WORLD HEALTH ORGANIZATION
ORGANISATION MONDIALE DE LA SANT.
"EGIONAl OFFICE FO" THE WESTERN '"ClfIC
BUIUAU "~GIONAl DU PACIFIQUE OCCIDENTAL
REGIONAL COMMITTEE Twenty-second Session Manila 21-29 September 1971
TECHNICAL DISCUSSIONS WPR/RC22/TD5 10 September 1971 ORIGINAL: ENGLISH
• HEALTH MANPOWER PROBLEMS IN DEVELOPING COUNTRIES
AND APPROACHES TO THEIR SOLUTION l by
Kung-pei Chen, M.D. Professor and Director of the Institute of Public Health College of Medicine, National Taiwan University Taipei, Taiwan
• Background document for reference use at the Technical Discussions on "Health Manpower in the Developing Countries: Problems and Needs". 1
CONTENTS
Page .1 • TNTRODUCTION •••••...•••••••.••.••••••••••..•••••••••••••.•• 1
1.1
Heal th manpower ......................................... .
1.2 2•
Importance of health manpower planning •......
j ••••••••
1 1
HEALTH MAN POWER PROBLEMS ...................•••.••.•.•.....• Health man power shortage .........•..•.•......•.......• Health manpower distribution ...•.•...•....•..•......•• 2.3 Ratios between oategories of the health manpow,r ••••.. 2.4 Medical specialization •...•.....•.....•.•.•..•.••....• 2·5 Util1zaUon and productivity of the health man!power ..• 2.6 Professionals and auxiliaries ........•.......••.....•• 2.1 'J f_ •
2 2
'"I
c..
3 4 J~
5 6 7
2.7 Bra1 n drain ................................. ~ .......... . 3. APPROACHES TO THE SOLUTION OF HEALTH MANPOWER PROBLEMS .. .....
8
• ,
3.1 Health manpower planning as a component of 3.2 3.3 3.11
nati onal heal th planning •............••.....••.....••. Ensuring availability of vital and health stat:l.stics data ...............•........•..•.••........ Supply and demand pr~Jection and its balancing .......• Need for innovation in medical and paramedical education . ~ ......... " .............. " " .. " ..... " .... " .... " " ........ " ...... . planning ....... ~ ..... " ... " .............. " . " ..... , " ... " ......' ... " ...... ..
8 8
8 13 14 "'-------
3.5 Research in health manpower development and TABLE 1 - POPULATION/HEALTH PERSONNEL RATIOS IN COUNTlUFS AND TERRITORIES OF THE WHO WESTERN PACIFIC REGION (1967) •••••••.•••••••••• - DISTRIBUTION OF GENERAL PRAC'I'ITICNERS AND SPECIAL:;:S'TS IN VARIOUS COUNTR:iES •••••••••••
17 19
TABLE 2
•
FIGURE 1
- HEALTH MANPOWER PATTERN .............••... .....• 10 ............................ ,. .. ..
21 23
RB:FERF.NCES .....................................
--<
WPR/RC22/TD5
page 1 1. 1.1 Health manpower There are three types of resources for any activity: and financial. human, material Human INl'RODUCrrON
Of these. the human resource is the most important. In
resources are essential for the effective utilization of material and
'--
financial resources to achieve the desired goals of an activity. order that the manpower can carry out properly the functions of an activity, education and technical training are necessary. power ma~
•
Health man-
therefore be described as human resource trained to engage in
health activity. 1.2 ImP9rtance of health manpower planning Health manpower planning acoording to Baker1i is the process of providing enough doctors, nurses and other health personnel to meet, but not exceed, future economic demands for their services. HallY sees the fundamental purpose of manpower study as the antiCipation of a future demand for human resources at a time when decisions can still be made to meet it. TaYlord! views health manpower planning as the employment of scientific analysis to permit prediction of shortages, systematic
• '~
attention to high-priority activities and rationalization of services • As long as health technology remains at a, primitive level, the social costs of inefficiency are not readily apparent. It is becoming In countries more generally recognized, however, that the proper development of human resources requires study and planning on a nation-wide scale. with a favourable manpower supply and large private sector, poor manpower planning may not seriously affect health services output and the level of health. Developing countries, on the other hand, have no such margin of It is, nevertheless" in the safety because of thei r limited resources. countries are being met. /Health manpower •••
developing countries where mistakes previously experienced in developed
WPR/RC22/TD5 page 2 Health manpower development in the developing countries would consequently require careful planning in order to meet the expected rise in the future demand issuing from population increase, urbanization, improved standard of living and expansion of health services. 2. HEALTH MANP<XtlER PROBLEMS
2.1
Heal th manpower shortage Shortage, especially of physicians and nurses, is a universal
phenomenon.
Shortages in these categories occur in both developed and
developing countries. Despite the high ratio of health manpower to the population in the United States of America,
•
KiPpel~
estimates that an increase by one The
million of the total health manpower will be required by 1975.
American Medical Association estimates that eight allied medical categories of health manpower are needed for each physician; the total required in 1975 would be 480 000. The increased demand 1n the United States of America, is ascribed to population increase, changes in the age compoSition (hence changes in the disease pattern), better education, increase in p~r
capita
income, urbanization and industrialization, an upsurge of all forms of health insurance and highly complex diagnostic and therapeutic procedures (Baker21, Goerke§i, GerberIiand
•
KiSSiC~).
Developing countries in the Western Pacific Region are faced with problems connected with health manpower shortages in one way or the other. These problems may be met partly by learning from the experience of the developed countries avoiding thereby their mistakes. Table 1 shows the numbers comprising each of the main health manpower categories among countries and terri tones in the Western Pacific Region2/;. 10/ Hiestand-- cites four criteria in assessing shortage of physicians
in the United States which may find applicability in other countries. These are: (i) low turn-over rate in the profession after graduation /(if the demand •••
WPR/RC22/TD5 page 3 (if the demand is high, very few will change jobs); (ii) high competition for admission to medical schools; (iii) high individual income in relation to other professions; and (iv) increased immigration of foreign physicians into the country. 2.2 Health manpower distribution In almost all countries of the world, there is a high concentration ""-
of health manpower in the large cities. The distribution of doctors in urban and rural areas in Europe and North America has been reported above a ratio of 2.5 to 1. it is 48 to 111/. In less developed countries, urban concentration is higher, e.g., in Ethiopia In the Republic of Korea the geographical distribution of physicians in provinces which are predominantly rural, is one for every 10 000 persons, whereas in Seoul, the ratiO is 1 to
•
~'
100~.
TaYlO~
reports in the Turkey survey that 61% of all doctors were
working in the three big cities where population. The high co~centration
5%
of the population lived, whereas
only 13% of them were working in rural areas inhabited by 68% of the
of physicians in urban communities has been (a) attraction to the cities because
ascribed to the following factors:
•
of the general facilities and services available: (b) better access to medical knowledge; (c) convenience afforded specialists to practice in large communities; (d) more medical care demand due to higher individual income; and (e) city dwellers tend to consult more outside of the family physician. Urban and rural demands for medical care vary according to country.
14/ reports that Lima residents averaged fourteen times more visits Hall-per caput than residents of small communities, Baker's study in China (Taiwan), on the other hand, showed. that physician visits per caput per year was 6.0 in the rural areas as against 3.6 in the cities; he reasoned that when high morbidity rates in rural areas were associated, as in Taiwan, with a better distribution of doctors, better economic condition land a good •••
WPR/RC22/TD5 page 4 and a good transportatIon system, the rates of doctor usage in rural areas tended to be
hi~.
2.3 Ratios between categories of the health manpower It is now generally recognized that while physicians alone can perform certain health care functions, others can be undertaken by other categories just as well. An index of the imbalance in the distribution of manpower categories in the developing countries is the higher ratio of physicians as against the lower ratio of nurses to the population. In some countries, e.g., China (Taiwan), Peru and Turkey, there are less nurses than physicians. this implies that certain health care services normally undertaken by nurses are performed by physicians. 2.4 Medical specialization The trend for specialization in the medical and paramedical fields is world-wide. Functions originally done by the nurse are now being -~ absorbed by allied professionals such as dietician, medical social worker, registered medioal record librarian, recreation therapist, physical therapist, occupational therapist, operating room teohnicians, medical assistant, etc.
r-
•
Gerbe~ observes that although medical education in the United States has recognized the importance of family doctors the educational programmes have not been sufficiently oriented to encourage general practitioner training. Of the 31 000 hospital residents in the United States under training in 1965, only 377 were in general practice. Contrasting ratios maybe observed between the general practitioner and the specialist in two groups of countries with different medical care systems. In countries with a national oomprehensive medical care system (national health insuranoe schemes such as Norway, Sweden, United Kingdom and West Germany), the general practitioner serving as family doctor !
•
comprises about fifty per oent. of the total number of phySicians. \
In
countries having free medical care, such as the United States of Amerioa, /Peru and Turkey, •••
WPR/RC22/TD5
page 5 Peru and Turkey, the specialist comprises the majority. of this contrast may be seen in Table 2. It is interesting to note in the Turkey survey 17, 18/ and from the observation of aershon-cohen12l that majority of the illnesses can be handled by the general practitioner, while only a small percentage of these illnesses need to be referred to the specialist. An illustration
--
In genera.l, young medical graduates seek specialization for social and economic reasons including professional satisfaction. higher social status, higher monetary reward and public acceptance. should include:
•
On the other hand,
measures calculated to attract young medical graduates for general practice (a) changes in the medical curricula which would stress the patient apart from the disease (such as the inculcation of better appreciation of the phYSical, biological and cultural factors in the community and the teaching of the physician's responsibility in the maintenance and promotion of individual and family health); (b) establishment of a residency and board speciality for general practice; (c) adoption of national comprehensive health care programmes (which would help regulate the numbers engaged in general practice and the specialities according to the demand). 2.5 Utilization and productivity of the health manpower Utilization of health manpower refers to the degree of effectiveness of the service of particular health workers as viewed from their functions and training. Productivity may be translated in terms of the health service output of a particular category per time unit. Differences in the utilization of physician visits and hospital care have been observed in the cases of China (Taiwan), Peru and Turkey. low utilization rate for hospital beds and high utilization rate for physician visits in Taiwan contrasts with the findings in Peru and Turkey. Factors to explain the situation in Taiwan are better access to medical care of the rural population. and the relatively better and more equitable individual income distribution. Another possible contributing factor is /the greater ••• The
~
• -y-
WPR/RC22/TD5 page 6 the greater emphasis given to high output and low cost ambulatory care in Taiwan instead of the more expensive hospital care. Selected indices of hospital bed productivity may be cited in the experience of Peru during 1964. The bed occupancy rates in both public The short-stay of low and private sectors were considerably below the generally' accepted standard of 75% to 85%, depending upon hospital size. bed discharge rate per year (16) is particularly hospital bed product1vity. indicati~e
The overall average of 14 dispharges per
bed-Jear if increased to the planning target of 20, would be equivalent to adding almost 13 000 additional beds operating in 1964 which would give a capital savings in cost of about $150 million in new constructions. The time analysiS 20j in the functions of nurses and other health
•
workers in health stations in Taiwan show that 30% of the working time of the average nurse was spent on non-professional jobs, such as statistical tabulation, preparing reports, etc., while other untrained health workers spent 20% of their time to nursing Care. necessarily compatible with their training. The underutilization of professionals invites the assignment of new duties not Over-utilization of professionals for functions which can be delegated to other health personnel under their direction tends to reduce the degree of their productivity. 2.6 Professionals and auxiliaries
Wright~
views the ideal structure of a country health manpower
•
supply as being roughly like a pyramid in which a relatively small number of highly trained professionals are supported by a.larger number of middle-level health workers, who in t~rn,
rest on a still larger base In many developing countries,
of trained auxiliaries and other personnel.
the health manpower supply assumes the shape of an hourglass where there is a relatively abundant number of ·high and low level manpower and scarCity of manpower at the middle level (Figure 1). jInthe hourglass ••.
WPR/RC22/TD5 page 7 In the hourglass pattern, medical care services are undertaken either - by highly trained professionals or by the auxiliaries; the average consequence is low health services output and quality. For example, the shortage of technicians in hospitals in Peru was observed by Hallgg/ to contribute to longer hospitalization; lacking laboratory and radiological services, many hospitals were obliged to admit a large number of patients without preliminary assessment which could have been done on an ambulatory basis. ~r
2.7
Brain drain
•
The brain drain may take place between developed countries, from developing to developed countries, and between developing countries • The main problem of the brain drain lies in the fact that developing countries particularly are deprived of skilled manpower to provide the services and to assist in national development after a substantial amount of usually scarce resources have been spent for their education and training. In the study of the PAHO Sub-committee on health manpower from Latin America were:
Migratio~
the causes
ascribed to the inflow to the United States of America of highly trained (a) the lower level of professional and economic level in the home country; (b) political instability at home;
•
and (0) better facilities for training and earning in the United States
of America • Adams and Dirl~
241
have suggested the following measures to help
control the brain drain:
(a) raiSing salaries (citing that a 20% salary . increase in one developed country would reduce emigration of its citizens salary structure (e.g., in Africa, highly trained professionals move to
to the United States of America to a "mere trickle"); (b) revising the other occupations offering more promising returns); (c) increasing professional opportunities (suggesting that a COWltry IS traditional policy on and attitudes to the various professions should be modified to conform to its needs for socio-economic expansion and growth); and (d) re-structuring investments in education and rationalizing manpower /pol1cies •••
WPR/RC22/TD5 page 8
policies (i.e., supply must be adjusted to demand and, demand as distinct from other needs).
h~ce,
investment
decisions on the manpower capital must be made in the li8ht of the effective
3.
APPROACHES TO THE SOIDrION OF HEALTH MANPCMER PROBLEMS
3.1
Health manpower planning as a component of national health planning A health manpower unit should be part of the National Health Planning
Office in the Ministry of Health.
The unit's functions should be to carry
~
out routine data collection, analyses of the current health manpower supply and demand, projection of the supply and demand, and to plan for health manpower developnent as part of the overall ra tional health planning exercise. In many countries national health planning is undertaken within the frame of the national socio-economic development plan. 3.2 Ensuring availability of vital and health statistics data The establishment of registration and reporting systems is a fundamental prerequisite not only for routine data collection and evaluation of the health services but for undertaking health manpower analysis. The collection of data should include, apart from vital events, information on.the outputs of health services, the actual health manpower in the public and private sectors and the existing teaching institutions for the different categories of health manpower. The registration system should provide for inclusion of the different health manpower oategories. Information on vital events would include births, marriages, morbid! ty and deaths. 3.3 Supplr and demand projection and its balancing Methods for projecting the country health manpower supply and demand should be developed depending upon the data available. surveys on health in the country may be explored. /There are ••• ~e
~
feasibility of
undertaking a national health manpower census or the conducting of household
WPR/RC22/TD5 page 9 There are two types of demandr v1z •• "met demand" and "unmet demand". The former ex1sts when the demand 1s sat1sf1ed by the existIng supplyJ the latter. when the demand cannot be met by the exist1ng supply. 3.3.1 Balancing supply and demand where supply1s short Cited below are possible approaohes for balanCing the supply and demand 1n the existence of supply shortase. ).).1.1 Better utilization and increasing the productivity of the existins health manpower
•
It is both praotioal and convenient for developing countries havins lim1ted h\lDl&ll. material and financial resources to increase the productivity and utilization of their health IIIU1power rather than to ircrease the supply.
Gerbe~. viz. : (1)
suggests three ways of increasing productiv1ty and utIl1zat1on.
More use of para!!!!d1cal professionals and
aux1liar~.!!
There 1s more thought being g1 ven to the re-&8sessment of the present pattern of rendering medical services with particular reference to the functioning of the various categories of the health manpower. Medical care output can be increased by delegating routine Jobs to auxiliaries leaving physicians to purel;y professional activities. • on the Turkey study. Based
TqlO~
noted that the greatest hidden resouroe in
health manpowr planning is b7 increuing the utilization and productivity of the IIIInpower especially b7 8stabl111b1ng a rational balance in the funotioning of professionals and awdliaries. activities to auxiliaries. SllverW has reported a paediatrio nurse-practitioner progralll\le utilizing nurses for the provision of ccmprehensive care to well children in the offices of private paed1atr1ciana. and identit;ying, appraising, and temporarily managing certain acute and chronic condi tiona of the sick
In other words. professionals
should perform work which only professionals can do and leave all routine
child:
this prooedure has resulted in 1IIIproved patient
Care and the IIOre
/eff101ent and •••
WPR/RC22/TD5 page 10 efficient and effective and the nurse. The functions being carried out by the medical assistant assistant medical 28 , 29/, in many ~se
of the skills and time of both the physician
office~
and
feldshe~
have been
st~ssed
quarters as having helped physicians increase their (2) Automation in medical practice
servi~es
output.
Services output can be increased by automated
system~
when feasible.
Automation will undoubtedly find important application in 'the technical, research and administrative aspects of medicine, although it may still be a long way off for the use of the private practitioner. analysis of various laboratory examinations and operation of medical care systems. (3) Reorganization of medical care facilities medi~al
Automated of
computeri~ation
•
medical records will certainly promote savings in manpower in the
Visible almost everywhere is the duplication of
facilities
(e.g., X-ray, ECG and other laboratory facilities within a circumscribal geographic area), which is uneconomical and contributes therefore to the wastage of resources. Pooling of medical oare facilities may not only reduce costs in a hospital servioe but also promote better diagnosis by the employment of fewer but better qualified personnel. One of the more significant developments of medioal developed countries has been the rapid growth of group olinios appeal to patients and to dootors alike beoause Multi-specialty group olinics, providing oomprehensive be medicine's best answer to the declining use of the some developing countries. 3.3.1.2 IncreaSing aotual supplY by reduoing manpower 10&ses ~ractice
in the
cl~nics. o~
These
•
the pooling of oare may doctor in
medioal talent and resources and the sharing of personnel land expenses. I
he~lth
fam~ly I
The second approach for balancing supply and demand 1s to reduce the losses without necessarily increasing the estimated supply. This measure is economically more reasonable than producing more but losing more, as /maybe •••
"
WPR/RC22/TD5 page 11 may be observed in some developing countries in the Region. Three ways
of reducing losses are (a) preventing young graduates from going abroad: (b) preventing young graduates from becoming "inactive" or changing the fields of their occupation; and (c) encouraging returning or inactive professionals to practice their professions.
Hies~d32/ has reported
that nearly half of the trained nurses are not employed: many of them do not work because incentives are not sufficient and hospitals and other employers are unwilling to make adjustments in their working hours to accommodate part-time workers.
•
The drop-out rates for nurses and midwives in the developing countries of this Region are quite
hi~.
Health authorities may be able to attract
them back by offering incentives such as higher pay, part-time employment, and more opportunities for job satisfaction. 3.3.1.3 Increasing the supply
In the presence of marked supply shortage the first and second approaches may be insufficient. increased by: In such a situation the supply may be (a) reducing the drop-out rates in the schools and improving In the Turkey study
the retention rate of students; (b) increasing the number of students per class: and (c) increasing the number of schools.
•
TaYlo~
reported that of the 7006 students admitted to medical schools,
only 55% graduated; the drop-out rate was 44.3% of all admissions; only 23.7% of the registered students graduated from the prescribed six years, while 58% required more than six years of study to graduate and of the latter, 10% took more than ten years to graduate. It seems apparent that the simpler and more economical way of increasing the supply of doctors is to eliminate unnecessary waste of school resources through strict screening of candidates for admission to medical schools and improvement of the medical curriculum. is more economical than establishing a new school. and facilities are also made. /3.3.2 Balancing supply ••• Increasing the enrollment per class, provided -the quality of teaching is not sacrificed, Schools should be encouraged to increase enrollments provided that additional teaching posts
WPR/RC22/TDs page 12 3.3.2 Balancing supply and demand when there is surplus supply In principle, demand can generate supply, hence the supply will increase if the demand is increased. government policy. Over-supply occurs when demand rises slowly or when the demand drops suddenly because ot changes in Over-supply may also arise as a result of unplanned educational expansion which may be observed in some developing countries. Three approaches as indicated below may be employed to balance supply and demand. 3.3.2.1 Reducing the supply Reduction in the supply may be accomplished through limiting enrollment per class or reducing the number of schools. requ1re prior1ty attention. Education authorities have to set up standards and requ1rements far profess1onal sohools as bases for soreening the good from poor qual1ty sohools. 3.3.2.2 Increas1ng the demand 1n the presenoe of surplus supply In prinoiple; the demand for serv10es increases with the rise of living standards and where the services are made more accessible to the population. Sometimes an existing demand for professional services may be met by less qualified personnel due to laok of legislative or regulatory measures or because 1ncentives are laoking on the part of professionals to meet the existing demand. While increased 11ving standards can result only from economic growth, national programmes for health serv10es expansion in the periphery oan. be stimulated in the private sector if this 1s accompanied by improvements in the national infrastructure (e.g., roads and communications). Opportunities for attracting the inaotive health manpower to return to practice would be promoted by regulations governing enforcement of qualifications requirements as a condition for licenSing to professional practice thus eliminating compet1tion from the unqualirie~.
In limiting the supply
,-,-.
•
output, sohools with poor teaching faoilities but hav1ng large enrollments
•
Another
/me~ would •••
WPR/RC22/TD5 page 13 means would be the organization of courses for the re-training of the health manpower in new fields or areas where the demand may be on the rise. 3.3.2.3 Reducing the manpower supply by permitting losses
The supply may be reduced through emigration or by instituting strict qualifying requirements. Brain drain is not always an economic loss. In Turkey, $70 million
•
were sent home in 1965 by Turkish health workers working overseas; this amount was equal to 15.2% of the nation's export earnings or 12.1% of its import bills22i. supply. While exportation of the manpower should not be the aim of planning, it nevertheless may be considered where there is an overAlthough national board examinations screen out pOQr quality graduates in situations where training standards vary widely, it is better policy to screen out candidates before enrollment rather than weed them out after they graduate. 3.4 Need for innovation in medical and paramedical education In his book entitled "The Crisis in Medical Education", EvanJ§! has drawn attention to the transitional phase of contemporary medicine because of the rapid advances being made • The aims and content of medical education would need a review and new orientation. The excellent curricula on the sciences and biological knowledge If the patient is to be regarded in the broad context need to be complemented by introducing to existing department of the behavioural sciences. of his social, cultural and biological make-up, the medical student's education should make him aware of the behavioural characteristics of man during his growth and development. The student should also be acquainted with the milieu in which people live and become ill and man's relationships with another human being, including the impelling spirit that sets him apart from other creatures. The objec'ives of medical education, particularly in a developing country, should be directed towards meeting the health needs of its /people and •••
•
WpWRC22/TD5
page 14 people and consequently medical graduates should be familiar with and be . able to cope with the health and medical problems that eXiist. A basic issue in medical education is whether to train the student for capability to render a reasonable quality of medical care to most of the people or to prepare him for the sophisticated care of only a small group of the country's population. "Another paramount contemporary issue is the changing nature and roles of the professional worker. The health professions are in the process of functional flux or evolution and the probability of changes must be recognized in the individual professions.
KissiC~
has observed
that complementary to establishing career mobility as an approach to effective utilization of the manpower is the downward transfer of functions resulting frequently in the creation of new disciplines; e.g., courses for "medical emergency technicians" at the Ohio State University; courses for "physician assistants" at Duke University; courses for "paediatric public health nursing practitioners" at the University of Colorado; and courses for "unit managers" at the University of Florida. It is therefore incumbent upon medical and paramedical educators and administrators to re-evaluate the functioning of the various services and to consider means of meeting the manpower required including the creation of new disciplines best able to meet new needs.
•
3.5 Research in health manpower develOpment and planning Manpower research deals in the main with the economics of supply, demand and utilization. It also deals with non-monetary factors as well Consequently, manpower research as motivations and institutional forces. sociology. Research can be undertaken in three areas: (a) supply and demand,
•
involves management, education, training, psychology, economics and
including the various factors and institutions influencing the development of potential and actual workers; (b) the utilization of workers, i.e., the particular duties which workers of different occupations perform and the !way, these
...
WPR/RC22/TD5
IBge 15 ways these duties change as a result of other changes in the economy, technology and society; and finally (c) medical and paramedical education. 3.5.1 Supply and demand Demand and supply change over time. The former is influenced by the
health and socio-economic condition of the population, advances in medicine and government action as regards the introduction of new medical services and/or their financing. New patterns of medical organization come into being as new technology is developed and new types of personnel are
•
trained2§! . The aims of research in regards to demand according to are:
Feldstei~
(a) to identify and estimate the relationships between the use of Since these influencing factors vary from country
a product or service and the factors influencing its use and (b) to predict future demand. to country. the relationShips between the variables and influencing factors should be clarified in each country. Many reports have been concerned with the shortage of health manpower,
especially the physician and the nurse. leadership of each particular profession. variety of terms: ... staffing practice or optimum standards.
"Shortage" often has meaning Professional leaders use a From the economist's point of
primarily in relation to the norm and value systems of those in the minimum standards, necessary levels of care, desirable
view, shortage indicates a discrepancy between the actual level of manpower supply and that which is deSired, given the existing structure and level of demands for service and health manpower. significance. The primary problem is the lack of the means to evaluate the shortage and to assess its One of the more important areas for health manpower study is to assess shortage scientifically. Another area for study is to determine the underlying factors contributing to professional inactivity and the causes of emigration of some of the health manpower categories. Disclosure of the factors may lead to the formulation of administrative remedies which can help ensure /better manpower .••
WPR/RC22/TD5 page 16 better manpower utilization and preventing their loss. Retirement of the
health manpower in the private sector is usually based on assumptions or opinions; surveys will help throw light on why, how and when private physicians or other professionals in the private sector retire from active practice. 3.5.2 Utilization of the health manpower
The extent and means by which health manpower is utilized have a bearing on his choice to be inactive or to seek other oceupations. the extent that improved utilization increases the effici'ency of an organization and the economy, the quantity and quality of services would also be raised. Necessary expenditures to help increase and improve staff performance may thus be made. Most of the information available on utilization practices are really in the realm of opinion rather than established by research. By looking at the contents of the activities of workers in their various tasks during a period of time it would be possible to assess whether other types of workers can perform those tasks more economically and satisfactorily. One realizes that major problems in making such assessments may be due to inadequate organization and supervision. Another apparently pervasive factor complicating such assessment is the frequent discrepancy between the training received and the functions being performed. To
•
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WPR/RC22/TD5 page 17/18 TABLE 1 - POPULATION/HEALTH PERSONNEL RATIOS IN COUNl'RIES AND TERRITORIES OF THE WHO WEST.ERN PACIFIC REGION (1967) Population Population Population per Rankper Rankper Rankphysician ing dentist ing I pharmacist ing 850 850 920 1 390 1 780 2 360 2 390 2 400 2 520 2 540 2 730 3 090 4 860 12 008 12 400 13 680 22 750 1 1 3 4 5 6 7 8 9 10 11
Country or TerritorY Australia* New Zealand
Population per nursing Rankpersonnel ing 150 190 410 1 240 450 880 960 910 2 750 7 260 600 820 1 630 4 000 3 200 1 530 1 2 3 10 4 7 9 8 13 18 5 6 12 16 14 11
3 350
4
1 309 1 280 1 700 1 670 11 510
2 1 4 3 7 6 12 8
3 020 2 810 3 020 5 490 9 040 8 330 16 330 17 190 22 020 19 140 27 000 13 560 92750 164 900 6 590 305 480 919 670
2 1 2 5 8 7 10 11
Japan Philippines Singapore Ryukyu Islands** Hong Kong Fiji Republic of Korea China (Taiwan) Western Samoa
3 860 24 580 12 890 2 590 14 750 13 400 54 000 58 100 14 510 63 420 451 500 136 490 344 880
5 11
13 12 14 9 15 16 6 17
9 13 14 10 15 18 16 17
•
Brunei West Malaysia Republic of Viet-Nam New Guinea Sarawak Khmer Republic * Laos Source:
12 13 14 15 16 17 18
3 670 4 460
15 17
33 240
18
1967 World Health Statistics Annual, 1970, Vol. III, WHO Geneva.
*Only
1966 data available.
** Only 1965 data available.
WPR/RC22/TD5 page 19/20
TABLE 2 - DISTRmUTION OF GENERAL PRACTITIONERS AND SPECIALISTS IN VARIOUS COUNTRIES
~ Country United States of AIIIerica a Turkeyb Peruo West aenaanyd Norway'i Swedend Uni ted K1ngdOllld Sources: a. PHS
Clinical General Practitioner Specialist (%) (%) 24.6% 24.1% 27.4% 51.2% 51.6% 54.1% 70.~
Others (%) 5.3% 10.4% 8.~
Total (%) 100.00% lOO.O~ 100.0~
65.5% 64.6% 39.7% 40.2% 39.6% 46.3%
•
9.1% 8.2% 6.3% 5.2%
100.0CY;i 100.~
100.00% lOO.~
48.5%
U.S.A.: "Health Manpower in the U.S •• 1965-1967". Vital Statistics Ser. 14. No.7. November 1968. Table 4. p. 19.
•
b. c. d.
Taylor. C.E.: "Health Manpower Planning in Turkey II • 1968. Table 3-20, p. 54. Hall, T.L.: "Health Manpower in Peru", 1969. Table 5-5. p. 104. World Health Statistics Annual, Vol. III, 1970, WHO, Geneva pp. 87, 91. 93 and 95.
WPR,/RC22/TD5 page 21/22 ANNEX
Figure 1.
HEALTH MANPOWER PA'ITERN
Professional
•
Technical
Technical
Auxiliary
Auxiliary
(Pyramid Pattern)
(Hourglass Pattern)
CLASSIFICATIONS OF HEALTH MANPOWER
•
1.
Professional - health workers with bachelors degree or above, such as physiCians, dentists, pharmacists, registered nurses, and medical technologists and sanitary engineers, etc. Technical -'health workers with educational background of junior college or vocational schools who work under the supervision of professionals, such as doctor's assistants, dental hygienists, laboratory technicians, assistant pharmacists, practical nurses, etc. Auxiliary - health workers with a short-time training course who pursue simple unskilled or semi-skilled work under the supervision of profeSSionals and technicians, such as nursing aides, laboratorY helpers, special project workers. Wright, R.D.: J. Medical Education, 38:511, June 1963.
2.
3.
Source:
WPR/RC22!TDS page 23
REFERENCES
1.
Baker, T.D. and Perlman, M. (1967) Health Manpower in a Developing Economy, Chapter 1, p. 1. Hall, T.L. (1969) Health Manpower in Peru - A Case Study in Planning, Chapter 4, p. 87. Taylor, G.E. et al. (1968) Hel'1lth Manpower Planning in Turkey, Preface, p. vi. Kippel, F. National Responsibility for Health Workers, Proc. Conference on Job Development and Training for Workers 10 Health Services, United States Departments of Labor and HEW, Washington, D.C., 14-17 February 1966, p. 11-15. Baker, T.D. and Perlman, M. (1967) Health Manpower in a Developing Economy, Chapter 1, p. 4. Goerke, L.S. (1965) Utilization, Recruitment, and Training of Health Manpower, Amer. J. publ. Hlth, 22" 1511-1520. Gerber, A. (1967) The Medical Manpower Shortage, J. med. Educ., ~, 306-317. Kissick, W.L. (1968) Health Manpower in Transition, Milbank memo Fd. Quart., 46, No.1. Part 2. p. 53-90. World Health Organization (1970) 1967 World Health Statistics Annual, Vol. III, WHO, Geneva. Hiestand, D.L. (1966) Research into Manpower for Health Service • Milbank memo Fd. Quart., 44, No.4, Part 2. p. 146-180. World Health Organization (1968) The Urban and Rural Distribution of Medical Manpower. WHO Chronicle. 22: 100. Chen. K.P. (1970) WHO ASSignment Report on Health Manpower Study in Korea, p. 34. Table 15. T8710r. C.E. et al. (1968) Health Manpower Planning in Turkey, Chapter 3. p. 51, Table 3-16. Hall, T.L. (1969) Health Manpower in Peru - A Case Study in Planning, Chapter 2, p. 52. Table 2-5. Baker. T.n. and Perlman. M. (1967) Health Manpower in a Developing EconOlV, Chapter 9, p. 140-141.
2.
3.
4.
• -~.
5.
6.
7.
8. 9.
•
10.
11.
12.
13.
14.
15.
WPR/RC22/TD5 page 24 16. Gerber, A. (1967) The Medical Manpower Shortage, J. med. Educ., 42, 306-317, p. 309-310. Taylor, C.E. et al. (1968) Health Manpower Plannina in Turkey, Chapter 3, Table 3-19, p. 53. Taylor, C.E. et al. (1968) Health Manpower Chapter 3, p. 54. Planni~
17. 18. 19. 20. 21.
in Turkey,
Gershon-Cohen J. (1969) Prescription for the Medic.ail Manpower Shortage, Pennsylvania Medicine: 70: 71-82 Yen, Y.T. (1970) Functional Analysis of Health Stattons in Taiwan, (unpublished: personal communication). Wright, R.A. (1963) A COlIIIIIentary on "Preparation in the United States of Foreign Medical Graduates for Academic Careers Abroad", J. med. Educ •• ~, 511-513. Hall, T.L. (1969) Health Manpower in Peru, Chapter 2, p. 63-65. PAHO Sub-COIIIDittee on Migration (1966) Migration of Health Personnel, Scientists and Engineers from Lat!n America, Scientific Publication No. 142, PAHO-WHO, Washington, D.C., p. 36-41Adams, W. and Dirlam, J .B. (1968) Agenda for Action - The Brain Drain, edt ted by Walter Adams, Part V, Summary and Conclusions I The MacMillan Co •• p. 248-256. Gerber, A. (1967) The Medical Manpower Shortage, J. med. Educ., 42, 306-317. p. 307-312. Taylor, C.E. et a1. (1968) Health Manpower Planning in Turkey, Chapter 8, p. 212. Silver, H.K. (1968) The Paediatric Nurse-Practitioner Programme, J. Ame·r. med. Ass., Vol. 208, No.4, 298-302. Stead, E.A. (1967) Training and Use of Paramedical fersonne1, N.Z. med. J. 277,800-801. World Health Organization (1968) Training of Medica! Assistants and Similar Personnel, WId Hlth Org. techno Rep. Se;., 385. Roainki, E.F. and Spencer, F;J. (1965) The Assistant Medical Officer, The Traini of the Medical Auxilia in Davelo i Countries, Un1 versi ty of North Carolina. Press. Chapel Hill, 1 9 pp.
•
22. 23.
24.
25. 26. 27. 28. 29. 30.
•
WPR/RC22/TD5 page 25 31. Sidel, V.W. (1968) Feldshers and "Feldsherism". The Role and Training of the Feldsher in the Union of Soviet Socialist Republic. New Engl. J. Med •• 278. 934-939. 987-992. Hiestand. D.L. (1966) Research into Manpower for Health Service. Milbank memo Fd. Quart .• 44. No.4. Part 2. p. 146-i80. p. 161. Chen. K.P. (1970) ASSignment Report on Health Manpower Study in Korea. p. 11, Table 30, p. 107. Taylor. C.E. et al. (1968) Health Manpower Planning in Turkey. Chapter 3. p. 111-113. Watanabe. S. (1969) The Brain Drain from Developing to Developed Countries. International Labour Review. 49, 401-423, p. 406-410 • Evans, J.L. (1964) The Crisis in Medical Education. The University of Michigan Press. 101. pp. 1-10. Kissick. W.L. (1968) Health Manpower in Transition. Milbank memo Fd. Quart., 46, No.1, Part 2, p. 53-90, p. 82-84. Ibid •• p.
32. 33. 34.
•
35. 36. 37. 38. 39.
87.
Feldstein, P.J. (1966) Research on the Demand for Health Services, Milbank memo Fd. Quart •• 44, No.3, Part 2, p. 128-165 •
•