Further information and comments

This Handbook is part of broader efforts to enhance country capacities to generate, analyse and use data to assess health workforce performance and track progress towards their HRH-related goals. Requests for further information on any of the tools, methods or approaches described here are welcomed. In order to ensure that future revisions of the Handbook are improved and remain responsive to country needs and situations, comments, feedback and sugges-tions are solicited from readers and potential users.

Some specific issues on which feedback are welcome include user-friendliness of the Handbook; feasibility and sustainability of the recommended indicators and related measurement and analysis strategies; and the Handbook’s helpfulness in stimulating country owner-ship and demand for strengthened HRH information, monitoring and evaluation systems.

Please send your questions, comments and feedback to:

Coordinator, Health Workforce Information and Governance

Department of Human Resources for Health World Health Organization

Avenue Appia 20

Geneva 1211, Switzerland Fax: +41–22–791–4747 Email: hrhstatistics@who.int

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Boundaries of the health workforce:

definition and classifications of health workers

DAVID HUNTER, MARIO R DAL POZ, TEENA KUNJUMEN

2.1 Introduction

The health workforce represents one of the key build-ing blocks of health systems and has been identified as a priority for action for strengthening those sys-tems (1). However, international assessments of human resources or other non-monetary inputs to health sys-tems tend to be less widespread than comparisons of health-care expenditures (2). This is in part due to lack of a common framework and adequate data for compar-ative health workforce analysis. Imprecise professional boundaries and differences in defining and categoriz-ing certain types of health workers across much of the world present further challenges in analysing health workforce data. For instance, a “nurse” in one country may be characterized by different educational require-ments, legislation and practice regulations, skills and scope of practice than a “nurse” elsewhere. In order to monitor trends in the health workforce situation across countries or over time, or for countries to share experi-ences and best practices, it is necessary to know how health workers are defined and classified in the original information source (3).

This chapter discusses the definition of the health workforce and its operationalization. Current uses of internationally standardized classifications for statisti-cal delineation, description and analysis of the health workforce are reviewed, and some options for future consideration are outlined.

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

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

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