Implementation of policy and management interventions to improve health and care workforce capacity to address the COVID-19 pandemic response: a systematic review.

BACKGROUND: The COVID-19 pandemic highlighted pre-existing weaknesses in health and care systems and services and shortages of health and care workers (HCWs). As a result, policymakers needed to adopt measures to improve the health and care workforce (HCWF) capacity. This review aims to identify countries' range of policies and management interventions implemented to improve HCWs' capacity to address the COVID-19 pandemic response, synthesize their evidence on effectiveness, and identify gaps in the evidence. METHODS: The literature was searched in PubMed, Embase, Scopus, LILACS-BVS, WHO's COVID-19 Research Database and the ILO, OECD and HSRM websites for literature and documents published between January 2020 and March 2022. Eligibility criteria were HCWs as participants and policy and management interventions aiming to improve HCWF capacity to address the COVID-19 pandemic response. Risk of bias was assessed with Joanna Briggs Institute (JBI) Critical Appraisal Tools (CAT) and certainty of the evidence in presented outcomes with GRADE. RESULTS: The searches retrieved 3378 documents. A total of 69 were included, but only 8 presented outcomes of interventions implemented. Most of the selected documents described at least one intervention implemented by countries at the organizational environment level to increase the flexibility and capacity of the HCWF to respond to the pandemic, followed by interventions to attract and retain HCWs in safe and decent working environments. There was a lack of studies addressing social protection, human resources for health information systems, and regarding the role of community health workers and other community-based providers. Regarding the risk of bias, most of documents were rated as medium or high quality (JBI's CAT), while the evidence presented for the outcomes of interventions was classified as mostly low-certainty evidence (GRADE). CONCLUSIONS: Countries have implemented various interventions, some innovative, in response to the pandemic, and others had their processes started earlier and accelerated by the pandemic. The evidence regarding the impact and efficacy of the strategies used by countries during the pandemic still requires further research.

An experience with the use of WISN tool to calculate staffing in a palliative care hospital in Brazil.

BACKGROUND: The article describes a healthcare staffing exercise that took place in a Cancer Hospital IV, Brazil's first public palliative care unit. There are numerous gaps in the literature on specialized cancer staffing. Palliative care is a therapy modality that should begin with the diagnosis of a chronic disease, at which point the personnel must be technically and numerically adequate, as well as well-distributed, to provide coverage of the population that requires this type of care. METHODS: The WISN tool was chosen after a systematic review of the use of workload studies in palliative care, because it fulfills this objective. The WISN method is based on a health worker's workload, was developed in the late 1990s in the health sector and has been field-tested and implemented in several countries. Direct observation was used as the fieldwork approach, which was carried out by 18 research assistants with the assistance of two supervisors. They monitored 60 professionals in seven categories for 2 weeks on weekdays in the morning and afternoon periods: nursing, pharmacy, physical therapy, medical, nutrition, psychology, and social services. RESULTS: Except for the medical staff, which at the time included additional physicians on loan from a partner institution to address a shortage in this professional group, all categories exhibited overload with WISN ratios ranging from 0.53 to 0.97. The analysis of time spent on individual activities indicated flaws with the services' informal organizations. The authors also noticed a strong emphasis on support activities and a lack of a clear schedule for training and research. The study's findings included a definition of standard activities for each professional group, an analysis and comparison of activities by categories, departments, and work shifts, a standard workload for training and research, and recommendations to include human resources planning as a fundamental part of a national policy for palliative care. CONCLUSIONS: The WISN tool can be used to plan human resources in cancer centers that provide palliative care, and it provides for a variety of analyses that can be combined with other approaches in the literature.

Application of workload indicators to assess the allocation of orthopedists in a national referral hospital in Brazil.

BACKGROUND: The study analyzes the allocation of specialized doctors' orthopedists in a high-complex hospital, using the WHO's Workload Indicators of Staffing Need (WISN) methodology and approach, which measures the workload pressure on the healthcare team (positive, negative, or well-adjusted). METHODS: In the first phase, the hospital's operations and activities were analyzed using the information system. The duration of the tasks performed by the specialist physicians was observed and directly measured in the second phase. Finally, the indicators were analyzed, and the workload was calculated using the WISN application. The measurement was made using the available work time per year divided by the time unit over the previous 12 months. RESULTS: The hand surgery care unit was WISN 1.0 and the ratios for the spine surgery care unit was 1.22, indicating enough physicians and no work overload among the groups surveyed. The ratio in the knee unit was 1.69, indicating that there was an excess of staffing for the workload. CONCLUSION: The workload findings and staffing calculations were useful in supporting and orienting the design and implementation of measures to increase the efficiency and effectiveness of health services.

Interprofessional education in healthcare and health workforce (HRH) planning in Brazil: experiences and good practices.

We report a review of interprofessional education (IPE) for health in Brazil with the objective of identifying experiences and good practices related to the different contexts of changing education and health systems. Our approach is an integrative bibliographic review using surveys and analysis of documents related to IPE in the Virtual Health Library scientific data base. The Brazilian scenario on IPE is still rudimentary, lacking clarity in its definition and scientific progress. Records of successful experiences of IPE and collaborative practices show some growth, with a tendency toward great adherence of professionals, students and teachers in the training model reshuffle. Collaborative practices are strategically used as innovative pedagogical approaches to foster the establishment of integrated teaching-service-community curricula, which coexist with traditional ones. IPE initiatives and collaborative practices have existed in Brazil since the mid-twentieth century. However, the dynamics of training models have not been accompanied by the same pace of change in health services, even under pressure to expand the primary health care (PHC) network and international influence for changes in educational models. The main challenge in this context is to make changes in the three components of training programmes: theoretical orientation, pedagogical approach and scenarios of practices, responding to population health needs and improving people's quality of life.

Internal migration of physicians who graduated in Brazil between 1980 and 2014.

BACKGROUND: The internal migration of physicians from one place to another in the same country can unbalance the supply and distribution of these professionals in national health systems. In addition to economic, social and demographic issues, there are individual and professional factors associated with a physician's decision to migrate. In Brazil, there is an ongoing debate as to whether opening medicine programmes in the interior of the country can induce physicians to stay in these locations. This article examines the migration of physicians in Brazil based on the location of the medical schools from which they graduated. METHODS: A cross-sectional design based on secondary data of 275,801 physicians registered in the Regional Councils of Medicine (Conselhos Regionais de Medicina-CRMs) who graduated between 1980 and 2014. The evaluated outcome was migration, which was defined as moving away from the state where they completed the medicine programme to another state where they currently work or live. RESULTS: 57.3% of the physicians in the study migrated. The probability of migration ratio was greater in small grouped municipalities and lower in state capitals. 93.4% of the physicians who trained in schools located in cities with less than 100,000 inhabitants migrated. Fewer women (54.2%) migrated than men (60.0%). More than half of the physicians who graduated between 1980 and 2014 are in federative units different from the unit in which they graduated. Individual factors, such as age, gender, time of graduation and specialty, vary between the physicians who did or did not migrate. CONCLUSIONS: The probability of migration ratio was greater in small municipalities of the Southeast region and strong in the states of Tocantins, Acre and Santa Catarina. New studies are recommended to deepen understanding of the factors related to the internal migration and non-migration of physicians to improve human resource for health policies.

The utilization of research evidence in Health Workforce Policies: the perspectives of Portuguese and Brazilian National Policy-Makers.

Background: The production of knowledge on Human Resources for Health (HRH) issues has increased exponentially since 2000 but integration of the research in the policy-making process is often lagging. We looked at how research on HRH contributes or not to inform policy decisions and interventions affecting the health workforce in Portugal and Brazil. Methods: We designed a comparative case study of semi-structured interviews with present and past national decision-makers, policy advisors and researchers. Issues explored included the existence of a national HRH policy and the use, or non-use, of research evidence by policy makers and reasons to do so. Interviews were audio recorded, transcribed, anonymized and analysed thematically. Results: Policy-makers in Brazil recognize a greater use of evidence in the process of defining HRH policy when compared to Portugal's. But the existence of formal instruments to support policy development is not sufficient to ensure that policies are informed by evidence. Conclusions: In both countries the importance of the use of evidence in the formulation of policies was recognized by policy-makers. However, the influence of other factors, such as political pressures from various lobby groups and from the media and the policy short timeframe which requires rapid responses, is predominant.

[Human Resources for health policy mapping in Francophone African countries.] / Cartographie des politiques en matière de ressources humaines de la santé en Afrique francophone.

OBJECTIVE: To identify all training, recruitment, deployment and retention programmes for healthcare human resources in five Francophone African countries in order to analyse progress in the authorities' efforts to resolve the problems of human resources for health. METHODS: Analysis of policy processes was based on the University of Wisconsin logical framework approach to identify and describe programmes detailing missions and objectives, and outcome indicators. Data were derived from document analysis and interviews with key resource persons (N = 69). RESULTS: Four main processes were identified: (1) training policies; (2) recruitment interventions; (3) strategies to improve governance by the creation of professional boards; (4) interventions on financial and non-financial incentive mechanisms. Two main groups of countries can be distinguished. One group presents a coherent succession of strategy integration (Burkina Faso, Mali) focusing on training policies to gradually move towards recruitment policies, deployment and incentive mechanisms. The other group presents a rupture of this political process with a return to training policies (Chad, Côte d'Ivoire) and recruitment and deployment policies (Côte d'Ivoire). CONCLUSION: This study highlights the absence of structural reforms to improve health care performance to achieve Universal Health Coverage. A lack of policy impact evaluation and evidence-based data was also observed.

The privatization of medical education in Brazil: trends and challenges.

BACKGROUND: Like other countries, Brazil is struggling with issues related to public policies designed to influence the distribution, establishment, supply and education of doctors. While the number of undergraduate medical schools and places available on medical schools has risen, the increase in the number of doctors in Brazil in recent decades has not benefitted the population homogeneously. The government has expanded the medical schools at the country's federal universities, while providing incentives for the creation of new undergraduate courses at private establishments. This article examines the trends and challenges of the privatization of medical education in Brazil. METHODS: This is a descriptive, cross-sectional study based on secondary data from official government databases on medical schools and courses and institutions offering such courses in Brazil. It takes into account the year when the medical schools received authorization to initiatte the activities, where they are situated, whether they are run by a public or private entity, how many places they offer, how many students they have enrolled, and their performance according to Ministry of Education evaluations. RESULTS: Brazil had 241 medical schools in 2014, offering a total of 20,340 places. The private higher education institutions are responsible for most of the enrolment of medical students nationally (54 %), especially in the southeast. However, enrolment in public institutions predominate more in the capitals than in other cities. Overal, the public medical schools performed better than the private schools in the last two National Exam of Students' (ENADE). CONCLUSION: The privatization of the teaching of medicine at undergraduate level in Brazil represents a great challenge: how to expand the number of places while assuring quality and democratic access to this form of education. Upon seeking to understand the configuration and trends in medical education in Brazil, it is hoped that this analysis may contribute to a broader research agenda in the future.

Assessment of human resources for health programme implementation in 15 Latin American and Caribbean countries.

BACKGROUND: The health systems in the Americas region are characterized by fragmentation and segmentation, which constitute an important barrier to expanding coverage, achieving integrated primary health care, and reducing inefficiency and discontinuity of care. An assessment of the human resources for health (HRH) programmes that have been implemented at the country level was developed as part of the measurement of the 20 HRH regional goals for 2007-2015, adopted in 2007 by the Pan American Sanitary Conference (CSPA). METHODS: The exercise was a combination of academic research and the development/application of an advocacy tool involving policy makers and stakeholders to influence the decision-making in the development, implementation, or change of HRH programmes while building evidence through a structured approach based on qualitative and quantitative information and the exchange and dissemination of best practices. RESULTS: This paper covers the methodological challenges, as well as a summary of the main findings of the study, which included 15 countries: Belize, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua and Panama in the Central America, Dominican Republic in the Caribbean, Chile, Colombia, Ecuador and Peru in the Andean sub region, and Argentina, Paraguay, and Uruguay in the South Cone. Despite the different contexts, the results showed that the programmes evaluated faced common challenges, such as lack of political support and financial unsustainability. CONCLUSIONS: The evaluation process allowed the exchange and dissemination of practices, interventions, and programmes currently running in the region. A shared lesson was the importance of careful planning of the implementation of programmes and interventions. The similarities in the problems and challenges of HRH among the participating countries highlighted the need for a cooperation programme on the evaluation and assessment of implementation strategies in the Americas region.

Posting and transfer: key to fostering trust in government health services.

Appropriate deployment or posting and transfer (P&T) of health workers - placing the right people in the right positions at the right time - lies at the heart of fostering communities' faith in government health services and cementing the role of the health system as a core social institution. The authors of this paper have been involved in an ongoing transnational dialogue about P&T practices and determinants. This dialogue seeks to call attention to the importance of P&T as a health system function; to urge donors and policy-makers working in health systems, HRH and public administration governance to consider how to address issues around P&T; and to suggest avenues and approaches to research. P&T is a vexed and unresolved issue in many low- and middle-income countries that requires, above all, political commitment to improving public sector services and to new thinking and research. It holds promise as a focal point for inter-disciplinary collaboration in research and implementation that can inform other areas in HRH and health systems strengthening. Innovative social science and management theorizing, and iterative, locally driven interventions that focus on establishing transparent professional norms and building the credibility of government administration, including the health services, are likely the way forward.

Monitoring the implementation of the WHO Global Code of Practice on the International Recruitment of Health Personnel.

OBJECTIVE: To present the findings of the first round of monitoring of the global implementation of the WHO Global Code of Practice on the International Recruitment of Health Personnel ("the Code"), a voluntary code adopted in 2010 by all 193 Member States of the World Health Organization (WHO). METHODS: WHO requested that its Member States designate a national authority for facilitating information exchange on health personnel migration and the implementation of the Code. Each designated authority was then sent a cross-sectional survey with 15 questions on a range of topics pertaining to the 10 articles included in the Code. FINDINGS: A national authority was designated by 85 countries. Only 56 countries reported on the status of Code implementation. Of these, 37 had taken steps towards implementing the Code, primarily by engaging relevant stakeholders. In 90% of countries, migrant health professionals reportedly enjoy the same legal rights and responsibilities as domestically trained health personnel. In the context of the Code, cooperation in the area of health workforce development goes beyond migration-related issues. An international comparative information base on health workforce mobility is needed but can only be developed through a collaborative, multi-partnered approach. CONCLUSION: Reporting on the implementation of the Code has been suboptimal in all but one WHO region. Greater collaboration among state and non-state actors is needed to raise awareness of the Code and reinforce its relevance as a potent framework for policy dialogue on ways to address the health workforce crisis.

Policies and Management Interventions to Enhance Health and Care Workforce Capacity for Addressing the COVID-19 Pandemic: Protocol for a Living Systematic Review.

BACKGROUND: Countries and health systems have had to make challenging resource allocation and capacity-building decisions to promote proper patient care and ensure health and care workers' safety and well-being, so that they can effectively address the present COVID-19 pandemic as well as upcoming public health problems and natural catastrophes. As innovations are already in place and updated evidence is published daily, more information is required to inform the development and implementation of policies and interventions to improve health and care workforce capacity to address the COVID-19 pandemic response. OBJECTIVE: The objective of this protocol review is to identify countries' range of experiences with policies and management interventions that can improve health and care workers' capacity to address the COVID-19 pandemic response and synthesize evidence on the effectiveness of the interventions. METHODS: We will conduct a living systematic review of quantitative, qualitative, and mixed methods studies and gray literature (technical and political documents) published in English, French, Hindi, Portuguese, Italian, and Spanish between January 1, 2000, and March 1, 2022. The databases to be searched are MEDLINE (PubMed), Embase, SCOPUS, and Latin American and Caribbean Health Sciences Literature. In addition, the World Health Organization's COVID-19 Research Database and the websites of international organizations (International Labour Organization, Economic Co-operation and Development, and The Health System Response Monitor) will be searched for unpublished studies and gray literature. Data will be extracted from the selected documents using an electronic form adapted from the Joanna Briggs Institute quantitative and qualitative tools for data extraction. A convergent integrated approach to synthesis and integration will be used. The risk of bias will be assessed with Joanna Briggs Institute critical appraisal tools, and the certainty of the evidence in the presented outcomes will be assessed with the Grading of Recommendations, Assessment, Development and Evaluation. RESULTS: The database and gray literature search retrieved 3378 documents. Data are being analyzed by 2 independent reviewers. The study is expected to be published by the end of 2023 in a peer-reviewed journal. CONCLUSIONS: This review will allow us to identify and describe the policies and strategies implemented by countries and their effectiveness, as well as identify gaps in the evidence. TRIAL REGISTRATION: PROSPERO CRD42022327041; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=327041. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/50306.

Human resources for mental health care: current situation and strategies for action.

A challenge faced by many countries is to provide adequate human resources for delivery of essential mental health interventions. The overwhelming worldwide shortage of human resources for mental health, particularly in low-income and middle-income countries, is well established. Here, we review the current state of human resources for mental health, needs, and strategies for action. At present, human resources for mental health in countries of low and middle income show a serious shortfall that is likely to grow unless effective steps are taken. Evidence suggests that mental health care can be delivered effectively in primary health-care settings, through community-based programmes and task-shifting approaches. Non-specialist health professionals, lay workers, affected individuals, and caregivers with brief training and appropriate supervision by mental health specialists are able to detect, diagnose, treat, and monitor individuals with mental disorders and reduce caregiver burden. We also discuss scale-up costs, human resources management, and leadership for mental health, particularly within the context of low-income and middle-income countries.

The mental health workforce gap in low- and middle-income countries: a needs-based approach.

OBJECTIVE: To estimate the shortage of mental health professionals in low- and middle-income countries (LMICs). METHODS: We used data from the World Health Organization's Assessment Instrument for Mental Health Systems (WHO-AIMS) from 58 LMICs, country-specific information on the burden of various mental disorders and a hypothetical core service delivery package to estimate how many psychiatrists, nurses and psychosocial care providers would be needed to provide mental health care to the total population of the countries studied. We focused on the following eight problems, to which WHO has attached priority: depression, schizophrenia, psychoses other than schizophrenia, suicide, epilepsy, dementia, disorders related to the use of alcohol and illicit drugs, and paediatric mental disorders. FINDINGS: All low-income countries and 59% of the middle-income countries in our sample were found to have far fewer professionals than they need to deliver a core set of mental health interventions. The 58 LMICs sampled would need to increase their total mental health workforce by 239,000 full-time equivalent professionals to address the current shortage. CONCLUSION: Country-specific policies are needed to overcome the large shortage of mental health-care staff and services throughout LMICs.

Priorities for research into human resources for health in low- and middle-income countries.

OBJECTIVE: To identify the human resources for health (HRH) policy concerns and research priorities of key stakeholders in low- and middle-income countries; to assess the extent to which existing HRH research addresses these concerns and priorities; and to develop a prioritized list of core research questions requiring immediate attention to facilitate policy development and implementation. METHODS: The study involved interviews with key informants, including health policy-makers, researchers and community and civil society representatives, in 24 low- and middle-income countries in four regions, a literature search for relevant reviews of research completed to date, and the assessment of interview and literature search findings at a consultative multinational workshop, during which research questions were prioritized. FINDINGS: Twenty-one research questions emerged from the key informant interviews, many of which had received little or no attention in the reviewed literature. The questions ranked as most important at the consultative workshop were: (i) To what extent do incentives work in attracting and retaining qualified health workers in underserviced areas? (ii) What is the impact of dual practice and multiple employment? and (iii) How can incentives be used to optimize efficiency and the quality of health care? CONCLUSION: There was a clear consensus about the type of HRH policy problems faced by different countries and the nature of evidence needed to tackle them. Coordinated action to support and implement research into the highest priority questions identified here could have a major impact on health worker policies and, ultimately, on the health of the poor.

Sub-national assessment of inequality trends in neonatal and child mortality in Brazil.

OBJECTIVE: Brazil's large socioeconomic inequalities together with the increase in neonatal mortality jeopardize the MDG-4 child mortality target by 2015. We measured inequality trends in neonatal and under five mortality across municipalities characterized by their socio-economic status in a period where major pro poor policies were implemented in Brazil to infer whether policies and interventions in newborn and child health have been successful in reaching the poor as well as the better off. METHODS: Using data from the 5,507 municipalities in 1991 and 2000, we developed accurate estimates of neonatal mortality at municipality level and used these data to investigate inequality trends in neonatal and under five mortality across municipalities characterized by socio-economic status. RESULTS: Child health policies and interventions have been more effective in reaching the better off than the worst off. Reduction of under five mortality at national level has been achieved by reducing the level of under five mortality among the better off. Poor municipalities suffer from worse newborn and child health than richer municipalities and the poor/rich gaps have increased. CONCLUSION: Our analysis highlights the importance of monitoring progress on MDGs at sub-national level and measuring inequality gaps to accurately target health and inter-sectoral policies. Further efforts are required to improve the measurement and monitoring of trends in neonatal and under five mortality at sub-national level, particularly in developing countries and countries with large socioeconomic inequalities.

A realist synthesis of randomised control trials involving use of community health workers for delivering child health interventions in low and middle income countries.

BACKGROUND: A key constraint to saturating coverage of interventions for reducing the burden of childhood illnesses in Low and Middle Income Countries (LMIC) is the lack of human resources. Community health workers (CHW) are potentially important actors in bridging this gap. Evidence exists on effectiveness of CHW in management of some childhood illnesses (IMCI). However, we need to know how and when this comes to be. We examine evidence from randomized control trials (RCT) on CHW interventions in IMCI in LMIC from a realist perspective with the aim to see if they can yield insight into the working of the interventions, when examined from a different perspective. METHODS: The realist approach involves educing the mechanisms through which an intervention produced an outcome in a particular context. 'Mechanisms' are reactions, triggered by the interaction of the intervention and a certain context, which lead to change. These are often only implicit and are actually hypothesized by the reviewer. This review is limited to unravelling these from the RCTs; it is thus a hypothesis generating exercise. RESULTS: Interventions to improve CHW performance included 'Skills based training of CHW', 'Supervision and referral support from public health services', 'Positioning of CHW in the community'. When interventions were applied in context of CHW programs embedded in local health services, with beneficiaries who valued services and had unmet needs, the interventions worked if following mechanisms were triggered: anticipation of being valued by the community; perception of improvement in social status; sense of relatedness with beneficiaries and public services; increase in self esteem; sense of self efficacy and enactive mastery of tasks; sense of credibility, legitimacy and assurance that there was a system for back-up support. Studies also showed that if context differed, even with similar interventions, negative mechanisms could be triggered, compromising CHW performance. CONCLUSION: The aim of this review was to explore if RCTs could yield insight into the working of the interventions, when examined from a different, a realist perspective. We found that RCTs did yield some insight, but the hypotheses generated were very general and not well refined. These hypotheses need to be tested and refined in further studies.

Characteristics and trends in the expansion of private dental schools in Brazil.

OBJECTIVE: This article describes and analyses the characteristics of the expansion of private dental education in Brazil from 1996 to December 2018 and its relationships with public policies and the country's labour and education market in dentistry. METHOD: The study used an exploratory and descriptive quantitative approach involving standardised data-collection techniques from open-access secondary databases. RESULT: From 1996 to 2018 there was an overall increase of 315% in dental schools (582% in the private sector and 49% in the public sector). Brazil had 374 dental schools in December 2018, 307 of which were private and 67 of which were public. The 374 schools offered 47,192 admission places, 89% of which were private. In five states, dental education is 100% private, while in another 19 states the private supply exceeds 70% of the total. In the other three states this offer is between 40% and 67%. From 1996 to 2016, the private sector's share of dental school graduates was 66%. Women represented 73% of Brazilian dental-school graduates in 2016. CONCLUSION: Privatisation of dental education in Brazil raises challenges for the development of policies, planning, organisation of care, and structuring of the training process for dentists, as well as the dynamics of the labour market in the health system.

The health worker shortage in Africa: are enough physicians and nurses being trained?

OBJECTIVE: To estimate systematically the inflow and outflow of health workers in Africa and examine whether current levels of pre-service training in the region suffice to address this serious problem, taking into account population increases and attrition of health workers due to premature death, retirement, resignation and dismissal. METHODS: Data on the current numbers and types of health workers and outputs from training programmes are from the 2005 WHO health workforce and training institutions' surveys. Supplementary information on population estimates and mortality is from the United Nations Population Division and WHO databases, respectively, and information on worker attrition was obtained from the published literature. Because of shortages of data in some settings, the study was restricted to 12 countries in sub-Saharan Africa. FINDINGS: Our results suggest that the health workforce shortage in Africa is even more critical than previously estimated. In 10 of the 12 countries studied, current pre-service training is insufficient to maintain the existing density of health workers once all causes of attrition are taken into account. Even if attrition were limited to involuntary factors such as premature mortality, with current workforce training patterns it would take 36 years for physicians and 29 years for nurses and midwives to reach WHO's recent target of 2.28 professionals per 1000 population for the countries taken as a whole--and some countries would never reach it. CONCLUSION: Pre-service training needs to be expanded as well as combined with other measures to increase health worker inflow and reduce the rate of outflow.