Part I: OVERVIEW
2 Boundaries of the health workforce: definition and classifications of health workers
2.2 Who are health workers?
Any health workforce analysis requires precise defini-tion of health workers. The World Health Organizadefini-tion (WHO) defines the health workforce as “all people engaged in actions whose primary intent is to enhance health” (4). This statement reinforces the WHO concept of health systems as comprising “all organizations, people and actions whose primary intent is to promote, restore or maintain health” (1). This infers, for example, that family members looking after the sick and other
informal caregivers and volunteers who contribute to the improvement of health should also be counted as part of the health workforce. But in practical terms, these are not often counted, due to lack of information on the unpaid workforce and the ensuing difficulty with regard to establishing the boundaries of what consti-tutes a health system.
Even then, the definition of a health action for classi-fying paid workers is not straightforward. Consider a nurse employed by a manufacturing company to pro-vide on-site health-care services for its employees:
the main goal of the actions of the nurse is to improve health, although the main goal of the actions of the employer is not. Then take the case of a gardener employed by a hospital: the gardener’s own actions do not directly improve health, although the actions of the employer – the hospital – do. There are many such non-clinical workers in health industries, such as man-agers, computer operators, clerks and trades workers, who provide managerial and infrastructural support.
There are also many skilled health-care providers who work outside facility-based service delivery points, including those in government ministries and depart-ments, public health offices, health and health systems research agencies, health professions education and training institutions, company and school-based clin-ics, residential care settings, rehabilitation centres, correctional facilities, military service and others. A classification system that considers the actions of the individual alone, or those of the place of work alone, may fail to capture them all in the health workforce.
In order to provide comparable and consistent data to inform decision-making, it is necessary to define the health workforce operationally. While there is no sin-gle measure of the health workforce, it is important to specify which elements of the definition and classifi-cation structure are being considered. For example, if one study includes the above-mentioned nurse work-ing for a private company while another does not, then the comparability of data from the two studies is compromised.
2
Table 2.1 provides a useful framework to capture health workers employed (or not employed) in the health and non-health industries. Three categories of workers rele-vant for health workforce analysis can be distinguished:
A. those with health vocational education and training working in the health services industry;
B. those with training in a non-health field (or with no formal training) working in the health services industry;
C. those with health training who are either working in a non-health-care–related industry, or who are cur-rently unemployed or not active in the labour market.
Categories A and C together form the trained (skilled) health workforce (active or inactive) available in a given country or region, while A and B represent the work-force employed in the health industry. The sum of the three elements A, B and C provides the total potential health workforce available. A fourth category, D, encap-sulates all non-health workers, that is, those workers without training for a health occupation and not work-ing in the health industry.
The advantage of this framework lies in the fact that it integrates the elements of training, current occupation and industry. In this context, “training” refers to the (for-mal and infor(for-mal) education undertaken by individuals to equip them with the skills necessary to perform the tasks required for competent performance in a job, “occupa-tion” refers to the tasks and duties performed in a job by individuals, and “industry” refers to the activities of the establishments or enterprises in which individuals are employed. Considering all three elements is essential to gain an understanding of the dynamics of the workforce.
The framework can be a useful tool for identifying poten-tial data sources and gaps for health workforce analysis.
A number of sources can be used to provide informa-tion and evidence to inform policy – notably, populainforma-tion censuses and surveys, health facility assessments and routine administrative records (including records on
public expenditure, staffing and payroll, professional training, registration and licensure). Health facility assessments or payroll records will only provide data for categories A and B, while data from professional regulatory associations tend to be limited to A and C. In contrast, nationally representative population censuses and labour force surveys with properly designed ques-tions on occupation, place of work and field of training can provide information on all three components.
2.3 Health workforce classification
Health workers play different roles and often have dif-ferent national history, culture and codes of practice.
Any attempt to compare the size and characteris-tics of the health workforce across countries or over time requires some level of harmonization of the available information. In order to compare and inte-grate data from different sources and countries, it is necessary to use internationally consistent or harmo-nized classification systems. Although some countries disseminate data using national educational, occupa-tional or industrial classifications that are not always comparable, most use classification systems that are either based on or linked to internationally standard-ized classifications, such as the International Standard Classification of Education (ISCED), the International Standard Classification of Occupations (ISCO) and the International Standard Industrial Classification of All Economic Activities (ISIC). These classifications provide a coherent framework for categorizing fields and levels of training, occupations and industries of employment, respectively, according to shared char-acteristics (5–7).
2.3.1 Classification of education and training
There are important challenges in clearly identifying the different types of education and training programmes for health workers from different institutions, having different Table 2.1 Framework for defining the health workforce
Individual’s training, occupation &
place of work
Working in the health industry Working in a non-health industry or unemployed/inactive
Training in health and employed in a health occupation
A. For example, physicians, nurses, midwives working in health-care facilities
C. For example, nurses working for private companies, pharmacists working at retail outlets Training in health but not employed in
a health occupation
A. For example, medically trained managers of health-care facilities
C. For example, medically trained university lecturers, unemployed nurses Training in a non-health field or no
formal training
B. For example, economists, clerks, gardeners working in health-care facilities
D. For example, primary school teachers, garage mechanics, bank accountants
Boundaries of the health workforce: definition and classifications of health workers
entrance criteria, curricula and durations of training, and then grouping them into categories that are nationally and internationally comparable. Comparability can be enhanced through the collection, processing and dis-semination of data following the ISCED standard, which provides a framework for the compilation and presen-tation of national and international education statistics and indicators for policy analysis and decision-making, whatever the structure of the national education systems and whatever the stage of economic development of a country (8). ISCED covers all organized and sustained learning activities for children, young people and adults.
It allows a variety of types of education programmes to be classified by level and field of education, such as ini-tial formal education, continuing education, non-formal education, distance education, apprenticeships, techni-cal-vocational education and special needs education.
The latest version of ISCED (referred to as ISCED-97) classifies seven educational levels, and nine broad fields (in other words, at the one-digit coding level) and 25 subfields (two-digit level). Table 2.2 shows the ISCED educational levels relevant for education and training leading to a health occupation. Most relevant specializations fall by level under subfield 72, “health”, including education in medicine, medical and health services, nursing and dental services.
Certain tools also exist that aim at providing guidelines on how to apply the ISCED classification. In one such manual, the two-digit fields of education from ISCED-97 are expanded to the three-digit level, capturing more details for vocational education and training while still ensuring cross-national comparability (9). The man-ual is intended to serve as a guide in countries where Table 2.2 Relevant levels of education and training for health occupations according to the
International Standard Classification of Education (ISCED-1997)
Level Name Description Typical duration Complementary dimensions
3 Upper secondary education
Typically begins at the end of full-time compulsory education for those countries that have a system of compulsory education.
Typically requires the completion of some 9 years of full-time education since the beginning of basic (primary) education.
Considerations for classifying this level include type of subsequent education or destination; programme orientation; and cumulative theoretical duration.
Level 3 corresponds to the typical minimum entrance requirement for education and training for a health occupation.
4 Post-secondary non-tertiary education
Programmes that straddle the boundary between upper secondary and post-secondary education from an international point of view, even though they might clearly be considered as upper secondary or post-secondary programmes in a national context.
Typical full-time equivalent duration of between 6 months and 2 years.
May include three programme orientations: (i) general education; (ii) prevocational or pretechnical education; and (iii) vocational or technical education.
Includes adult education (for example, technical courses given during an individual’s professional life on specific subjects).
5 First stage of tertiary education
Tertiary programmes having an advanced educational content (but not leading directly to the award of an advanced research qualification).
Typical full-time equivalent duration of at least 2 years, although some programmes are of 4 or more years.
Programmes usually giving access to occupations with high skills requirements.
Includes programmes leading to a master’s degree.
6 Second stage of tertiary education
Tertiary programmes leading to the award of an advanced research qualification (i.e. entails advanced study and original research, not only coursework).
Very restricted scope at this level.
Source: United Nations Educational, Scientific and Cultural Organization (8).
comprehensive national classifications are not devel-oped, based on an analysis of the descriptions of the content of training programmes. Table 2.3 presents the three-digit details for health-related specializations.
2.3.2 Classification of occupations
Another useful classification system for health workforce analysis is ISCO, developed by the International Labour Organization (10). This system of classification enables jobs to be arranged into a hierarchical system specified according to the precision needed, in major (one-digit level), sub-major (two-digit level), minor (three-digit level) and unit (four-digit level) groups. The basic cri-teria used to define the grouping system are the “skill level” and “skill specialization” required to carry out the tasks and duties of the occupations (6). Skill level refers to the complexity and range of tasks required for the job. Skill specialization is related to the field of knowl-edge required, tools and machinery used, the materials worked on or with and the goods or services produced.
In the most recent version of ISCO, revised in 2008 (known as ISCO-08), the main occupations of inter-est with health care-related specialization fall within two sub-major groups: sub-major group 22, “health professionals” (generally well-trained workers in jobs that normally require a university degree for competent performance); and sub-major group 32, “health associ-ate professionals” (generally requiring knowledge and skills acquired through advanced formal education and training but not equivalent to a university degree).
Health professionals include medical doctors (an occu-pational title used interchangeably with “physicians” in this Handbook), nursing and midwifery professionals, and others such as dentists and pharmacists. Health associate professionals include medical and pharma-ceutical technicians, nursing and midwifery associate professionals and others such as dental assistants, physiotherapy technicians and dispensing opticians (Table 2.4, page 18).
For the earlier version of ISCO (adopted in 1988, or ISCO-88) – against which currently available data were being classified at the time of publication of this Handbook – the relevant information needed to be coded to a degree of detail that minimally corre-sponded to the three-digit level in order for health occupations to be properly identified. Information at the two-digit level did not allow distinction of health occu-pations from other life sciences occuoccu-pations. However, drawing on consultations between the International Labour Organization, WHO and other stakeholders, the newly adopted 2008 version stemmed from the recog-nition that the previous version was outdated in some areas (11).
Most health occupations can be identified at the two-digit or three-two-digit levels of ISCO-08. However, a four-digit code is needed to distinguish practitioner specializations (such as dentists from pharmacists), and also to separately identify some other allied health workers, such as psychologists and social work pro-fessionals, classified in the same minor group as other social scientists, including economists and sociologists.
A significant improvement in ISCO-08 for the purposes of health workforce analysis is the creation of addi-tional unit groups, notably for distinguishing generalist from specialist medical doctors, and for identifying a number of types of allied health workers. For example, a growing number of countries, especially low-income countries with critical shortages of highly skilled medical and nursing professionals, are turning to
“community health workers” – community health aides selected, trained and working in the communities from which they come – to render certain basic health serv-ices (12). This category is specified in ISCO-08 (unit group code 3253).
Another improvement is in the treatment of veterinary occupations. In ISCO-88, veterinary occupations were found in the same minor groups as human health occu-pations; therefore coding was needed at the four-digit level to distinguish veterinarians and veterinary assist-ants. However, in ISCO-08, these two occupational groups are now classified in separate minor groups.
As a result, data disseminated at even the three-digit level will allow human health occupations to be dis-tinguished from veterinary occupations at both the professional and associate professional levels.
Other occupations of interest include managers and personal care workers in health services. In ISCO-08, managers of health and aged care services are separately identified at the four-digit level (unit group codes 1342 and 1343, respectively). “Personal care workers in health services” are identified in a separate minor group (code 532), which includes unit groups for health-care assistants and home-based personal care workers. Information classified according to the previous ISCO-88 was required at the most detailed four-digit level in order to differentiate childcare workers from personal care workers in health services.
Certain documents produced by the International Labour Organization guide countries on how to develop, maintain and revise a national occupation classification and its mapping to the international standard (13, 14).
The most up-to-date information and latest advice can be found on the ISCO web site (10).
Boundaries of the health workforce: definition and classifications of health workers
Table 2.3 Fields of vocational training related to health according to Fields of training manual
Code Field Description
Fields of training directly related to health
721 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.
Programmes with the following main content are classified here: medicine, medical science, medical training. Medical specializations are included here, such as
anaesthesiology, anatomy, cardiology, dermatology, epidemiology, forensic medicine, gerontology, haematology, internal medicine, neurology, obstetrics and gynaecology, oncology, ophthalmology, paediatrics, preventive and social medicine, psychiatry, surgery.
722 Medical services The study of physical disorders, treating diseases and maintaining the physical well-being of humans, using non-surgical procedures.
Training programmes classified here comprise a wide range of services such as ambulance service, chiropractic, hearing aid technology, medical laboratory technology, medical X-ray techniques, nutrition and dietetics, occupational therapy, optometry, orthopaedic prosthetics, emergency paramedical technologies, pharmacy, physiotherapy, radiotherapy, speech pathology and therapy, vocational rehabilitation.
723 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.
Training programmes with the following main content are classified here: assistant nursing, basic nursing, care of old people, care of the disabled, infant hygiene (nursing), midwifery, nursing aide/orderly, psychiatric nursing.
724 Dental studies 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.
Training programmes with the following main content are classified here: clinical dentistry, dental assisting, dental hygiene, dental laboratory technology, dental nursing, dental science, dental surgery, odontology, orthodontics.
Fields of training associated with health 762 Social work and
counselling
The study of the welfare needs of communities, specific groups and individuals and the appropriate ways of meeting these needs. The focus is on social welfare with emphasis on social policy and practice.
Among the training programmes classified here: alcohol and drug abuse counselling, crisis support, social practice, social work (welfare).
850 Environmental protection
The study of the relationships between living organisms and the 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.
Among the training programmes classified here: air pollution control, community sanitation, environmental toxicology, garbage disposal, water pollution control.
862 Occupational health and safety
The study of recognizing, evaluating and controlling environmental factors associated with the workplace.
Among the training classified here: ergonomics (occupational health and safety), health and safety in the workplace, labour welfare (safety), occupational health and industrial hygiene, stress at work.
Source: Adapted from European Centre for the Development of Vocational Training and Eurostat (9).
ISCO-2008ISCO-1988 Group codeOccupational titleGroup codeOccupational title Sub- majorMinor UnitSub- majorMinor Unit 22 Health professionals22Life science and health professionals 221 Medical doctors222Health professionals (except nursing) 2211Generalist medical practitioners 2221Medical doctors 2212Specialist medical practitioners 222 Nursing and midwifery professionals223Nursing and midwifery professionals 2221Nursing professionals2230Nursing and midwifery professionals 2222Midwifery professionals 223Traditional and complementary medicine professionals 2230Traditional and complementary medicine professionals 224 Paramedical practitioners 2240Paramedical practitioners 226 Other health professionals222Health professionals (except nursing) 2261Dentists2222Dentists 2262Pharmacists2224Pharmacists 2263Environmental and occupational health and hygiene professionals 2264Physiotherapists 2265Dieticians and nutritionists 2266Audiologists and speech therapists 2267Optometrists and ophthalmic opticians 2269Health professionals n.e.c.2229Health professionals (except nursing) n.e.c. 32 Health associate professionals31Physical and engineering science associate professionals 321 Medical and pharmaceutical technicians313Optical and electronic equipment operators 3211Medical imaging and therapeutic equipment technicians 3133Medical equipment operators 3212Medical and pathology laboratory technicians 32Life science and health associate professionals 322Modern health associate professionals (except nursing) 3213Pharmaceutical technicians and assistants3228Pharmaceutical assistants 3214Medical and dental prosthetic and related technicians
Table 2.4 Occupational titles related to health according to the International Standard Classification of Occupations (ISCO), 1988 and 2008 revisions Continues…
Boundaries of the health workforce: definition and classifications of health workers
ISCO-2008ISCO-1988 Group codeOccupational titleGroup codeOccupational title Sub- majorMinor UnitSub- majorMinor Unit 322 Nursing and midwifery associate professionals323Nursing and midwifery associate professionals 3221Nursing associate professionals3231Nursing associate professionals 3222Midwifery associate professionals3232Midwifery associate professionals 323Traditional and complementary medicine associate professionals324Traditional medicine practitioners and faith healers 3230Traditional and complementary medicine associate professionals3241Traditional medicine practitioners 325 Other health associate professionals322Modern health associate professionals (except nursing) 3251Dental assistants and therapists3225Dental assistants 3252Medical records and health information technicians 3253Community health workers 3254Dispensing opticians3224Optometrists and opticians 3255Physiotherapy technicians and assistants3226Physiotherapists and related associate professionals 3256Medical assistants3221Medical assistants 3257Environmental and occupational health inspectors and associates3222Sanitarians 3258Ambulance workers 3259Health associate professionals n.e.c.3229Modern health associate professionals (except nursing) n.e.c. 53Personal care workers51Personal and protective workers 532 Personal care workers in health services513 Personal care and related workers 5321Health care assistants5132Institution-based personal care workers 5322Home-based personal care workers5133Home-based personal care workers 5329Personal care workers in health services n.e.c. Additional health-related unit groupsAdditional health-related unit groups 1342Health service managers 1343Aged care service managers 2634Psychologists2445Psychologists 2635Social work and counselling professionals2446Social work professionals 3344Medical secretaries Notes: This table presents an overview of the treatment of health occupations in the 1988 and 2008 versions of ISCO and should not be used for correspondence. Occupations related to the veterinary field are excluded from the thematic view. n.e.c. = not elsewhere classified. Source: International Labour Organization (10).
2.3.3 Classification of branches of economic activity
As mentioned earlier, in addition to health-care service providers, there are many non-health-trained work-ers acting to keep health institutions functioning. It is estimated that about one third of the global health
As mentioned earlier, in addition to health-care service providers, there are many non-health-trained work-ers acting to keep health institutions functioning. It is estimated that about one third of the global health