Equity in availability of and access to the nursing workforce

5.2.1 Key findings

Around 81% of the world’s nurses are found in the American, European and Western Pacific regions, which account for 51% of the world’s population.

Individual countries experiencing low densities of nurses are mostly in the African, South-East Asia and Eastern Mediterranean regions, and parts of Latin America.

Global inequalities in availability of nursing personnel are largely income driven, with a density of 9.1 nurses per 10 000 population in low-income countries compared to 107.7 per 10 000 population in high-income economies.

There are significant disparities within countries: in 35 countries with data

disaggregated by urban–rural area, 36% of nurses are deployed in rural areas, where 49% of the population lives. In 76 countries with available data, 75% of nurses are employed in the public sector, with the remaining 25% in the private sector.

90. The path to universal health coverage requires addressing demographic, geographical and skills disparities in availability of and access to the health workforce.

5.2.2 Equity across regions

91. Figure 5.5 shows the global variation in nursing personnel density per 10 000 population, with the greatest gaps concentrated in the African, South-East Asia and Eastern Mediterranean regions and some countries in Latin America.

5.2.3 Equity in nursing availability within regions

92. Figure 5.6 illustrates the variation in nurse density within regions: each dot represents a country. All regions show significant variation in nursing density, but the disparity is greatest in the

Eastern Mediterranean Region, with a ratio of highest to lowest density of 121 to 1, and in the African Region, with a ratio of 100 to 1. Also, in the Region of the Americas a few large countries have high densities of nursing personnel while most of the other countries have relatively low densities: 87% of the nurses in this region are located in Brazil, Canada and the United States, which account for around 57% of the population. Lower density disparities – 10 to 1 – are observed in the European Region. Countries in the African Region are clustered at the lower end of the column, indicating that only a few African countries have a density of over 25 nurses per 10 000 population. Similar patterns are observed in the South-East Asia and South-Eastern Mediterranean regions. The density variance is largely driven by income levels, with a density of 9.1 nurses per 10 000 population

Figure 5.5 Density of nursing personnel per 10 000 population in 2018

Note: “Nursing personnel” includes nursing professionals and nursing associate professionals.

Source: NHWA 2019. Latest available data over the period 2013–2018.

not reported not applicable

0 5001,000 2,000 3,000 4,000 km

< 10 10 to 19 20 to 29 30 to 39 40 to 49 50 to 74 75 to 99 100 +

0 50 100 150 200

Ratio maximum: minimum density

100:1 22:1 18:1 10:1 12:1 33:1

WHO regions

Africa Eastern

Mediterranean Europe

Americas South-East

Asia Western

Pacific

Number of nurses per 10 000 population

Note: “Nursing personnel” includes nursing professionals and nursing associate professionals.

Source: NHWA 2019. Latest available headcount reported by countries between 2013 and 2018.

Figure 5.6 Regional disparities in density of nursing personnel per 10 000 population (2018)

in low-income countries versus 107.7 per 10 000 population in high-income countries (Table 5.5 and Figure 5.7).

93. When considering the 46 countries classified as least developed by the United Nations Committee for Development Policy as of December 2018, the density of nursing personnel is 6.4 per 10 000, which is six times less than the average for all other countries, and substantially lower than the average

8 Countries with a Fragile States Index score of 80+.

Source: https://fragilestatesindex.org/.

for low-income countries. The great majority of these countries are also considered as vulnerable (“high warning”

or “alert” categories) according to the Fragile States Index.⁸ Box 5.1 presents further information on equity within countries.

Level of income

Low-income Lower

middle-income

Upper middle-income

High-income 0

50 100 150 200

Number of nurses per 10 000 population

Note: “Nursing personnel” includes nursing professionals and nursing associate professionals.

Source: NHWA 2019. Latest available headcount reported by countries between 2013 and 2018. Income grouping is from the World Bank classifi cation as of 2018.

Figure 5.7 Density of nursing personnel per 10 000 population by income group (2018)

Box 5.1 Equity within countries

Nursing availability in rural areas

The distribution of the nursing workforce within countries is equally important in relation to equity of access. A total of 35 countries (mostly in Latin America and Africa)⁹ provided data on the proportion of the nursing workforce in rural areas. On average, in these countries, some 36% of nurses work in rural areas, compared to 50% of the population residing there.

Nursing availability in public and private sectors

Within countries, another potential source of inequity is distribution by public versus private sector. In 76 countries providing data, an average of 75% of nurses worked in the public sector, with relatively low variability among regions.

INCOME GROUP

Number of countries reporting/total

Density per 10 000 population

Ratio highest to lowest

Overall Low High

Low-income 30/31 9.1 0.6 42.0 68:1

Lower middle-income 44/46 16.7 1.8 104.6 57:1

Upper middle-income 60/60 35.6 5.0 124.2 25:1

High-income 57/57 107.7 19.4 196.1 10:1

Global 191/194 36.9 0.6 196.1 319:1

Note: “Nursing personnel” includes nursing professionals and nursing associate professionals.

Source: NHWA 2019. Most recent available headcount reported by countries between 2013 and 2018.

For Cook Islands and Niue, income group classifications were not available. They were therefore classified as upper middle-income, similarly to other countries in the same area. Income grouping is from the World Bank classification as of 2018.

Density of nursing personnel per income group (2018)

Table 5.5

Antigua and Barbuda, Belize, Brazil, Brunei Darussalam, Cambodia, Ecuador, Egypt, El Salvador, Eswatini, Gambia, Ghana, Guinea-Bissau, Guyana, Honduras, Iceland, Kenya, Lao People’s Democratic Republic, Madagascar, Marshall Islands, Mongolia, Myanmar, Pakistan, Paraguay, Peru, Samoa, Serbia, Sierra Leone, Sri Lanka, Tajikistan, Thailand, Timor-Leste, Uganda, United Republic of Tanzania, Uruguay, Venezuela (Bolivarian Republic of).

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