehabilitative health-care provision versus other functions such as teaching or research)
and by sex.

Definition
The distribution of health workers according to selected characteristics ― notably, by occupation,
geographical region, place of work and sex.
 Numerator: The number of health workers with a given characteristic (e.g. working in a privately operated
health facility).
 Denominator: The total number of health workers.

Data collection methodology

The means of measuring the distribution of the health workforce is a simple disaggregation of the stock of
health workers (see above indicator of density) according to the selected characteristics.

Comparability issues
Data on occupation and place of work should ideally be classified by or mapped to the ISCO and ISIC,
respectively.

Periodicity
Monthly, quarterly or annually for routine administrative records. A validation exercise should be conducted
every 3–5 years against a national population- or facility-based assessment.

Complementary dimensions
Because counts of workers in the private sector are likely to be less accurate when drawing on administrative
sources than counts of those in the public sector, and because private for-profit providers are often less
accessible to low-income populations, it is recommended that national and international reports include
statistics disaggregated by employment sector (public, private for-profit and private not-for-profit). Additional
information on health workers’ demographic characteristics may also be important for policy and planning,
e.g. the age distribution can lend insights into the numbers of workers approaching retirement age.

8
Recommended core indicator 3: Annual number of graduates of health
professions educational institutions per 100 000 population – by level and
field of education

Another commonly reported indicator for monitoring health workforce metrics is the annual output (or
number of graduates) of health professions educational institutions relative to the population (or to the
current active health workforce). This is actually not one measure but the aggregate of multiple pieces of
information, depending on the number of cadres in the health system. The number and type of newly trained
health workers is relevant everywhere: in countries that need increased production among all cadres, in
countries that need more workers in rural and underserved areas, and in countries receiving large numbers of
foreign-trained workers that are aiming towards national self-sufficiency of health workforce regeneration.

Definition
Number of graduates of health professions educational institutions (including schools of medicine, dentistry,
pharmacy, nursing, midwifery and other health services) during the last academic year, divided by the total
population.
 Numerator: The absolute number of graduates of health professions educational institutions in the past
academic year (by level and field of education).
 Denominator: Total population.

Data collection methodology

Ideally assessed through routine administrative records from individual training institutions (both public and
private) submitted regularly (e.g. annually) and collated into a centralized HRIS or database maintained by the
ministry of health or other mandated agency. In some cases, data may be validated against registries of
professional regulatory bodies where certification or licensure is required for practice.

Comparability issues
Data on health worker education and training should ideally be classified by or mapped to the ISCED.

Periodicity
Annual.

Complementary dimensions
Data on the output of health professions educational institutions can be used to assess health workforce
renewal or the ratio of entry to the health workforce (that is, the number of graduates relative to the total
active health workforce). When combined with information on the numbers of foreign-trained health workers
in the country, this information can be used to assess the level of national self-sufficiency in human resources
for health. Data from school records can also be used to obtain information on student applications,
enrolments and attrition as well as institutional capacity and curriculum content, that is, the different
components of the education pipeline for the production and quality assurance of health workers (21).

9
4. Additional considerations for monitoring
national workforce plans and actions
Strengthening the performance of health systems depends on more than just increasing the numbers of health
workers: actions for assessing and strengthening their recruitment, distribution, retention and productivity are
also important. Actions may include, for example: adopting new approaches to pre-service and in-service
training; strengthening workforce management; establishing or improving incentives for addressing
distribution and retention challenges; or task shifting (delegating tasks, where appropriate, to less specialized
health workers). Such strategic plans should normally include targets for monitoring health workforce metrics
in both the short and the long term and adaptation to any major health sector reforms (for example,
decentralization). At the same time, the plans should be harmonized with broader strategies for social and
economic development (e.g. the national poverty reduction strategy paper). They should also focus on the
human resources development needs of priority health programmes and aim to integrate these into a primary
health-care framework, based on epidemiological evidence.

Table 2 presents a series of indicators for monitoring human resources dynamics and their potential means of
verification. Not all of the indicators necessarily require a numerical answer; for example, the existence of a
documented human resources management and development plan could be a relevant indicator for providing
information on a particular strategic direction (22). The list suggested here is neither exhaustive nor absolute,
but an attempt to build a framework for monitoring and evaluation of health workforce strategies and actions
at the country level. Disaggregation of relevant indicators allows for monitoring progress in actions to
improve equity in access and coverage of essential health interventions, especially among underserved
communities or other nationally prioritized population groups. A number of tools and resources exist to assist
countries in setting their health personnel needs and targets (23). Approaches should focus not only on health
service providers, but also the health management and support staff needed to keep systems and services
running.

It will be imperative to review the present selection of proposed indicators at the national and sub-national
levels, particularly in the process of establishing appropriate country-specific baselines and targets.
Throughout this discussion, it is important to keep in mind the need, where possible, routinely to compile,
analyse and act on data collected through existing administrative processes. This routine data collection can
then be supplemented and validated through periodic or ad hoc surveys and other standard statistical sources.

Sharing information is important so that improved human resources strategies can be compared and used by
others. Intercountry knowledge sharing as part of the HRIS strengthening process provides models that help
to avoid repeating mistakes and standardizes information and evidence across regions and countries. In
particular, health workforce observatories are one valuable mechanism that can be used for widely
disseminating information and evidence for effective practices at the national, regional and global levels (see
Box 3).

10
Table 2: Selected indicators for monitoring country actions for strengthening the health workforce
Examples of country-led activities Possible output indicator Potential data source(s) Related outcome indicator
Effective management and development of human resources Costed, prioritized human resources Government reports and/or interviews with key
in health systems require top-level direction – a documented management/development plan exists informants (e.g. senior management in ministry
plan is one element of such direction of health)
Activities aiming to strengthen the information and evidence Number of national data points on the Data dissemination reports (e.g. government,
base for policy and planning include regularly compiling and stock and distribution of health workers professional regulatory bodies, census/survey
using validated statistics on human resources for health to produced within the last three years reports)
support decision-making
Health worker density per
Activities aiming to increase the size and capacity of the Number of entrants into community health Routine administrative records of training
10 000 population
national health workforce may include recruitment and training training programmes (with nationally programmes and/or interviews with key
of community health workers (i.e. community health aides approved curriculum) in the past 12 informants (e.g. programme managers)
selected, trained and working in the communities from which months, e.g. by sex
they come)
Activities aiming to increase the capacity of health professions Number of students in medical, nursing Routine administrative records of education and
educational institutions include increasing the quantity and and midwifery (pre-service) education training institutions and/or interviews with key
quality of instructors and auxiliary staff programmes per qualified instructor informants (e.g. faculty directors)
Activities focusing on strengthening recruitment and Number of health workers newly recruited Routine administrative records on facility
deployment systems include incentive schemes to ensure that at primary health-care facilities in the past staffing and/or interviews with key informants
primary health-care facilities meet their nationally 12 months, e.g. expressed as percentage (e.g. facility managers)
Distribution of health
recommended staffing norms of planned recruitment target
workers (by geographical
Effective interaction with or regulation of the private sector Private provider registration system is up Government reports and/or interviews with key area, place of work)
requires accurate knowledge of the numbers, types and to date and accurate informants (e.g. ministry, professional
qualifications of private sector providers regulatory bodies, associations of private
providers)
The performance of health workers requires effective Number of senior staff at primary health- Routine administrative records of training
management. Related activities include training programmes care facilities who received in-service programmes and/or interviews with key
for updating skills for effective human resources management management training (with nationally informants (e.g. programme managers)
and development approved curriculum) in the past 12
months
Rate of retention of
Activities related to optimizing health worker motivation and Percentage of health service providers at Ideally assessed through a sample survey of health service providers
productivity may include strengthening supervision, potentially primary health-care facilities who received health workers; also can be assessed via at primary health-care
one of the most effective instruments to improve the personal supervision in the past six facility administrative records facilities in the past 12
competence of individual workers months months
Activities aiming to reduce inefficiencies may include Number of days of health worker Ideally assessed though facility staffing/payroll
identifying and reducing worker absenteeism, known to be a absenteeism relative to the total number of records; can also be assessed by means of
significant problem in the public health system in many scheduled working days over a given special study cross-examining duty roster lists
contexts period among staff at primary health-care with actual head-counts on the day of visit
facilities

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Table 2: Selected indicators for monitoring country actions for strengthening the health workforce
Examples of country-led activities Possible output indicator Potential data source(s) Related outcome indicator
Among countries that receive large numbers of health workers Number of health workers trained abroad Entry visas, work permits and other Proportion of nationally
from abroad, efforts may be undertaken to manage the newly entering into the country in the past administrative sources (e.g. professional trained health workers
pressures of the international health workforce market and its 12 months, e.g. relative to the number of regulatory bodies); migration estimates over (e.g. with distribution of
impact on migration nationally trained graduates longer periods can also sometimes be derived foreign trained workers
from population census sources by country of origin)

Box 3 A mechanism for sharing experiences, information and evidence to support policy decision making: health workforce observatories

Initiatives for supporting the development, implementation, monitoring and evaluation of human resources for health actions and strategies should
ensure not only the collection and processing of appropriate data, but also dissemination and utilization for policy and managerial decisions. Health
workforce observatories are being increasingly promoted to improve the translation of information and evidence into policy-making and practice
by offering a cooperative mechanism for countries and partners to produce and share information and knowledge. Although the functions of and
triggering force for the emergence of health workforce observatories differ across countries and regions, depending on specific contexts and needs,
all have the common objective of bridging the gap between evidence and policies.

Some examples of health workforce observatories at the national and regional levels include:

 Africa Health Workforce Observatory (http://www.afro.who.int/hrh-observatory)

 Eastern Mediterranean Region Observatory on Human Resources for Health (http://www.emro.who.int/hrh%2Dobs)
 Latin America and Caribbean Observatory of Human Resources in Health (http://www.observatoriorh.org)
 Observatorio Andino de Recursos Humanos en Salud (http://bvsde.per.paho.org/oarhs2/index.php)
 Observatório de Recursos Humanos en Saúde do Brasil (http://www.ObservaRH.org.br)
 Ghana Health Workforce Observatory (http://www.ghanahrhobservatory.org)
 Sudan National Human Resources for Health Observatory (http://www.hrhobservatory.sd/)

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To sum up, practical and affordable strategies Box 4 Financial resource needs for a timely and
exist for generating timely and reliable statistics on comprehensive human resources information system
the health workforce and for developing the
capacity to collect, manage, analyse and In practical terms, the cost of collecting and processing
disseminate them (Box 4). The cost of not nationally representative data on the health workforce will
improving workforce statistics is much higher be marginal for exercises that already include questions on
than that of investing in these strategies: poorly occupation, education and place of work (e.g. population
informed decisions and unmonitored census or labour force survey). While little research has
interventions can have long-term social and been undertaken into the investment levels needed to
economic effects, which is critical because impacts ensure a sound HRIS drawing primarily on administrative
data sources, estimates of the cost of a comprehensive
of interventions and effects of adjustments can
health information system including a human resources
sometimes take several years to be observable (up component range from US$ 0.53 to US$ 2.99 annually per
to eight years in the case of producing physicians). capita (24). The cost of a household- or facility-based
assessment with a sufficient sample size allowing for
Given the diversity of potential information disaggregated estimates will vary depending on the level of
sources, monitoring and evaluation of human technical support required in the country and the final
resources for health requires good collaboration sample size, ranging from US$ 350 000 to over
between the ministry of health and other sectors US$ 1 million. In general, guidelines suggest that health
that can be reliable sources of information, information, monitoring and evaluation costs comprise
notably the central statistical office, ministry of between 3% and 11% of total project funds (25).
education, ministry of finance, ministry of labour,
health professional regulatory and licensing bodies, associations of private providers, and individual health-
care facilities and health training institutions. Ideally, a commitment should be established in advance to
investigate purposeful ways to put the data to use. Discussions between representatives of the various
stakeholder groups, under the leadership of the ministry of health, are recommended from the beginning to
set an agenda for data harmonization, publication and use, taking into account the timeline for data collection
and processing and the information needs for health workforce policy and planning.

Selected tools and resources

 Human Resources for Health Action Framework: http://www.capacityproject.org/framework

 Tools and guidelines for human resources for health situation analysis:
http://www.who.int/hrh/tools/situation_analysis/en/index.html

 Tools and guidelines for human resources for health planning:

http://www.who.int/hrh/tools/planning/en/index.html

 Tools and guidelines for human resources for health management systems:
http://www.who.int/hrh/tools/management/en/index.html

 HRIS Strengthening Implementation Toolkit: http://www.capacityproject.org/hris/hris-toolkit/index.html

 Human Resources for Health (online journal): http://www.human-resources-health.com

 Spotlight on Health Workforce Statistics (fact files): http://www.who.int/hrh/statistics/spotlight/en/index.html

 Service Availability Mapping (assessment tool and country reports):

http://www.who.int/healthinfo/systems/serviceavailabilitymapping/en/

13
References
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15
Annex: Mapping health workforce statistics: relevant codes in
selected international standard classifications for social and
economic statistics
 

Classification of education and training

Comparability of information on education and training of health workers can be enhanced through the
collection, processing and dissemination of data following the ISCED standard, which provides a framework
for the compilation and presentation of national and international education statistics and indicators for policy
analysis and decision-making. The ISCED allows a variety of types of education programmes to be classified
by level and field of education. Most specializations relevant to health workforce monitoring fall under
subfield 72 “health”, including education in medicine, medical and health services, nursing and dental services
(see Table A.1). Depending on the field, relevant levels may range from upper secondary to second stage of
tertiary education.

Classification of occupations
In order to facilitate harmonization of information on the health workforce situation within and across
countries, data on health workers should ideally be mapped to the latest revision of ISCO (or its national
equivalent). This classification offers a system for classifying and aggregating occupational information for
purposes of statistical delineation, description and analysis. It uses a hierarchical structure of occupational
titles and codes, essentially reflecting the distinction of subgroups of the health workforce according to
assumed differences in skill level and skill specialization required to fulfil the tasks and duties of jobs (see
Table A.2).

Classification of braches of economic activity

The ISIC classification can form a basis for analysis of data on place of work, as it allows pooling of
information on workers in health services across different types of economic systems within a comparative
framework. In ISIC, economic producing units are grouped into successively broader levels of classification in
a four-level hierarchy; the grouping is done according to similarities in the character of the goods and services
produced, the uses to which the goods and services are put, and the inputs, process and technology of
production. Relevant information for health workforce analysis essentially falls under ISIC division 86,
“human health activities”. Data disaggregated at the lowest levels of the classification may allow further
analysis across all the different types of health systems activities, including public health services, supplies
procurement and financing (see Table A.3).

Other classifications
It is also of significance to countries and stakeholders to be able to distinguish the different categories of
human resources within health systems, such as those who are regular employees of the systems and those
who are not, or those whose basic salaries are drawn from the government budget in comparison with health
workers who are funded by other sources. A full list of international classifications for the collection and
dissemination of economic and social statistics is available at the United Nations Statistics Division web site
(26).

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Table A.1 Fields of education related to health in the International Standard Classification of Education (ISCED-97)
Code Name Specializations
Fields of education directly related to health

72 Health Medicine The study of the principles and procedures used in preventing,
diagnosing, caring for and treating illness, disease and injury in
humans and the maintenance of general health. Principally, this field
consists of training of physicians.
Medical services The study of physical disorders, treating diseases and maintaining the
physical well-being of humans, using non-surgical procedures.
Nursing The study of providing health care for the sick, disabled or infirm and
assisting physicians and other medical and health professionals
diagnose and treat patients.
Dental services The study of diagnosing, treating and preventing diseases and
abnormalities of the teeth and gums. It includes the study of designing,
making and repairing dental prostheses and orthodontic appliances. It
also includes the study of providing assistance to dentists.

Fields of education associated with health

76 Social services Social work and The study of the welfare needs of communities, specific groups and
counselling individuals and the appropriate ways of meeting these needs.
Programmes in social work, social welfare, crisis support and
counselling are included here.
85 Environmental Environmental The study of the relationships between living organisms and the
protection protection environment in order to protect a wide range of natural resources.
Programmes in services to the community dealing with items that affect
public health, such as hygiene standards in food and water supply, are
included here.
86 Security services Occupational The study of recognizing, evaluating and controlling environmental
health and safety factors associated with the workplace. Programmes in occupational
health and industrial hygiene, labour welfare (safety) and ergonomics
are included here.
Source: adapted from (16, 19).

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Table A.2 Occupational titles related to health in the International Standard Classification of Occupations (ISCO-08)
GROUP CODE OCCUPATIONAL TITLE
Sub-major Minor Unit
22 HEALTH PROFESSIONALS
221 Medical doctors
2211 Generalist medical practitioners
2212 Specialist medical practitioners
222 Nursing and midwifery professionals
2221 Nursing professionals
2222 Midwifery professionals
223 2230 Traditional and complementary medicine professionals
224 2240 Paramedical practitioners
226 Other health professionals
2261 Dentists
2262 Pharmacists
2263 Environmental and occupational health and hygiene professionals
2264 Physiotherapists
2265 Dieticians and nutritionists
2266 Audiologists and speech therapists
2267 Optometrists and ophthalmic opticians
2269 Health professionals n.e.c.
32 HEALTH ASSOCIATE PROFESSIONALS
321 Medical and pharmaceutical technicians
3211 Medical imaging and therapeutic equipment technicians
3212 Medical and pathology laboratory technicians
3213 Pharmaceutical technicians and assistants
3214 Medical and dental prosthetic and related technicians
322 Nursing and midwifery associate professionals
3221 Nursing associate professionals
3222 Midwifery associate professionals
323 3230 Traditional and complementary medicine associate professionals
325 Other health associate professionals
3251 Dental assistants and therapists
3252 Medical records and health information technicians
3253 Community health workers
3254 Dispensing opticians
3255 Physiotherapy technicians and assistants
3256 Medical assistants
3257 Environmental and occupational health inspectors and associates
3258 Ambulance workers
3259 Health associate professionals n.e.c.
ADDITIONAL HEALTH RELATED UNIT GROUPS
1342 Health service managers
1343 Aged care service managers
2634 Psychologists
2635 Social work and counselling professionals
3344 Medical secretaries
5321 Health care assistants
5322 Home-based personal care workers
5329 Personal care workers in health services n.e.c.
Source: (14).
n.e.c. = not elsewhere classified

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Table A.3 Economic sectors related to health in the International Standard Industrial Classification of all Economic
Activities (ISIC), fourth revision
Code
ECONOMIC ACTIVITY
Section Division Group Class
Core health industry groups and classes
Q 86 Human health activities
861 8610 Hospital activities
862 8620 Medical and dental practice activities
869 8690 Other human health activities
Selected associated classes
C 21 210 2100 Manufacture of pharmaceuticals, medicinal chemical and botanical products
32 325 3250 Manufacture of medical and dental instruments and supplies
E 36 360 3600 Water collection, treatment and supply
37 370 3700 Sewerage
G 47 477 4772 Retail sale of pharmaceutical and medical goods, cosmetic and toilet articles in
specialized stores
K 65 651 6512 Non-life insurance (including provision of health insurance)
M 71 712 7120 Technical testing and analysis (include testing in the field of food hygiene; testing
and measuring air and water pollution)
O 84 841 8412 Regulation of the activities of providing health care, education, cultural services and
other social services
8430 Compulsory social security activities (including funding and administration of
government-provided social security programmes for sickness, work-accident,
temporary disablement, etc.)
Q 87 871 8710 Residential nursing care facilities
872 8720 Residential care activities for mental retardation, mental health and substance abuse
88 881 8810 Social work activities for the elderly and disabled (without accommodation)
Source: (15).

19