Nursing World S: Investing in Education, Jobs and Leadership

S TAT E O F T H E
WORLDʼS
NURSING 2020
Investing in education,
jobs and leadership
S TAT E O F T H E
2020
jobs and leadership
State of the world's nursing 2020: investing in education, jobs and leadership.
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CONTENTS
Foreword. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
Message from the Co-Chairs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii
Contributors and acknowledgements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x
Executive summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
CHAPTER 1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
CHAPTER
2 Nursing in a context of broader workforce and health priorities. . . . . . . . . . . . . 5
2.1 Role of the health workforce in achieving the 2030 Agenda . . . . . . . . . . . . . . . . . . . 5
2.2 Who is a nurse? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
CHAPTER
3 Nursing roles in 21st-century health systems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
3.1 Role of nursing in achieving universal health coverage. . . . . . . . . . . . . . . . . . . . . . . 11
3.2 Role of nursing in dealing with emergencies, epidemics and disasters. . . . . . . . . . 15
3.3 Role of nursing in achieving population health and well-being. . . . . . . . . . . . . . . . . 16
CHAPTER
4 Policy levers to enable the nursing workforce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
4.1 Pre-service education and training. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
4.2 Workforce inflows and outflows. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
4.3 Equitable distribution and efficiency. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
4.4 Regulation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
CHAPTER
5 Current status of evidence and data on the nursing workforce. . . . . . . . . . . . . . 35
5.1 Nursing workforce availability, composition and distribution . . . . . . . . . . . . . . . . . . 37
5.2 Equity in availability of and access to the nursing workforce. . . . . . . . . . . . . . . . . . 43
5.3 International nurse migration and mobility. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
5.4 Regulation of nursing education and practice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
5.5 Education and nursing workforce supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
5.6 Regulation of employment and working conditions. . . . . . . . . . . . . . . . . . . . . . . . . 55
5.7 Governance and leadership. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59
5.8 Assessing the current trajectory towards 2030 SDG outcomes . . . . . . . . . . . . . . . 61
CHAPTER 6 Future directions for nursing workforce policy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

6.1 Strengthening the evidence base for planning, monitoring and accountability. . . . . 68
6.2 Mobility and migration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
6.3 Developing and supporting the nursing workforce. . . . . . . . . . . . . . . . . . . . . . . . . . 72
6.4 Building institutional capacity and leadership skills for effective governance. . . . . . 82
6.5 Catalysing investment for the creation of nursing jobs. . . . . . . . . . . . . . . . . . . . . . . 84
6.6 Research and evidence agenda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
CHAPTER
7 Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Annex 1. Who is a nurse?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Annex 2. Methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
Web Annex. Nursing roles in 21st-century health systems
https://apps.who.int/iris/bitstream/handle/10665/332852/9789240007017-eng.pdf
Contents iii
Tables
5.1 Number of nurses globally and density per 10 000 population, by WHO region, 2018 . . . . . . . . . . . . . 38
5.2 Changes in nursing stock due to better data and actual increase between 2013 and 2018 . . . . . . . . . 38
5.3 urses as a percentage of health professionals (medical doctors, nurses,
N
midwives, dentists and pharmacists), by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
5.4 Percentage of female nursing personnel, by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
5.5 Density of nursing personnel per income group (2018) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
5.6 Percentage of nursing personnel foreign born (or foreign trained) per income group . . . . . . . . . . . . . . 48
5.7 P ercentage of responding countries reporting existence of nursing regulations on
education and training, by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
5.8 Production of graduate nurses, by WHO region and income group . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
5.9 P ercentage of countries responding on existence of nursing regulations on
working conditions, by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
5.10 Leadership and governance indicators: percentage of countries with chief nursing
officer position and nursing leadership development programme, by WHO region . . . . . . . . . . . . . . . . 60
5.11 Simulation of projected stock of nursing personnel from 2018
to 2030 under three scenarios, by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
A2.1 List of 36 indicators used for the State of the world’s nursing 2020 report . . . . . . . . . . . . . . . . . . . . . 111
A2.2 Estimates of shortage of nursing personnel (millions) in countries below
the Global Strategy threshold by income level: 2018 and 2030 (three scenarios) . . . . . . . . . . . . . . . . 116
Boxes
3.1 Nursing contribution to patient safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
3.2 Nurse-led model of community care for ageing populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
4.1 Australia: engaging underrepresented populations in the nursing workforce . . . . . . . . . . . . . . . . . . . . 21
4.2 Cost of nursing education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
4.3 Addressing the shortage of nurse educators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
4.4 Global skills partnerships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
4.5 Examples of economic demand for nurses in high-income countries . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
4.6 Expanding access via nurse prescribing in Poland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
4.7 Example of a specialist nursing role in the African Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
4.8 Rural retention guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
4.9 Examples of harmonization of education standards and licensure examination . . . . . . . . . . . . . . . . . . 33
5.1 Equity within countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
6.1 Scotland health labour market analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
6.2 E ast, Central and Southern African Health Community: national collaboration on
nursing data reporting using NHWA indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
6.3 Germany’s approach to managing migration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
6.4 Technology in nursing education and practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
6.5 Pakistan efforts to increase nurse education capacity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
6.6 Expanding access to community health services in Oman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
6.7 African Health Profession Regulatory Collaborative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
6.8 Health worker strikes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
6.9 Leadership fellowship in the Western Pacific Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
6.10 Investing in human capital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
A1.1 ISCO definitions of nursing personnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
iv
Figures
1. Density of nursing personnel per 10 000 population in 2018 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
2. Relative proportions of nurses aged over 55 years and below 35 years (selected countries) . . . . . . . . xiv
3. Projected increase (to 2030) of nursing stock, by WHO region and by country income group . . . . . . . xv
4. Average duration (years) of education for nursing professionals, by WHO region . . . . . . . . . . . . . . . xvi
5. Percentage of countries with regulatory provisions on working conditions . . . . . . . . . . . . . . . . . . . . xvii
6. Percentage of female and male nursing personnel, by WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . xx
2.1 Global Strategy on Human Resources for Health: strategic objectives and relevance for nursing . . . . . 7
2.2 Number of distinct nursing titles within each WHO region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
3.1 Nursing contribution to the triple billion targets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
4.1 Public policy levers to shape health labour markets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
5.1 Number of countries with workforce data available in the WHO NHWA (1990–2018) . . . . . . . . . . . . . 36
5.2 Proportion of nursing headcount within each occupation group, by WHO region . . . . . . . . . . . . . . . . . 40
5.3 Percentage of nursing personnel aged below 35 years and 55 years or over, by WHO region . . . . . . . 41
5.4 Relative proportions of nurses aged over 55 years and below 35 years . . . . . . . . . . . . . . . . . . . . . . . . 42
5.5 Density of nursing personnel per 10 000 population in 2018 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
5.6 Regional disparities in density of nursing personnel per 10 000 population (2018) . . . . . . . . . . . . . . . . 44
5.7 Density of nursing personnel per 10 000 population by income group (2018) . . . . . . . . . . . . . . . . . . . . 45
5.8 P ercentage of responding countries indicating existence of nursing
regulations and standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
5.9 Map of nursing education regulation scores, by country . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
5.10 Average duration (years) of education for nursing professionals, by WHO region . . . . . . . . . . . . . . . . 54
5.11 Percentage of countries with regulatory provisions on working conditions . . . . . . . . . . . . . . . . . . . . . 56
5.12 Map of regulation of working conditions score . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
5.13 Percentage of countries with advanced nursing role by level of density of medical
doctors per 10 000 population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
5.14 Association between GCNO and nursing leadership programme
and the regulatory environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
5.15 Projection of nursing personnel density per 10 000 population in 2030 (global distribution) . . . . . . . . 62
5.16 Projected increase (to 2030) of nursing stock, by WHO region and by country income group . . . . . . . 63
5.17 Estimation of shortages of nursing workforce in 2013, 2018 and 2030 . . . . . . . . . . . . . . . . . . . . . . . . . 64
A2.1 Number of indicators reported globally for the State of the world’s nursing 2020 report . . . . . . . . . . 112
A2.2 Correlation of education indicators with a multiple correspondence analysis . . . . . . . . . . . . . . . . . . 113
A2.3 Correlation of working condition indicators with a multiple correspondence analysis . . . . . . . . . . . . 114
A2.4 Evolution of global nursing stock (millions) under a “business as usual”scenario
and three “increased production of graduate nurses” scenarios, 2018 to 2030 . . . . . . . . . . . . . . . . . 115
Contents v
Investment in nurses
will contribute not
only to health-related
SDG targets, but also
to education (SDG 4),
gender (SDG 5),
Tedros Ghebreyesus
decent work Director-General, WHO
and economic
growth (SDG 8).
Elisabeth Iro
Chief Nursing Officer, WHO
Annette Kennedy
President
International Council of Nurses
Sheila Tlou
Co-Chair, Nursing Now
Nigel Crisp
Co-Chair, Nursing Now
ISBN 978-92-4-000329-3 (electronic version)

ISBN 978-92-4-000330-9 (print version)
© World Health Organization 2020. Some rights reserved.

This work is available under the CC BY-NC-SA 3.0 IGO licence.
Cover images
Row 1 (left to right): © Vladimir Gerdo/TASS via Getty, © Irene R. Lengui/L’IV Com, © Tanya Habjouqa
Row 2 (left to right): © Jaime S. Singlador/Photoshare, © AKDN/Christopher Wilton-Steer
vi State of the world’s nursing 2020
SDG 3
FOREWORD
The State of the world’s nursing 2020: investing in education, jobs and leadership
comes as the world witnesses unprecedented political commitment to universal
health coverage. At the same time, our emergency preparedness and response
capacity is being tested by the current COVID-19 outbreak and mass population
displacement caused by confl ict. Nurses provide vital care in each of these
circumstances. Now, more than ever, the world needs them working to the full
extent of their education and training.
SDG 4
This first State of the world’s nursing report reveals much to celebrate about the
nursing workforce. Opportunities for advanced nursing education and enhanced
professional roles, including at the policy level, can drive improvements in
population health. At the same time, we continue to see vast inequities in the
distribution of nurses around the world which we must address.
2020 is the International Year of the Nurse and the Midwife. This is an opportunity
to leverage the evidence in the State of the world’s nursing 2020 report and commit
5
to an agenda that will drive and sustain progress to 2030. To this end, we urge
governments and all relevant stakeholders to:
SDG
• invest in the massive acceleration of nursing education – faculty, infrastructure
and students – to address global needs, meet domestic demand, and respond to
changing technologies and advancing models of integrated health and social care;
• create at least 6 million new nursing jobs by 2030, primarily in low- and middle-
income countries, to offset the projected shortages and redress the inequitable
distribution of nurses across the world;
• strengthen nurse leadership – both current and future leaders – to ensure that
nurses have an influential role in health policy formulation and decision-making,
and contribute to the effectiveness of health and social care systems.
All countries can take action in support of this agenda. Most countries can accomplish
these actions with their own resources. For countries requiring assistance by the
international community, we must direct a growing share of human capital
investments into the health and social care economy. Such investments will also
drive progress across the Sustainable Development Goals, with dividends for
gender equity, women’s economic empowerment and youth employment.
Let us seize this opportunity to commit to a decade of action that begins with
investing in nursing education, jobs and leadership.
SDG 8
Foreword vii
Message from the Co-Chairs
The Seventy-second World Health Assembly designated 2020 as the International Year of the Nurse
and the Midwife not only to honour the 200th anniversary of the birth of Florence Nightingale, but
also to recognize the daily contributions of nurses and midwives to the health and well-being of
populations across the globe.
With a global spotlight on nurses in the context of the COVID-19 pandemic, we are honoured to
present the first ever State of the world's nursing report on World Health Day. This report provides
the most up-to-date evidence and cutting-edge policy options on the global nursing workforce. It
also presents a compelling case for considerable – yet feasible – investment in nursing education,
jobs, and leadership, which is required to strengthen the nursing workforce to deliver the
Sustainable Development Goals, improve health for all, and strengthen the primary health care
workforce on our journey towards universal health coverage.
The State of the world’s nursing 2020 report resulted from remarkable national-level collaboration.
In many countries, the drive for data reporting was led by the government chief nursing and
midwifery officers, who were supported by the provision of data from ministries of education,
labour and finance. Nurse educators and regulators shared and triangulated data. National nursing
associations and Nursing Now groups played key advocacy roles in reporting and engagement
on the issues that would be addressed in the report. These relationships are critical to robust and
routine reporting on nursing and will facilitate even stronger reports in the future.
What we have achieved together is impressive. But what we are yet to achieve is vastly more
important. We must use the national, regional and global data and the International Year of
the Nurse and the Midwife to foster closer dialogue and collaboration between all sectors on
strengthening the workforce to better provide primary care and progress towards universal health
coverage. We must catalyse and sustain investments in nursing education, jobs and leadership.
The health of the world requires the commitment of all countries to support and invest in the
nursing workforce. We hope you will join this call to action.
James Campbell Howard Catton Mary Watkins

Director Chief Executive Officer Alternate Co-Chair
Health Workforce Department International Council of Nurses Nursing Now
World Health Organization
viii State of the world’s nursing 2020

Contributors and acknowledgements
STEERING COMMITTEE Nkosinathi R. Nkwanyana, Claudine Diango Nobou, Cassoma Pedro Norberto,
Co-Chairs: Howard Catton, Mary Watkins Olga Novela, Emmanuel Ntawuyirusha, Titi Nelly Nthabana, Paul Nyachae,
Members: Sultana N. Afdhal, Sumaya Mohamed Al-Blooshi, David Benton, Martinho Ogedge, Francisca Okafor, Petua Kiboko Olobo, Yacouba Ouedraogo,
Sharon Brownie, Peter Johnson, Francisca Okafor, Nancy Reynolds, Jacob Pooda, Tarloh Quiwonkpa, Noudjalta Remadji, Bagnou Sahia, Dawda
Debra Thoms, Elizabeth Iro (ex officio), James Campbell (ex officio) Samateh, Rigbe Samuel, Nené Catirona Sanca, Ekan Ndi Sandrine, Mwila
Sekeseke, Malick Seydi, Moibah Sheriff, Tulipoka Soko, Repent Khamis George
WORLD HEALTH ORGANIZATION Stephen, Yao Theodore, Justin Tiendrebeogo, Francina Tjituka, Teklu Tsegay,
Lead authors: Carey McCarthy, Mathieu Boniol, Karen Daniels, Nkala Victorine, Solomon Woldeamanuel, Ambrose Wreh, Jacky Yabili, Issa Yahaya,
Giorgio Cometto, Khassoum Diallo, An'war Deen Lawani, James Campbell Nasir Yama, Barnabas Yeboah, Rabesata Juste Yolande
Administrative support: Beatrice Wamutitu, Elizabeth Tecson
Contributors: Jonathan Abrahams, Adam Ahmat, Onyema Ajuebor, Region of the Americas
Benedetta Allegranzi, Avni Amin, Georgina Arroyo, James Asamani, Ian Maria Lucia Aicardi, Ramon Abrego, Sofía Achucarro, Asif Ali, Augustina
Askew, Sofonias Getachew Asrat, Shamsuzzoha Babar Syed, Rachel Baggaley, Ambrose-Popo, Dennis Israel Anas Morales, Jennifer Andall, Elizabeth Anderson,
Valentina Baltag, Ana Pilar Betran Lazaga, Melisssa Bingham, Moussa Bizo, John Francisco Ariza Montoya, Joy Arnell, Sandra Barrow, Lianne Bellisario,
Nancy Bolan, Carolyn Brody, Lugemba Budiaki, Richard Carr, Silvia Cassiani, Luis Gabriel Bernal Pulido, Shellon Bess, Irma Bois, Rafael Borda, Jennifer Breads,
Alessandro Cassini, Jorge Castilla Echenique, Paula Cavalcante, Momodou Leonardo Brito, Silvia Brizuela, Hazel Brown, Robin Buckland, Rodrigo Castro,
Ceesay, Peter Cowley, Vânia de la Fuente-Núñez, Ibadat Dhillon, Neelam Kerthney Charlemagne-Surage, Andrei Chell, Alba Consuelo Flores, Alberto Cosme
Dhingra-Kumar, Linda Doull, Nathalie Drew Bold, Tarun Dua, James Fitzgerald, Lopes de Souza, Hernando Cubides, Natalie Cueppens, Lerivan da Silva,
Siobhan Fitzpatrick, Helga Fogstad, Nathan Ford, Pierre Formenty, Dongbo Fu, Gaye Davies, Carolina de Bass, Gina Dean, Marcos del Risco del Río, Nester
Claudia Garcia-Moreno, Fethiye Gulin Gedik, Regina Guthold, Indrajit Hazarika, Edwards, Fulvia Elizondo Sibaja, Juliana Ferreira Lima Costa, Evelin Flores de Nieto,
Pascale Heilberg, Albert Mohlakola Hlabana, Lisa Hoffmann, Aboubacar Janett Flynn, Mireye Fuentes, Luis Felipe Garcia Ruano, Rosa George,
Inoua, Gabrielle Jacob, Manoj Jhalani, Rita Kabra, Mikiko Kanda, Ruth Kanyiru, Claudia Godoy, Cristian González Opelt, Zaila González Vivo, Stacie Goring,
Aminata Sakho Kelly, James Kiarie, Hyo Jeong Kim, Teena Kunjumen, Ivette Cataline Grijalva Saenz, Norka Rocio Guillen Ponce, Jascinth Hannibal,
Etienne Langlois, Anais Legand, Ornella Lincetto, Francis Magombo, Sharon Harper, Carla Harry, Gustavo Hoff, Gail Hudson, Brenda Jeffers,
Mary Manandhar, Karifa Mara, Regis Antoine Mbary-Daba, Frances McConville, Linda Johnson, Claudia Leija Hernandez, Lisa Little, Javier Cesar Loayza Tamirano,
Michelle McIsaac, Hedieh Mehrtash, Nabil Menasria, Nana Mensah-Abrampah, Howard Lynch, Marcelo Marques, Diana Isabel Martinez Changuan, Ithinnia
Jean Jacques Salvador Millogo, Ann-Beth Moller, Margaret Montgomery, Martinez Mora, Jacqueline Matthew-Fevrier, Ann Matute, Lynn McNeely,
Ashley Moore, Manjulaa Narasimhan, Stephanie Ngo, Susan Norris, Thameshwar Merai, Fernando Munar Jimenez, Karen Nelson, Kerry Nesseler,
Ian Norton, Stephen Nurse-Findlay, Jennifer Nyoni, Asiya Odugleh-Kolev, Mirna Nobrega, Susan Orsega, Bete Paz, Emiliana Peña, Juan Lucas Pereyra,
Alana Officer, Mie Okamura, Sunny Okoroafor, Olufemi Oladapo, Carolina Walter Perez Lazaro, Pauline Peters, Betty Ann Pilgrim, Enma Porras Marroquin,
Omar, Zoe Oparah, Arwa Oweis, Monica Padilla, Edith Pereira, Silvia Perel Jorge Ramanho, Jason Roffenbender, Desreen Silcott, Margaret Smith, Tiago
Levin, Vladimir Poznyak, Vinayak Mohan Prasad, Jacqui Reilly, Preyanka Relan, Souza, Delores Stapleton Harris, Jackurlyn Sutton, Aldira Samantha Teixeira,
Teri Reynolds, Paul Rogers, David Ross, Aurora Saares, Salim Sadruddin, Silvia Tejada, Roody Thermidor, Camille Thomas-Gerald, Kc Dianne Torres Quintero,
Begoña Sagastuy, Farba Lamine Sall, Diah Saminarsih, Julia Samuelson, Pedro Diaz Urteaga, Carlos Valli, Alessandro Vasconcelos, Auristela Vasquez,
Alison Schafer, Cris Scotter, Justin Adanmavokin Sossou, Susan Sparks, Jeaneth Vega Chavez
Simone Marie St Claire, Julie Storr, Tigest Tamrat, Ai Tanimizu, Martin Taylor,
Nuria Toto Polanco, Prosper Tumusime, Özge Tunçalp, Anthony Twyman, South-East Asia Region
Nicole Valentine, Mark Van Ommeren, Cherian Varghese, Gemma Vestal, Leela Adhikari, Kimat Adhikari, Sabina Alam, Ahlaam Ali, Nan Nan Aung,
Marco Vitoria, Victoria Willet, Masahiro Zakoji, Tomas Zapata Lopez Hla Hla Aye, Rathi Balachandran, Alam Ara Begum, Norberta Belo, K. S.
Bharati, Vinay Bothra, Jermias da Cruz, Atul Dahal, Dileep De Silva, Padmal De
Silva, Apriyanti Shinta Dewi, Maria Dolores Castello, Aminath Fariha Mohamed,
CONTRIBUTORS TO EVIDENCE REVIEW
Horacio Fernandes Ribeiro, Harindarjeet Goyal, Nalika Gunawardena,
Thomas Alvarez, Sarah Abboud, Neeraj Agrawal, Chantelle Allen,
Anil Kumar Gupta, Htay Htay Hlaing, Fathimath Hudha, Aneega Ibrahim,
António Fernando Amaral, Bethany Arnold, Mukul Bakhshi, Myra Betron,
Sugeng Eko Irianto, Aishath Irufa, Uraiporn Janta-um-mou, Shivangini Kar
Aurelija Blaževičienė, Julia Bluestone, Jo Booth, Debora Bossemeyer,
Dave, RADC Karunaratne, Daw Nwe Nwe Khin, Thitipat Kuha, Daw Khin Ma
Irma Brito, Erica Burton, Kenrick Cato, Scholastica Chibehe, Marie Clarisse,
Ma Kyaw, Khin Mar Kyi, Sirima Leelawong, Buddhika Loku Balasuriyage,
Kay Currie, Sheena Currie, Francois-Xavier Daoudal, Annette de Jong,
Hussain Maaniu, Dilip Mairembam, Daw Yin Mya, Kavita Narayan, Thinakorn
Ana de la Osada, Jennifer Dohrn, Jo-Ann Donner, Manya Dotson, Helen Du Toit,
Noree, Md Nuruzzaman, Kyaw Soe Nyunt, Tandin Pemo, Wichavee
Christine Duffield, Kamal Eldeirawi, Lawrie Elliot, Maria Engström,
Ploysongsri, Pooja Pradhan, Ms Rahmath, Mariyam Rasheed, Tomasia
Diana Estevez, Cherrie Evans, Betty Ferrell, Laura Fitzgerald, Ann Gardulf,
Ana Marioa do Rosario e Souza, Joao Noronha Roy, Bhim Prasad Sapkota,
Nancy Glass, Claire Glenton, Patricia Gomez, Deb Grant, Meghan Greeley,
Teeraporn Sathira-Angkura, Tini Setiawan, Mariyam Shafeeq, Mohammad
Doris Grinspun, Valerie A. Gruss, Mark Hathaway, Karen Heaton, Aisha
Shahjajan, Jayendra Sharma, May Thwel Hla Shwe Alaka Singh, Sasamon
Holloway, Melissa Hozjan, Anne Hradsky, Tonda Hughes, Carol Huston,
Srisuthisak, Rattanaporn Tangthanaseth, Roshani Tui Tui, Fikru Tesfaye Tullu,
Anne Hyre, Darlene Irby, Brigitte Ireson-Valois, Susan Jacoby, Krista Jones, Liviu Vedrasco, Nani Hidayanti Widodo, Panarut Wisawatapnimit, Sonam
Rosemary Kamunya, Joyce Kenkre, Jarmila Kliescikova, Tamara Kredo, Yangchen
Margrieta Langins, Margret Lepp, Isabelle Lessard, Simon Lewin, Ricky Lu,
Jill Maben, Elizabeth Madigan, Andrea Marelli, Adelais Markaki, Mokgadi
European Region
Matlakala, Donna McCarthy Beckett, Sonja McIlfatrick, Susan Munabi-
Aizat Asanova, Angel Abad Bassols, Zaza Bokhua, Ayşe Boysan,
Babigumira, Dawn Munro, Angeline Mutenga, Khine Haymar Myint,
Matt Edwards, Anastasia Gazheva, Shoshy Goldberg, Rivka Hazan Hazoref,
Madeline A Naegle, Edgar Necochea, Wendy Nicholson, Jan Nilsson,
Jacques Huguenin, Natalia Kamynina, Kristin Klein, Sergiu Otgon, Marija
Lisa Noguchi, Shelley Nowlan, Araceli Ocampo-Balabagno, Johis Ortega,
Palibrk, Cecilija Rotim, Vasos Scoutellas, Jesmond Sharples, Artūras Šimkus
Jane Otai, Piret Paal, Anne Pfitzer, Lusine Poghosyan, Zamira Rahmonova,
Amelia Ranotsi, Veronica Reis, Jim Ricca, Chandrakant Ruparelia, Marla Salmon,
Eastern Mediterranean Region
Jane Salvage, Diana Schmalkuche, Franklin Shaffer, Judith Shamian, Bongi
Anmal Abu Awad, Alawia Ahmad, Mohammad Alghamdy, Mohamed Bahadi,
Sibanda, Jennifer Snyder, Suzanne Stalls, Stacie Stender, Barbara Stillwell,
Kamran Baig, Omar Cherkaoui, Ishraga Elbashier, Kawther Mahmoud,
Sheryl Stogis, Luisa Strani, Hannah Tappis, Gaudencia Tibaijuka,
Fouzia Mushtaq, Nathalie Richa, Anmal Swaid Salim, Mohammed Tarawneh,
Vicky Treacy-Wong, Erica Troncosco, Annukka Tuomikoski, Paul Tuthill,
Nasir Yama, Lubna Yaqoob
Carlos Van der Laat, Tener Goodwin Veenema, Meggy Verputten,
Isabelle Vioret, Cynthia Vlasich, Jamie Waterall, Jean White, Jill White,
Barbara Wienkamp-Weber, Tegbar Yigzaw
Western Pacific Region
Amelia Afuha'amango, Lele Ah Mu, Thelma Ali, Carter Apaisam,
Jasmin Mohamed Ariff, Margareth Broodkoorn, Moralene Capelle,
CONTRIBUTORS TO DATA REPORTING AND ANALYSIS
Teofila Cruz, Ervina Hj Emran, Louisa Helgenberger, Seungryeong Hong, Mary
WHO wishes to acknowledge all National Health Workforce Accounts focal points,
Kata, Asena Kauyaca, Mary Kililo Samor, Virya Koy, Hillia Langrine, Michael
government chief nursing and midwifery officers, Novametrics (Martin Boyce,
Larui, Margaret Leong, Fuatai Maiava, Antonnette Merur, Helen Murdoch,
Andrea Nove) and others who contributed to the data reporting and analysis process.
Amanda Neill, Quoc Huy Nguyen, Jane O'Malley, Lay Tin Ong, Daphne Ringi,
African Region Michael Roche, Michele Rumsey, Filoiala Sakaio, Yuoko Shimada, Bo Yee Shu,
Hannatu Abdullahi, Solomon Abebe, Medeyele Alakpadong, Fatimetou Aly, Bertha Tarileo, Puasina Tatui, Alaita Taulima, Khampasong Theppanya, Lisa
Baba Amivi, Gislain Arnaud, Yao Badie, Elsheikh Badr, Tamali Banda, Townsend, Uchaa Tuvshin, Ben Ung, Hang Zhou
Tereza Belay, Ana Bella, El`Hadj Bencherik, Mohamed Berthé, Mohamed Bouh,
Silvino N'dafa Braba, Cynthia Chasokela, Kete Jean Chrysostome, Ahanhanzon EDITORIAL COORDINATION, DESIGN AND PRODUCTION
Agonglo Clarisse, Maria da Luz Medina da Cruz, Mohamed`Faza Diallo, Sharad Agarwal, Prographics Inc, John Dawson, WHO departments for
Demba Moussa Diallo, Bakala Dieudonné, Mamady Doukouré, Khalid Elmardi, translation, publications and print. Her Royal Highness Princess Muna of
Jean-Baptiste Godui, Dembo Guirassy, Fatima Halidani, Simon Hlungwani, Idriss Jordan, individual nurses and partner agencies are acknowledged for their
Moudjiegou Igalas, Mary Nandili Ishepe, Hamza Ismaila, Shakuri Ayinla Kadiri, Tchaa support to the photos. WHO wishes to pay a special tribute to Salome Karwah,
Kadjanta, Edna Kamaiyo, Hossinatu Mary Kanu, Sellu Keifala, Jean Chrysostome a nurse in Liberia who survived the Ebola virus, but succumbed to childbirth
Kette, Emile Koroma, Emile Koroma, Seraphin Kouakou, Hannah Kou-Kigo, complications when refused care.
Feroze Lall Mahomed, Samkelisiwe Lukhele, Cipriano Mainga, Mpoeetsi Makau,
Nonhlanhla Makhanya, Abed Malika, Saturini Manangwa, Miriam Mangeya, JHPIEGO AND JOHNS HOPKINS UNIVERSITY SCHOOL OF
Phelelo Marole, Lamin Marong, Jesele Martins, Murebwayire Mary, Thembi NURSING are acknowledged for contributing to the evidence review
Mavuso, Gylian Mein, Kamel Messar, Janet K Michael, Lucy Mkutumula, Khumo and data reporting processes to develop this report. Peter Johnson, Nancy
Modisaeman, Flavia Moetsana-Poka, Ceesay Momodou, Mathapelo Mothebe, Reynolds, Jennifer Breads, Anna Bryant, Patrica Davidson, Lisa DiAndreth,
Jamiru Mpiima, Jane Mudyara, Chilweza Musonda Muzongwe, Lonia Mwape, Judith Fullerton, Leah Hart, Mark Kubue, Semakaleng Phafoli, Timothy
Wendin Manegdé Félicité Nana, Mariam Ndagije, Ekiri Nguie, Al Nkhoma, Roberton, Elizabeth Thompson
Contributors and acknowledgements ix

Glossary
The labour market is the structure that the efficiency and timeliness of translating
allows labour services to be sought (i.e. economic demand into creating and filling
demand) and offered (i.e. supply). Wages job openings.
and conditions of employment (for example,
adequate infrastructure, supportive Pre-service education refers to a formal
management, opportunities for professional learning programme that takes place prior
development and career progression) play to and as a prerequisite for employment in
a role determining the choices made by a service setting (3).
health workers and employers (1).
Licensing refers to the process of certifying
Demand refers to the jobs being offered on that an individual can perform the roles and
the market. Demand is the number of health tasks within a defined scope of practice to
workers that a health system can support in the required standard and conferring a licence
terms of funded positions or economic demand to legally authorize them to exercise a certain
for services. It is correlated with the expenditure profession within a given jurisdiction.
on health by the government, private insurance,
and out-of-pocket payments (2). Accreditation refers to the process of
evaluation of education institutions against
Supply. The supply of health workers refers to predefined standards required for the
the pool of qualified health workers willing to delivery of education. The outcome of the
work in the health care sector. It is a function process is the certification of the suitability
of the training capacity and the net migration, of education programmes and of the
deaths, and retirements of health workers (2). competence of education institutions in
the delivery of education.
Need is the number of health workers required
to attain the service delivery objectives of Credentialing is the process of obtaining,
a health system. Health labour markets are verifying, and assessing the qualifications of
primarily shaped by supply and demand and a practitioner to provide care or services in or
only indirectly by need (1). for a health care organization. Credentials are
documented evidence of licensure, education,
The absorption capacity for health care training, experience, or other qualifications (4).
workers by the health labour market refers
to the ability of the health system (which Professional certification is the voluntary
includes both the public and the private sector) process by which an entity grants a time-
to fully and productively employ the pool of limited recognition and use of a credential
available qualified health workers (mainly to an individual after verifying that he or she
generated through education and immigration). has met predetermined and standardized
The absorption capacity is influenced by criteria (5).
REFERENCES FOR GLOSSARY

1. McPake B, Maeda A, Araujo EC, Lemiere C, El Maghraby A, Cometto G. Why do health labour market forces matter?
Bulletin of the World Health Organization. 2013;91:841–6. doi:10.2471/BLT.13.118794.
2. Scheffler RM, Campbell J, Cometto G, Maeda A, Liu J, Bruckner TA et al. Forecasting imbalances in the global health
labor market and devising policy responses. Human Resources for Health. 2018;16:5. doi:10.1186/s12960-017-0264-6.
3. Integrated Management of Childhood Illness (IMCI): planning, implementing and evaluating pre-service training. Geneva:
World Health Organization; 2001.
4. Ambulatory Care Program: the who, what, when, and where’s of credentialing and privileging. Joint Commission (https://
www.jointcommission.org/assets/1/6/AHC_who_what_when_and_where_credentialing_booklet.pdf, accessed
5 March 2020).
5. Credentialing definitions. American Nurses Credentialing Center (https://www.nursingworld.org/education-events/faculty-

resources/research-grants/styles-credentialing-research-grants/credentialing-definitions/, accessed 5 March 2020).
x State of the world’s nursing 2020

EXECUTIVE SUMMARY 2020
Above images:
© AKDN/Christopher Wilton-Steer, © WHO/Yoshi Shimizu, © WHO/Conor Ashleigh
xi
EXECUTIVE SUMMARY
Central role of nurses in achieving

universal health coverage and the
Sustainable Development Goals
Nurses are critical to deliver on the promise of “leaving no one behind” and the global effort
to achieve the Sustainable Development Goals (SDGs). They make a central contribution to
national and global targets related to a range of health priorities, including universal health
coverage, mental health and noncommunicable diseases, emergency preparedness and
response, patient safety, and the delivery of integrated, people-centred care.
No global health agenda can be realized without concerted and sustained efforts to maximize
the contributions of the nursing workforce and their roles within interprofessional health
teams. To do so requires policy interventions that enable them to have maximum impact and
effectiveness by optimizing nurses’ scope and leadership, alongside accelerated investment
in their education, skills and jobs. Such investments will also contribute to the SDG targets
related to education, gender, decent work and inclusive economic growth.
This State of the world’s nursing 2020 report, developed by the World Health Organization
(WHO) in partnership with the International Council of Nurses and the global Nursing Now
campaign, and with the support of governments and wider partners, provides a compelling
case on the value of the nursing workforce globally.
© Shapecharge/Getty Images
Nursing is the largest

occupational group in
the health sector,
accounting for
approximately
59%
of the health
professions.
Current status of evidence in 2020
The nursing workforce is expanding in size and professional scope. However, the expansion is not
equitable, is insufficient to meet rising demand, and is leaving some populations behind.
191 countries provided data for this report, an all-time high and a 53% increase compared
to 2018 data availability. Around 80% of countries reported on 15 indicators or more. However,
there are significant gaps in data on education capacity, financing, salary and wages, and health
labour market flows. This impedes the ability to conduct health labour market analyses that will
inform nursing workforce policy and investment decisions.
The global nursing workforce is 27.9 million, of which 19.3 million are professional nurses.
This indicates an increase of 4.7 million in the total stock over the period 2013–2018, and confirms
that nursing is the largest occupational group in the health sector, accounting for approximately
59% of the health professions. The 27.9 million nursing personnel include 19.3 million (69%)
professional nurses, 6.0 million (22%) associate professional nurses and 2.6 million (9%) who are
not classified either way.
The world does not have a global nursing workforce commensurate with the universal
health coverage and SDG targets. Over 80% of the world’s nurses are found in countries that
account for half of the world’s population. The global shortage of nurses, estimated to be 6.6
million in 2016, had decreased slightly to 5.9 million nurses in 2018. An estimated 5.3 million (89%)
of that shortage is concentrated in low- and lower middle-income countries, where the growth in
the number of nurses is barely keeping pace with population growth, improving only marginally
the nurse-to-population density levels. Figure 1 illustrates the wide variation in density of nursing
personnel to population, with the greatest gaps in countries in the African, South-East Asia and
Eastern Mediterranean regions and some countries in Latin America.
Figure 1 Density of nursing personnel per 10 000 population in 2018

< 10 10 to 19 20 to 29 30 to 39 40 to 49 50 to 74 75 to 99 100 +
not applicable not reported
0 500 1,000 2,000 3,000 4,000

km
*Includes nursing professionals and associates.

Source: National Health Workforce Accounts, World Health Organization 2019. Latest available data over the period 2013–2018.
Executive
Executive summary
summary 3 xiii
Ageing health workforce patterns in some regions threaten the stability of the nursing
stock. Globally, the nursing workforce is relatively young, but there are disparities across regions,
with substantially older age structures in the American and European regions. Countries with
lower numbers of early career nurses (aged under 35 years) as a proportion of those approaching
retirement (aged 55 years and over) will have to increase graduate numbers and strengthen
retention packages to maintain access to health services. Countries with a young nursing
workforce should enhance their equitable distribution across the country. As shown in Figure 2,
countries with higher proportions of nurses nearing retirement compared to young nurses (the
countries above the green line) will face future challenges in maintaining the nursing workforce.
Figure 2 Relative proportions of nurses aged over 55 years and below 35 years (selected countries)
Each dot represents a country Green line indicates where the number of nurses near retirement
equals the number of young nurses in the workforce.
70%
60% 18 countries at risk

of an ageing workforce
Percentage of nurses aged 55+ years
50%
40%
30%
20%
10%
0%
0% 10% 20% 30% 40% 50% 60% 70%
Percentage of nurses less than 35 years
*Includes nursing professionals and nursing associate professionals.

Source: National Health Workforce Accounts, World Health Organization
2019. Latest available data reported between 2013 and 2018.
xiv 4 StateState ofworld’s

of the the world’s nursing
nursing 20202020
To address the shortage by 2030 in all countries, the total number of nurse
graduates would need to increase by 8% per year on average, alongside an improved
capacity to employ and retain these graduates. Without this increase, current trends
indicate 36 million nurses by 2030, leaving a projected needs-based shortage of 5.7 million,
primarily in the African, South-East Asia and Eastern Mediterranean regions. In parallel, a
number of countries in the American, European and Western Pacific regions would still
be challenged with nationally defined shortages. Figure 3 shows projected increases in
numbers of nurses by WHO region and by country income group.
ENGLISH
Figure 3 Projected increase (to 2030) of nursing stock, by WHO region and by country income group
Americas Eastern Mediterranean High income Low income

43% 4% 6% 6%
Africa
6% Lower middle
Europe income
7% 27%
BY REGION BY INCOME
South-East
Asia
18%
Western Pacific Upper middle income
22% 61%
*Includes nursing professionals and nursing associate professionals.
While the patterns are evolving,

equitable distribution
and retention of nurses is a
NEAR-UNIVERSAL
CHALLENGE.
EXECUTIVE
Executive
SUMMARY
summary
Executive summary 5 xv
© ICAP/Sven Torfinn
Figure 4 Average duration (years) of education for nursing professionals, by WHO region
WHO REGION 2 years 3 years 4 years 5 years
Africa
Americas
South-East Asia
Europe
Eastern Mediterranean
Western Pacific
Global
0% 20% 40% 60% 80% 100%

Source: National Health Workforce Accounts 2019 for 99 countries and Sigma database for 58 countries. Latest available data reported by countries
between 2013 and 2018.
The majority of countries (152 out of 157 responding; 97%) reported that the
minimum duration for nurse education is a three-year programme. A large majority
of countries reported standards for education content and duration (91%), accreditation
mechanisms (89%), national standards for faculty qualifications (77%) and interprofessional
education (67%). However, less is known about the effectiveness of these policies and
mechanisms. Further, there is still considerable variety in the minimum education and training
levels of nurses, alongside capacity constraints such as faculty shortages, infrastructure
limitations and the availability of clinical placement sites. As shown in Figure 4, the duration
of nursing education is predominantly three or four years globally.
© Nazeer Al-Khatib/AFP via Getty

A total of 78 countries (53% of those providing a
response) reported having advanced practice roles
for nurses. There is strong evidence that advanced
practice nurses can increase access to primary health care
in rural communities and address disparities in access to
care for vulnerable populations in urban settings. Nurses
at all levels, when enabled and supported to work to the
full scope of their education and training, can provide
effective primary and preventive health care, amongst
many other health services that are instrumental to
achieving universal health coverage.
One nurse out of every eight practises in a

country other than the one where they were
born or trained. The international mobility of the
nursing workforce is increasing. While the patterns are
evolving, equitable distribution and retention of nurses
is a near-universal challenge. Unmanaged migration
xvi 6 StateState ofworld’s

nursing 20202020
can exacerbate shortages and contribute to inequitable access to health services. Many high-
income countries in different regions appear to have an excessive reliance on international nursing
mobility due to low numbers of graduate nurses or existing shortages vis-à-vis the number of
nursing jobs available and the ability to employ new graduate nurses in the health system.
Most countries (86%) have a body responsible for the regulation of nursing. Almost
two thirds (64%) of countries require an initial competency assessment to enter nursing
practice and almost three quarters (73%) require continued professional development for
nurses to continue practising. However, the regulation of nursing education and practice is not
harmonized beyond a few subregional mutual recognition arrangements. Regulatory bodies are
challenged to keep education and practice regulations updated and nursing workforce registries
current in a highly mobile, team-based and digital era. Figure 5 shows the proportions of
reporting countries with regulatory provisions on working conditions in place.
Nursing remains a highly gendered profession with associated biases in the workplace.
Approximately 90% of the nursing workforce is female, but few leadership positions in health
are held by nurses or women. There is some evidence of a gender-based pay gap, as well
as other forms of gender-based discrimination in the work environment. Legal protections,
including working hours and conditions, minimum wage, and social protection, were reported
to be in place in most countries, but not equitably across regions. Just over a third of countries
(37%) reported measures in place to prevent attacks on health workers.
A total of 82 out of 115 responding countries (71%) reported having a national nursing
leadership position with responsibility for providing input into nursing and health
policy. A national nursing leadership development programme was in place in 78 countries
(53% of those responding). Both the presence of a government chief nursing officer (or
equivalent) position and the existence of a nursing leadership programme are associated
with a stronger regulatory environment for nursing.
Figure 5 Percentage of countries with regulatory provisions on working conditions
Regulation on working hours and conditions

(133 yes out of 142) 94%
Regulation on social protection

91%
(125 yes out of 137)
Regulation on minimum wage 89%

Nursing council 86%

Existence of advanced nursing roles 53%

(50 yes out of 95)
Measures to prevent attacks on health workers 37%

(20 yes out of 55)
0% 20% 40% 60% 80% 100%
Percentage of countries reporting yes
Source: National Health Workforce Accounts, World Health Organization 2019.
Executive summary
Executive summary 7 xvii
TEN KEY ACTIONS
Future
directions
for nursing
workforce
policy
© John W. Poole/NPR
1 Countries affected by shortages will need to increase funding to educate

and employ at least 5.9 million additional nurses. Additional investments in
nursing education are estimated to be in the range of US$ 10 per capita in low- and
middle-income countries. Further investments would be required to employ nurses
upon graduation. In most countries this can be achieved with domestic funds. Actions
include review and management of national wage bills and, in some countries, lifting
restrictions on the supply of nurses. Where domestic resources are constrained in the
medium and long term, for example in low-income countries and conflict-affected or
vulnerable contexts, mechanisms such as institutional fund-pooling arrangements should
be considered. Development partners and international financing institutions can help by
transferring human capital investments for education, employment, gender, health and
skills development into national health workforce strategies for advancing primary health
care and achieving universal health coverage. Investments in the nursing workforce can
also help drive progress in job creation, gender equity and youth engagement.
xviii 8 StateState ofworld’s

nursing 20202020
2 Countries should strengthen capacity for health workforce data collection,
analysis and use. Actions required include accelerating the implementation of National
Health Workforce Accounts and using the data for health labour market analyses to
guide policy development and investment decisions. Collation of nursing data will require
participation across government bodies, as well as engagement of key stakeholders such
as the regulatory councils, nursing education institutions, health service providers and
professional associations.
3 Nurse mobility and migration must be effectively monitored and responsibly

and ethically managed. Actions needed include reinforcement of the implementation of
the WHO Global Code of Practice on the International Recruitment of Health Personnel
by countries, recruiters and international stakeholders. Partnerships and collaboration with
regulatory bodies, health workforce information systems, employers, government ministries
and other stakeholders can improve the ability to monitor, govern and regulate international
nurse mobility. Countries that are overreliant on migrant nurses should aim towards greater
self-sufficiency by investing more in domestic production of nurses. Countries experiencing
excessive losses of their nursing workforce through out-migration should consider
mitigating measures and retention packages, such as improving salaries (and pay equity)
and working conditions, creating professional development opportunities, and allowing
nurses to work to their full scope of education and training.
4 Nurse education and training programmes must graduate nurses

who drive progress in primary health care and universal health coverage.
Actions include investment in nursing faculty, availability of clinical placement sites and
accessibility of programmes offered to attract a diverse student body. Nursing should
emerge as a career choice grounded in science, technology, teamwork and health equity.
Government chief nurses and other national stakeholders can lead national dialogue on the
appropriate entry-level and specialization programmes for nurses to ensure there is adequate
supply to meet health system demand for graduates. Curricula must be aligned with national
health priorities as well as emerging global issues to prepare nurses to work effectively in
interprofessional teams and maximize graduate competencies in health technology.
5 Nursing leadership and governance is critical to nursing workforce

strengthening. Actions include establishing and supporting the role of a senior nurse in the
government responsible for strengthening the national nursing workforce and contributing to
health policy decisions. Government chief nurses should drive efforts to strengthen nursing
workforce data and lead policy dialogue that results in evidenced-based decision-making on
investment in the nursing workforce. Leadership programmes should be in place or organized
to nurture leadership development in young nurses. Fragile and conflict-affected settings
will typically require a particular focus in order to (re)build the institutional foundations and
individual capacity for effective nursing workforce governance and stewardship.
Executive summary
Executive summary 9 xix
6 Planners and regulators should optimize the contributions of nursing
practice. Actions include ensuring that nurses in primary health care teams are working
to their full scope of practice. Effective nurse-led models of care should be expanded
when appropriate to meet population health needs and improve access to primary
health care, including a growing demand related to noncommunicable diseases and the
integration of health and social care. Workplace policies must address the issues known
to impact nurse retention in practice settings; this includes the support required for
nurse-led models of care and advanced practice roles, leveraging opportunities arising
from digital health technology and taking into account ageing patterns within the nursing
workforce.
7 Policy-makers, employers and regulators should coordinate actions in

support of decent work. Countries must provide an enabling environment for nursing
practice to improve attraction, deployment, retention and motivation of the nursing
workforce. Adequate staffing levels and workplace and occupational health and safety
must be prioritized and enforced, with special efforts paid to nurses operating in fragile,
conflict-affected and vulnerable settings. Remuneration should be fair and adequate to
attract, retain and motivate nurses. Further, countries should prioritize and enforce policies
to address and respond to sexual harassment, violence and discrimination within nursing.
8 Countries should deliberately plan for gender-sensitive nursing workforce

policies. Actions include implementing an equitable and gender-neutral system of
remuneration among health workers, and ensuring that policies and laws addressing the
gender pay gap apply to the private sector as well. Gender considerations should inform
nursing policies across the education, practice, regulatory and leadership functions, taking
account of the fact that the nursing workforce is still predominantly female (Figure 6).
Policy considerations should include enabling work environments for women, for example
through flexible and manageable working hours that accommodate the changing needs of
nurses as women, and gender-transformative leadership development opportunities for
women in the nursing workforce.
Figure 6 Percentage of female and male nursing personnel, by WHO region
WHO REGION Females Males
Africa 76% 24%

Americas 87% 13%
South-East Asia 89% 11%
Europe 89% 11%
Eastern Mediterranean 78% 22%
Western Pacific 95% 5%
0% 20% 40% 60% 80% 100%
Source: National Health Workforce Accounts, World Health Organization 2019. Latest available data reported between 2013 and 2018.
xx 10 StateState ofworld’s
nursing 20202020
Workplace policies must address the issues known
to impact nurse retention in practice settings; this
includes the support required for nurse-led models
of care and advanced practice roles.
9 Professional nursing regulation must be modernized. Actions include

harmonizing nursing education and credentialing standards, instituting mutual
recognition of nursing education and professional credentials, and developing
interoperable systems that allow regulators to easily and quickly verify nurses’
credentials and disciplinary history. Regulatory frameworks, including scope of
practice, initial competency assessments and requirements for continuous professional
development, should facilitate nurses working to the full scope of their education and
training in dynamic interprofessional teams.
10 Collaboration is key. Actions include intersectoral dialogue led by ministries of

health and government chief nurses, and engaging other relevant ministries (such as
education, immigration, finance, labour) and stakeholders from the public and private
sectors. A key element is to strengthen capacity for effective public policy stewardship
so that private sector investments, educational capacity and nurses’ roles in health
service provision can be optimized and aligned to public policy goals. Professional
nursing associations, education institutions and educators, nursing regulatory bodies
and unions, nursing student and youth groups, grass-roots groups, and global
campaigns such as Nursing Now are valuable contributors to strengthening the
role of nursing in care teams working to achieve population health priorities.
© Yoshinobu Oka via Sasakawa Health Foundation

CONCLUSION
jobs and leadership
This report has provided robust data and evidence on the nursing workforce. This
intelligence is needed to support policy dialogue and facilitate decision-making to
invest in nursing to strengthen primary health care, achieve universal health coverage,
and advance towards the SDGs.
Despite signs of progress, the report has also highlighted key areas of concern. An
acceleration of progress will be required in many low- and lower middle-income
countries in the African, South-East Asia and Eastern Mediterranean regions in order
to address key gaps. However, there is no room for complacency in upper middle-
and high-income countries, where constrained supply capacity, an older age structure
of the nursing workforce and an overreliance on international recruitment jointly pose
a threat to the attainment of national nursing workforce requirements.
National governments, with support where relevant from their domestic and international
partners, should catalyse and lead an acceleration of efforts to:
build leadership, stewardship and management capacity for the

nursing workforce to advance the relevant education, health, employment
and gender agendas;
optimize return on current investments in nursing through adoption of

required policy options in education, decent work, fair remuneration, deployment,
practice, productivity, regulation and retention of the nursing workforce;
accelerate and sustain additional investment in nursing education,

skills and jobs.
The investments required will necessitate additional financial resources. If these are made
available, the returns for societies and economies can be measured in terms of improved
health outcomes for billions of people, creation of millions of qualified employment
opportunities, particularly for women and young people, and enhanced global
health security. The case for investing in nursing education, jobs and
leadership is clear: relevant stakeholders must commit to action.
© St Thomas’ Hospital, London

© Carrie Tudor/The Union
CHAPTER
1
Introduction
1. The nursing workforce, comprising standards and nurse professional

nursing professionals and nursing associations emerged in the 1800s,
associates,1 is the world’s largest single progressively raising the quality,
occupation in the health sector and is a competencies and working conditions
foundation of the interprofessional health of the nursing profession. The 1900s
teams that deliver on the promise of saw the growth of specializations
health for all. and autonomy, along with stronger
professional regulation to ensure public
2. Nurses’ responsibilities and roles as accountability and safety (1). The first
advanced practitioners, clinicians, international organization for health care
leaders, policy-makers, researchers, professionals, founded in 1899, was
scientists and teachers are central the International Council of Nurses.
to the effective functioning of health Currently in its 121st year of operation,
professionals’ education and practice. the International Council of Nurses is
Improvements in population health a federation of more than 130 national
and well-being have been, and will nurse associations, representing more
continue to be, ably realized through than 20 million nurses worldwide (2).
the industry, innovation and inspiration
of the nursing profession. 4. Since its first years of existence, the
World Health Organization (WHO)
3. Nursing has existed for centuries and has recognized the enormous value
has evolved considerably since the birth and contribution of the nursing and
200 years ago of Florence Nightingale, midwifery workforces (3). Over the
considered the founder of modern years, nurses and midwives have
nursing. Structured education, clinical contributed to major global health
1 As defined by the International Labour Organization’s International Standard Classification of Occupations

(https://www.ilo.org/public/english/bureau/stat/isco/isco08/).
Introduction 1
landmarks, including the eradication and the Midwife, as designated by
of smallpox, the fight against the World Health Assembly (7), this
communicable diseases, and the landmark report aims to inform national,
dramatic reductions in maternal, regional and global actions related to
newborn and child mortality and the nursing workforce in the decade
morbidity worldwide (4, 5). Their remaining to achieve the Sustainable
prominent role has translated into Development Goals (SDGs).
an unparalleled level of attention by
the World Health Assembly, which 6. The report presents comprehensive,
has adopted over a 70-year period 10 up-to-date evidence on the current
resolutions to promote the uptake of nursing workforce globally; takes stock
international standards to educate, of the main issues, challenges and
employ and retain nurses and known evidence regarding the role of
midwives as part of broader workforce the nursing profession in the attainment
development priorities (3, 6). of health goals; and provides concrete
policy options to advance the nursing
5. This State of the world’s nursing profession as part of an integrated
2020 report, developed by WHO in approach to strengthen the health
partnership with the International workforce, primary health care and
Council of Nurses and the global health systems.
Nursing Now campaign, explores
the contemporary evidence with the 7. An online section available on the WHO
objective of providing a vision and website2 contains individual country
forward-looking agenda for nursing profiles presenting the data provided by
policy. As the world celebrates 2020 countries for this report.
as the International Year of the Nurse
2 http://apps.who.int/nhwaportal.
© WHO/NOOR/Sebastian Liste
Individual chapter themes
CHAPTER 2 Nursing in a context of broader workforce and health priorities

The chapter presents the contributions of the health workforce to the 2030 Agenda for
Sustainable Development and, in particular, SDG 3 on good health and well-being (8).
CHAPTER 3 Nursing roles in 21st-century health systems

The chapter outlines the role and contributions of nurses to deliver priority health
interventions with respect to the WHO “triple billion” targets of achieving universal
health coverage, addressing health emergencies, and increasing health and well-being
for all (9).
CHAPTER 4 Policy levers to enable the nursing workforce

The chapter describes the broader health labour market and workforce policy levers
and governance determinants to address the challenges to nurses working to their full
potential in health facilities and communities, both in countries and globally.
CHAPTER 5 Current status of evidence and data on the nursing workforce

The chapter provides an analytical overview of the current nursing workforce, including
the areas of greatest relevance for national, regional and global policy development,
namely stock, composition and distribution; production capacity; education, regulation,
practice, policy and governance environment; leadership; and labour market factors.
It also highlights progress and challenges in relation to the nursing contribution to
addressing the projected shortfall of 18 million health workers by 2030.
CHAPTER 6 Future directions for nursing workforce policy

The chapter outlines a forward-looking agenda with policy options and a call to action
for Member States, education institutions, regulatory bodies, professional associations,
development partners, international organizations and other stakeholders.
Introduction 3
© Cecilie Arcurs/ Getty Image
4 State of the world’s nursing 2020

CHAPTER
2
Nursing in a context of
broader workforce and
health priorities
2.1 Role of the health workforce in of universal health coverage is a goal

achieving the 2030 Agenda to which all United Nations Member
States have explicitly and unanimously
8. In 2015, the world ushered in the United committed, including through the United
Nations Sustainable Development Nations General Assembly’s Political
Agenda for 2030 with 17 ambitious Declaration of the High-Level Meeting
and interrelated goals in areas of critical on Universal Health Coverage (10)
importance for humanity and the planet and the resolution of the International
(8). The SDGs include eradicating poverty Parliamentary Union (11).
(SDG 1), achieving good health and well-
being for all (SDG 3), ensuring inclusive 10. Primary health care is the cornerstone of
and equitable education (SDG 4), universal health coverage. World leaders
achieving gender equality (SDG 5), and marked the 40th anniversary of the 1978
promoting decent work and inclusive and Alma-Ata Declaration on Primary Health
sustainable economic growth (SDG 8). Care with the Astana Declaration3 (12) to
firmly establish primary health care as
9. WHO leads the global health the main approach to achieving universal
community’s efforts to accelerate health coverage. WHO has embedded
progress on SDG 3, which is rooted the SDG and primary health care logic
in the concept of universal health in the development and implementation
coverage. The progressive realization of its own 13th General Programme
3 Astana Declaration on Primary Health Care: From Alma-Ata towards Universal Health Coverage and the Sustainable Development Goals.
Nursing in a context of broader workforce and health priorities 5

of Work, in the form of “triple billion” 13. Contrary to the long-standing — and
targets: 1 billion more people benefiting erroneous — notion that the health
from universal health coverage, 1 billion workforce represents a cost to be
more people better protected from contained (17, 18), in 2016 the United
health emergencies, and 1 billion more Nations High-Level Commission on
people enjoying better health and Health Employment and Economic
well-being (9). Growth (the “Commission”) published
evidence that jobs and employment
11. WHO’s 2019 Global Monitoring Report — in health promote economic growth
Primary health care on the road to and increase the productivity of other
universal health coverage — found sectors (17, 18). Investment in the health
evidence of remarkable progress system and its workforce substantially
towards improved service coverage, contributes to inclusive economic
with countries increasingly establishing growth (SDG 8), particularly through
legal mandates for universal access the employment and empowerment of
to health services and products in women (SDG 5) and young people (19,
their national legal frameworks (13). 20). Women account for 70% of the
However, progress has been uneven social and health care workforce globally
across and within countries, and financial (21), and nearly 90% of the nursing and
protection for the most vulnerable midwifery workforce (22, 23).
remains a challenge. Weak health
systems and socioeconomic factors 14. The Commission provided a rationale for
are hindering progress; better data and investment in health and social sectors,
evidence are needed to identify the and a framework on how that investment
investment priorities and track progress. can expand education capacity to ensure
Opportunities exist to shift from rigid a sustainable supply of health workers
delivery models and roles to more agile, and transform their competencies
accessible and articulated systems. to meet needs, producing a health
workforce with the right skills to fill
12. WHO estimates that the overall decent jobs in the right places for better
investments needed to achieve the health health service delivery, and in sufficient
targets in SDG 3 by 2030 total US$ 3.9 numbers to avert the projected 18 million
trillion (10). Over the 12-year period, more health workforce shortfall.
than 40% of this investment is for the
remuneration, salaries and emoluments 15. In 2017, WHO Member States
of the health workforce required to adopted a five-year plan to achieve
address the projected shortage of 18 the Commission’s recommendations,
million health workers by 2030 (14–16). encompassed in the Working for Health
Estimates that include the additional programme and a Multi-Partner Trust
investment required in the education Fund of WHO, the International Labour
and lifelong learning needs of the health Organization (ILO) and the Organisation
workforce indicate that an average for Economic Co-operation and
of more than 50% of health-related Development (OECD) (15, 17). WHO
investments will need to be directed at implements these recommendations in
developing, remunerating and maintaining alignment with the approaches for health
the health workforce. workforce strengthening outlined in the

Global Strategy on Human Resources for health workforce. This necessitates
Health: Workforce 2030 (Figure 2.1) (16). a comprehensive understanding and
quantification of supply, demand and
16. Accelerating progress towards universal needs, which are used to conduct health
health coverage and achieving SDG 3 labour market analyses that inform
is possible by refocusing attention integrated health workforce strategies
on the investment needs for the and plans.
Figure 2.1 Global Strategy on Human Resources for Health: strategic objectives and
relevance for nursing
Key areas for nursing

include positively managing
include maximizing
nurse migration, ensuring
the contributions
the quality of nursing
of nurses via an
education, and investing in
optimized scope of
the retention of nurses in
practice and nurses’
rural, remote, or otherwise
roles in providing
underserved communities.
preventive and STR
primary care. IV E1 AT
E CT EG
IC
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OB OB
IC
J
EG
EC
AT
Optimize the performance, Catalyse investment in

TIV
STR
quality, productivity, human resources for health

E2
effectiveness, skill aligned to address population

mix, retention, health needs, account for
address inefficiencies, health labour market dynamics,
maldistribution for equity, education policies, shortages
universal health coverage. and maldistribution.
Build the capacity Strengthen data for

of institutions for human resources for
effective public policy health monitoring
stewardship, leadership, and accountability.
and governance on
STR
human resources
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for health.
AT
TIV
EG
EC
IC
BJ
BJ
O
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EC C
TIV GI
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STR
include having an accurate
count or “stock” of
Key areas for nursing the nursing workforce
include engaging and understanding the
nursing leaders in requisite information with
health policy-making which to conduct a health
and the development labour market analysis.
of nursing leadership. Data for monitoring and
accountability requires
the engagement not just
of government ministries,
but also nursing and
intersectoral stakeholders.

17. The nursing workforce faces challenges to be specific about “who is a
common to all health occupations, nurse”. The evidence synthesized in
including adequate numbers, equitable Chapters 3 and 4 represents a broad
distribution and retention, quality interpretation of nursing as reflected in
education, effective regulation, the published literature. In Chapter 5,
conducive working conditions, and which presents the data gathered and
quality and efficiency within universal analyses conducted specifically for this
health coverage (24–26). However, there report, the terminology specifically and
are challenges that are specific to the singularly refers to two occupational
nursing profession, including issues of groups defined by the 2008 International
gender bias, policy leadership, regulation, Standard Classification of Occupations
and varied levels of education and (ISCO-08): professional nurse (ISCO
practice roles (25). A clear understanding code 2221), and nursing associate
of these issues and priorities can professional (ISCO code 3221).
facilitate the adoption of appropriate
policy and investment decisions. 19. Countries reported data according
to who they determined met the
definitions for those two occupations;
2.2 Who is a nurse? countries were not asked to report
on other occupation groups (such as
18. This report aims to present the best midwives, nursing assistants or other
available, internationally comparable auxiliary health workers). Some countries
evidence and data on the nursing classify some of their health workers
workforce. To that end, it is necessary as “nurse-midwives”, who have a
© AKDN/Christopher Wilton-Steer
hybrid educational pathway and role. As assessed at a global level (Figure 2.2).
“nurse-midwife” is not an internationally Data in the Global Regulatory Atlas (29)
classified occupational group, the report suggest there are at least 144 distinct
only included data referring to health titles of nurses around the world that
workers that countries categorized as require a licensure examination, including
professional or associate professional specialist and advanced practice titles.
nurses. More information about This reflects a range in the number of
these definitions and how countries types of nurses from 10 different titles
were supported to report on their in the South-East Asia Region to over 30
nursing personnel can be found in the in the Region of the Americas and the
description of methods in Chapter 5, as European Region.
well as in Annex 1 to this report.
22. The role of a nurse in one country may
20. Nursing encompasses autonomous and be different from the role of a nurse
collaborative care of individuals of all with the same title in another country.
ages, families, groups and communities, This underscores the importance of
sick or well and in all settings; it includes internationally standardized definitions
the promotion of health, the prevention to support discussions of who is a
of illness, and the care of ill, disabled nurse, understand nursing functions,
and dying people (7, 27). Additional and plan health services in which
key nursing roles include advocacy, the contributions of nurses is optimized
promotion of a safe environment, towards achieving population
participation in patient and health health goals.
services management, shaping health
policy, education, and research (27, 28).
Nurses provide a wide variety of health Figure 2.2 Number of distinct nursing titles
care services for people in all health within each WHO region
care settings, from tertiary hospitals to
35
health posts in remote communities.
Number of distinct titles in countries in each WHO region
The title “nurse”, in its various forms, 32

30 31
should indicate a person who has met
the legal, educational and administrative
25
requirements to practise nursing.
20
21. There are a variety of educational 20
19
pathways to practise with the title
15
“nurse”. After completing an entry-level
nursing programme, higher education
10 11
and specialist qualifications are also 10
often available, usually resulting in
5
different titles and roles. The outcome
is an assortment of nursing titles, roles
0
and competencies, even within the same Americas Africa South-East Europe Eastern Western
Asia Mediterranean Pacific
country. The variety seen in any one
WHO region
country is magnified when examined at a
Note: Numbers indicate nursing titles requiring an examination in each country,
regional level and increases further when grouped by region. Source: NCSBN Global Regulatory Atlas (29).

© WHO/Atul Loke

CHAPTER
3
Nursing roles in
21st-century health
systems
23. This chapter provides a synthesis of services (30). The review shows that
the contemporary evidence base (for nursing-led primary care services can,
a detailed synthesis see web annex) in certain settings and under the right
on the roles and responsibilities of circumstances, lead to similar or in
nurses contributing to SDG 3 and more some cases even better patient health
specifically with respect to WHO’s outcomes and higher patient satisfaction
mission “to promote health, keep the than other care delivery models; nurses
world safe and serve the vulnerable” and probably also have longer consultations
the triple billion targets of its General with patients (30). Other Cochrane
Programme of Work. reviews have shown that nurses are
effective in the initiation and follow-up
of HIV therapy (31), and that nursing
3.1 Role of nursing in achieving interventions for tobacco cessation
universal health coverage increase the likelihood of quitting (32).
A further Cochrane review has shown
24. A Cochrane review has shown nurses that non-specialist health workers,
to be effective in the delivery of including nurses, may improve outcomes
primary health care across a wide for general and perinatal depression,
range of services for communicable post-traumatic stress disorder and
and noncommunicable diseases, alcohol use disorders, and patient and
including clinical decision-making carer outcomes for dementia (33). A
roles for some conditions, as well as Campbell systematic review has shown
health care education and preventive that sexual assault nurse examiners or
Nursing roles in 21st-century health systems 11

forensic nurse examiners are effective in 26. The historical contribution of nurses to
sexual assault forensic examination and prevention, treatment and control of
documentation, that these nurses could communicable or infectious diseases
provide sexually transmitted infection is also well documented (4, 49). For
and pregnancy prophylaxis, and that example, nurse-led interventions can
this care represents good value for lead to an increase in vaccination
money (34). rates (50). Nurses have been active
across the globe in the management
25. Nurses are important to ensuring quality and prevention of tuberculosis, and
of care and patient safety, preventing can engage effectively in both clinical
and controlling infections, and combating and non-clinical tasks, such as health
antimicrobial resistance (35). This is promotion and psychosocial support
achieved through carrying out multiple (51–54), performing voluntary male
functions, including monitoring patients medical circumcision (55–61), and
for clinical deterioration, detecting errors designing and implementing HIV pre-
and near misses (36), implementing exposure prophylaxis programmes (62).
infection prevention interventions, control Nurses can also be effectively engaged
monitoring and mentorship (37), and in combating neglected tropical diseases
ensuring that good practices involving through community education, mass
water, sanitation and hand hygiene are chemoprophylaxis, identifying and
maintained (38). In outbreaks such as diagnosing disease cases, determining
COVID-19 where hand hygiene, physical disease prevalence, screening and
distancing and surface disinfection are confirming suspected cases identified
central to containment, the infection and referred by community health
prevention and control role of nurses is workers, dispensing drugs, performing
crucial (Box 3.1). certain types of surgery (for example
Box 3.1 Nursing contribution to patient safety
Annually more than 8 million deaths in low- and middle-income countries are attributed to
poor quality of care (39). Nurses can contribute to improved quality of care and to patient
safety through the prevention of adverse events, but this requires that they work at their
optimal capacity, within strong teams, and within a good working environment. Nurses play
an essential role in ensuring patient safety by monitoring patients for clinical deterioration,
detecting errors and near misses, understanding care processes and weaknesses inherent
in some systems, and performing numerous other actions to ensure patients receive high-
quality care (36). Burnout amongst nurses and doctors due to high workload, long journeys
and ineffective interpersonal relationships has been associated with worsening patient
safety (40), whereas good work environments, safe staffing of nurses and education in
mixed-skill teams are correlated with reduced hospital length of stay, lower incidence of
adverse events such as pneumonia, gastritis, upper gastrointestinal bleeds, pressure ulcers,
and catheter-associated urinary tract infections, and reduced overall mortality (41–48).

for trachoma), and providing patient for multiple NCDs, such as hypertension,
education on managing disease, such cardiovascular disease, diabetes, mental
as lymphoedema self-care (63). In health, neurological conditions, respiratory
several settings across Africa, nurses diseases and cancer (70). In carrying
also contribute to improved quality of out these tasks nurses have improved
communicable disease care through the health outcomes, such as reductions in
training, mentoring and supervision of blood pressure and lower depression
community health workers (63–65). scores, and have offered equivalent care
for patients with heart failure or diabetes
27. Nurses play a crucial role in health (30, 70). Nurses have also contributed
promotion, health literacy and the to behaviour change, such as increased
management of noncommunicable uptake of medications, and patients treated
diseases (NCDs) (66–72). With the by nurses are more likely to keep follow-
right knowledge, skills, opportunities up appointments (30, 70). An extended
and financial support, they are uniquely role of nurses within health care teams,
placed to act as effective practitioners, enabled by appropriate orientation of
health coaches, spokespersons, and nursing education and scope of practice,
knowledge brokers for patients and may support the integration of NCDs into
families throughout the life course (73). primary care (74, 75). While potentially
The success of nurses in NCD care relevant in a variety of settings, an
and prevention has been repeatedly expanded role of nurses has the potential,
demonstrated (66–72) in a range of in contexts characterized by a shortage of
NCD tasks, including screening and physician specialists, to advance health
providing primary health care services equity (73, 76).
© WHO/Tania Habjouqa

28. Nurses contribute to care across devices (82). Evidence also supports
the life course. Nurses, working the efficacy of nurses in cervical
with midwives, obstetricians and cancer screening and provision of HIV
other physician specialists, provide services for women of reproductive
antenatal, intrapartum and postnatal age and beyond (83, 84). Provision of
care for childbearing women (77). information and advocacy with age-
Neonatal nurses with specialized eligible adolescents and their parents
skills in newborn care are effective in or caregivers are central components of
delivering special support and timely, the nurses’ role in expansion of human
high-quality inpatient care, supported papillomavirus vaccination services
by other neonatal specialists. In most (83, 85, 86). Nurses play a central role
countries nurses form the backbone of in the provision of care for older adults
school health services providing care and can be instrumental in the delivery
for children and adolescents (78–81). of integrated care, which results in
Nurses offer services across the better outcomes for older populations
spectrum of sexual and reproductive (Box 3.2) (87). As primary providers of
health; for example, they safely and palliative care, nurses enable an end-of-
effectively provide oral and injectable life experience characterized by dignity
contraceptives, implants and intrauterine and compassion.
Box 3.2 Nurse-led model of community care for ageing populations
Motivated by Japan’s status as a “super-ageing” society, the Sasakawa Memorial Health

Foundation began a programme in 2014 to enable nurses to establish and operate
community-based home care nursing centres (88). The centres act as community health
hubs from which nurses provide services that enable ageing adults to live with dignity
at home and to improve the quality of life of people in the community. The Sasakawa
Memorial Health Foundation also supports a network to enhance cooperation between
centres, collect data, and advocate establishment of community-based home care
nursing centres (89).
An eight-month programme in elder care and home care nursing prepares nurses to
conduct physical assessments, meet the primary health care needs of community residents,
and assist families to provide palliative and end-of-life care in the home. Additional
coursework focuses on entrepreneurship, management and business plans to develop
and operate a home care nursing centre (89).
By March 2019, 67 nurses had completed the programme and over 56 of them operate
home care nursing centres in 23 districts throughout Japan. Staffing at the centres averages
70% nurses and 30% other professionals, attesting to the interprofessional collaborative
approach applied in meeting the primary health care needs of the communities served at
the centres and in their homes. As a network, the centres averaged 25 000 visits per month.
The support of families in providing end-of-life care has contributed to a reduction in health
care costs associated with hospital admission and medical procedures (90).

© National Health Commission of the People's Republic of China
3.2 Role of nursing in dealing with their own countries’ capacity to respond
emergencies, epidemics and to future disaster and emergency
disasters situations (97). This may be particularly
important to increase the resilience of
29. Nurses are involved in delivering care for health systems that have been made
clinical emergencies (such as accidents more vulnerable through disasters and
or heart attacks), preventing and conflict (98).
responding to epidemic outbreaks, and
responding to disasters and humanitarian 31. In settings affected by fragility and
crises. Nurses are often the first provider conflict, health workers, including
that a patient sees in a health facility; nurses, confront a number of both
their roles may vary depending on personal and professional challenges,
context, but often include triage, early such as the threat of abduction, having to
recognition of life-threatening conditions, cope with the death of colleagues, fear
administration of medications, of their own death, increased workload,
performance of life-saving procedures, and increased complexity in the workload
and initiation of early referral. (for example, having to deal with firearm
wounds), as well as the erosion of ethical
30. Nurses have played a pivotal role as and professional standards (99). Despite
part of teams managing epidemics these conditions, nurses and other
that threaten health across the globe, health workers have shown resilience
including severe acute respiratory and commitment in the face of these
syndrome (SARS) in 2003 (91), the challenges and have continued to deliver
Middle East respiratory coronavirus essential services (99). With support,
(MERS-CoV) outbreak in 2015 (92), Zika nurses in conflict settings or catering to
virus disease in 2016 (93, 94), Ebola refugee populations have been able to
virus disease in 2014 (95, 96) and the achieve treatment success for a range of
COVID-19 outbreak that began in 2019. diverse conditions, such as pulmonary
Through the WHO Emergency Medical tuberculosis (100) and other respiratory
Teams Initiative, nurses and other health tract infections, dental caries and post-
workers are trained to better support traumatic stress disorder (101).

3.3 Role of nursing in achieving 33. Enabling and sustaining healthier
population health and well-being populations is dependent on both
ensuring the health of young people
32. Enhancing the health and well-being of through their equitable access to
populations requires nurses and other universal health coverage, and ensuring
health workers to address the social that they are healthy and willing to
determinants of health, and in so doing continue the work of sustainable
contribute towards the achievement development into the next generation.
of the SDGs. The prevention of Nurses understand and are capable of
diarrhoeal diseases through the adopting the approaches needed to be
promotion of handwashing, nutrition and responsive to the expectations of young
sanitation (102, 103) represent areas people, including being trustworthy,
with emerging evidence of nursing non-judgemental, and client centred;
effectiveness in addressing the social meeting them on their own terms;
determinants of health (4). Nurses may and being accessible (107–110).
be among the first to deal with the
impacts of climate change (104–106), 34. Nurses have shown positive results
which will include efforts to strengthen in areas that represent a particular
the resilience of the poor and those challenge to women, such as family
vulnerable to climate-related events, planning and abortion care (111, 112).
as well as reducing the mortality from Optimizing their role in the delivery of
climate-sensitive diseases such as these services can lead to better access
diarrhoeal diseases, malaria, African to reproductive health care for many
trypanosomiasis, leishmaniasis, women. Nurses offer social support to
schistosomiasis, intestinal nematode women for maternal health care during
infections and dengue fever. critical life events (for example, prenatal
© WHO/Yoshi Shimizu

and postpartum periods (113) and breast nurses and midwives as the health
cancer) and are key to ensuring that professionals who most often (45% and
women receive respectful care in health 24%, respectively) conduct in-person
services settings (114, 115). Nurses are identifications (116). In concluding this
also essential to the fight against gender- chapter, Figure 3.1 summarizes the
based violence: studies on screening contribution of nursing to the triple
for intimate partner violence report billion targets.
Figure 3.1 Nursing contribution to the triple billion targets
UNIVERSAL HEALTH COVERAGE

• Front-line providers of primary care
• Preventing and treating wide range of communicable
and noncommunicable diseases
• Offering care across the life course, from birth to death
EMERGENCIES, NURSES HEALTH AND

EPIDEMICS AS PART OF WELL-BEING
AND DISASTERS • Addressing the social
• Delivering care for MULTIDISCIPLINARY determinants of health
clinical emergencies through collaborative action
• Responding to epidemics,
TEAMS • Addressing and treating the
disasters and humanitarian impacts of climate change
crises • Ensuring access for
• Recognizing life-threatening vulnerable groups,
conditions and performing including women and
life-saving procedures youths

© WHO/ Yoshi Shimizu

CHAPTER
4
Policy levers to enable
the nursing workforce
35. Optimizing the contribution of the framework are societal, economic and
nursing profession, as described in the population factors that affect the health
preceding chapter, requires a conducive labour market. Some of these factors
policy and practice environment. Many of (gender bias, country income level) are
the factors that influence the availability, discussed in detail in this report, while
distribution, capacity, enabling work others, such as demographic trends
environment and performance of the (ageing, growth patterns) and climate
nursing workforce can be analysed change, should be considered more
through a public policy perspective, directly in the national-level context
utilizing the WHO health labour market when designing and implementing
framework (117) (Figure 4.1). relevant nursing workforce policies.
36. Based on this framework, the report

considers four dimensions that 4.1 Pre-service education and
characterize the health workforce policy training
discourse on nursing, consolidating
the evidence base from peer-reviewed 37. The purpose of nursing education is
literature on (a) pre-service education to produce a nursing workforce that
and training; (b) workforce inflows and can meet the health needs of the
outflows; (c) equitable distribution and population, in quantitative, qualitative and
efficiency; and (d) regulation (including distributive terms. The intake and output
the private sector). Also referenced in the of nursing education institutions should
Policy levers to enable the nursing workforce 19

Figure 4.1 Public policy levers to shape health labour markets
Economy, population and broader societal drivers

Education sector Labour market dynamics
Education sector Labour market dynamics
Training in Pool of qualified Employed Health care Available, accessible,
High health health workers sector acceptable health Universal
school Education Poor of qualified Health care workforce that
Health health
High School
Employed
with safe, effective person-

Universal health coverage
Training in
in health health workers* sector** delivers quality
workforce coverage
certified health srvices

other fields services
equipped
Education in Migration to deliver
Unemployed
other field Unemployed quality health
Other sectors service
Out of
Out of labour force
Abroad Labour Force
Abroad Other Sectors
Policies on production Policies to address inflows and outflows Policies to address maldistribution
• on infrastructure and material • to address immigration and emigration and inefficiencies
Policies on production
• on enrolment Policies to address
• to attract inflows
unemployed and
health outflows
workers •Policies
to improve to productivity
address and performance
• ononselecting studentsand
infrastructure • toaddress
• to bring health workers
migration andback into the health
emigration •maldistribution andcomposition
to improve skill mix inefficiencies
• on teaching staff
material • tocare sector
attract unemployed health workers •• totoretain
improve
healthproductivity
workers in and
• on enrolment • to bring health workers back into the health underserved
performance areas
• on selecting students care sector • to improve skill mix composition
• on teaching staff • to refrain health workers in
undeserved
Policies to regulate private sector
• to manage dual practice
Policies to regulate
• to improve theofprivate
quality trainingsector
• to •manage dualservice
to enhance practice
delivery
• to improve quality of training
• to enhance service delivery
Source: Adapted from Sousa A, Scheffler RM, Nyoni J, Boerma T. A comprehensive health labour market framework for universal health coverage.
* SupplyBulletin of the World
of qualified healthHealth Organization.
and social workforce2013;91:892–4.
willing to work
** Demand for health and social workfoce in the health and health-realted social care sectors
Source: Adapted from Sousa A, Scheffler RM, Nyoni J, Boerma T. A comprehensive health labour market framework for universal health coverage.
Bulletin of the World Health Organization. 2013;91:892-4. (UPDATE TO TRA).
therefore be tailored to the needs and of qualified faculty to accomplish

absorption capacity of the health sector. programme mission and objectives,
Ensuring there is no mismatch can be along with infrastructure and capacity
facilitated by regular dialogue between for clinical education (120). Squires et
and coordination among the health, al. reported that “macro” factors such
education, labour and finance sectors. as health system capacity for health
workers (hospital beds per population)
38. The number of students enrolling in and and gender empowerment also affect
completing nurse education programmes the production of nurses in a given
is affected first by the basic education country (121).
levels of the population and by the
educational prerequisites to enrol in a 39. Gender issues can affect enrolment
nursing programme (118, 119). Enrolment of nursing students and thus impact
in nursing programmes is affected by the supply of nurses. The social and
programme location, cost, programme economic undervaluing of nursing work
capacity, clinical affiliations and level limits nurses’ opportunities to participate
of nursing education offered. Each of in decision-making and become leaders
these in turn is influenced by numbers within health care systems (22, 23, 122),

which may undermine efforts to recruit 41. The location of nursing schools and
qualified applicants to nursing education training programmes also affects the
programmes. Biased perceptions of pool of qualified applicants. Nursing
women’s role in caregiving and social education programmes are primarily
gender norms make recruitment of situated in urban centres with universities
male students an ongoing challenge: and hospitals, leaving potential students
while a nursing education for women from rural and remote areas with far
may be regarded as upward mobility, fewer education options (129). With an
this may not be so for men (123–125). increasing focus on the geographical
Furthermore, opportunities for women in distribution of the health workforce,
other occupational groups may be limited and the social accountability of training
by cultural or systemic constraints, institutions, some programmes are
making nursing education the only or incorporating rural training sites or
most obvious pathway for a career in actively recruiting and supporting
health care for women, instead of a students from communities historically
valued option for aspiring health workers underrepresented in post-secondary
of any gender. education. Online distance education
programmes combined with appropriate
40. In some settings, certain race, ethnic opportunities for clinical education may
or other vulnerable groups may be offer effective options for potential
underrepresented in nursing education students in rural areas (130); while
(126). This may have negative impacts there should be constant attention to
on the cultural fit between nurses and monitoring and preserving quality of
the communities they serve. Although education, this approach has potential, in
there is an increasing focus across the some settings, to enhance the diversity
nursing profession on ensuring that of students in nursing programmes (131).
education and training incorporate
cultural competencies, greater efforts 42. Costs (in terms of both tuition fees
are needed to increase the selection and living expenses) can affect student
and recruitment of students from ability to attend or complete a nursing
underrepresented populations (Box 4.1). education programme. While the cost
Box 4.1 Australia: engaging underrepresented populations in the

nursing workforce
In Australia, Indigenous Australians have been requesting increased care from Indigenous
practitioners so as to increase their access not just to care, but to culturally safe care (127).
The solution however has not been as simple as increasing the numbers of Indigenous and
Aboriginal and Torres Strait Islander students, but also ensuring that the challenges these
students face are addressed, such as building an enabling environment, having Indigenous
nurse educators, embedding Indigenous content in the curriculum, and addressing the
financial needs of students (127, 128).

of nursing education can vary widely certificate programme to completion of
(Box 4.2), public programmes are secondary school (12th grade) plus two
more heavily subsidized and often less years of university-level education to
expensive than private programmes enter a degree programme (135, 136).
that rely on student tuition and private While the variety of programmes and
contributions. The cost of living, entry requirements can enable a broader
alongside low or no earnings when range of people to enter the profession,
studying full time, adds to the personal employers often fail to differentiate
cost of study. Different countries practice roles based on the level of
have varying funding schemes, which education, creating a mismatch with
may include options or incentives the supply system that is producing a
for students from underrepresented generalist and the employer who has
groups or for those willing to practise in structured their services in a specialist
underserved areas upon graduation. or differentiated care context.
43. There are a variety of entry-level 44. Some countries around the world
educational programmes that produce educate a substantial proportion of their
nurses with different qualifications nursing workforce at the certificate
and professional roles but who meet and diploma level, often at stand-alone
the nursing professional and nursing training institutions that focus on task-
association classification criteria (ISCO- oriented clinical skills (137). University
08). Entry-level programmes may degree (bachelor’s) programmes
prepare nurses at the certificate level, typically include additional coursework
diploma level and degree (bachelor’s) in leadership, case management, and
level; the academic requirements for socioeconomic factors that affect health
an entry-level nursing programme can and patient outcomes in diverse inpatient
vary from completion of the ninth grade and outpatient settings; sometimes a
or below and 17 years of age for a research component is also included.
Box 4.2 Cost of nursing education
Around the globe it is estimated that US$ 27.2 billion is spent annually on nursing and
midwifery education (132). While nurses and midwives form more than half of the global
health workforce, the spending on nursing and midwifery education is around a quarter of
the global expenditure on health worker education. Estimates published in 2010 presented
an average cost per nursing graduate of US$ 50 000 globally, with a range from an average
of around US$ 3000 per nurse in China to over US$ 100 000 in North America (132). This
variance can be attributed to the proportional share of the public and private sectors in
financing, owning and managing educational institutions, as models for financing nursing
education differ both within and between countries (133). Another factor driving variability
in the cost of nursing education is the different levels of qualification that coexist and
diversity in the duration and prequalification of the education programmes (134). More and
better data on nursing and midwifery graduates, and the cost of education and training, are
needed to guide investments to meet the estimated shortages by 2030.

These programmes also emphasize 46. A critical but often challenging
“critical thinking skills” that can contribute component of nursing education is
to more advanced clinical judgements securing adequate time and exposure
and increase the safety of care provision. for students in clinical practice settings.
Research findings indicate that patients During clinical practicums, students
who are cared for by a higher proportion apply and integrate the critical thinking,
of degree-prepared nurses are less likely clinical assessment and nursing care
to die, stay in the hospital for shorter competencies learned in educational
periods, and face lower health care costs settings. Clinical teaching faculty
(46, 138, 139). However, most studies is required to provide appropriate
indicating better patient outcomes for supervision and conduct clinical skills
degree-prepared nurses took place in assessment. Because many nursing
hospitals and have not been replicated programmes are located in urban
in ambulatory and community settings, areas, providing appropriate clinical
limiting the generalizability of findings experiences in rural or remote facilities
(140). Additional evidence suggests can be challenging. That exposure can
that baccalaureate-prepared nurses be instrumental to a student’s eventual
may not use the full complement of decision on where to practise (144).
their knowledge and skills in the Some online or distance programmes
workplace (141). have been shown to increase access
to rural and remote clinical facilities
45. Nurses can also be prepared as post- previously not associated with a “brick
baccalaureate specialists or at the and mortar” education institution (145,
master’s degree level for specialty 146). Alternatively, telehealth technology
or advanced practice, or can obtain a and simulation laboratories can provide
doctoral degree in nursing, either the appropriate and complementary clinical
practice-oriented Doctor of Nursing experiences in primary care (147–150).
Practice, or the research-oriented Doctor Online distance education programmes
of Philosophy (142). Increasing the should be monitored and held to the
educational qualifications of professional same accreditation and quality standards
nurses will require articulation between as other education institutions.
different levels of programmes that build
on and provide credit for prior learning 47. Many countries have experienced a
(143). In countries in which there is substantial growth of private sector
demand for degree-prepared nurses, health education institutions, both not-
education programmes that “bridge” or for-profit and for-profit (151, 152). The
“upgrade” an existing nursing credential latter group is more often associated
can represent an important career with higher tuition fees and may be
development mechanism and generate subject to different regulatory authority
high rates of private return. Of note, requirements and accreditation (152).
preparation of nurses at the bachelor’s They may be disconnected from the
level is needed for postgraduate health and education public policy
education at the master’s or doctoral objectives, and thus may not always be
level, which in turn can affect quantity and aligned with population–health priorities,
quality of faculty for entry-level nursing especially if the intention is to educate
programmes. nurses for the growing international

health labour market. When no quality qualified nurse faculty (19, 20, 154).
assurance mechanisms are in place, Challenges include their employment
the content and delivery modalities of setting (educational organization versus
the curriculum may not meet national clinical agency), which may involve
standards, including required clinical salary differences and protected time
experience, producing graduates who are for teaching. A report by the American
not equipped with the knowledge, skills Association of Colleges of Nursing
or behaviours to provide safe and quality proposed merging education and clinical
care (153). A proliferation of private practice roles of nurse faculty (joint
schools not affiliated with hospitals or appointments) to increase the status,
academic medical centres can place remuneration and engagement of expert
pressure on existing clinical placement clinicians in nursing education (155).
sites and call into question the quality of Other strategies include academic–
the training provided therein. clinical partnerships in which clinicians
receive academic training to prepare
48. One of the biggest challenges in them to precept students in their
nurse education is the recruitment clinical settings, as well as incentives to
and retention of sufficient numbers of further their education, such as tuition
Box 4.3 Addressing the shortage of nurse educators
The challenge of nurse educator shortage, which is experienced across the globe, may
be alleviated through more collaborative approaches such as pooling resources across
institutions, and possibly even across countries (156).
In Thailand, a collaborative approach to increasing the academic credentials of nursing

faculty is the Programme of Higher Nursing Education Development, conducted at Chiang
Mai University and funded by the China Medical Board (157). This programme, started in
1994, focuses on training masters and doctorally prepared nurse educators to teach in the
growing number of baccalaureate nursing programmes across China. The programme has
subsequently expanded its impact across 10 countries in East and South-East Asia, allowing
the expansion of nurse education programmes and mutual recognition of nurse credentials
across the region (157).
In the United States, the Veterans Affairs Nursing Academic Partnership programme
provides funding for salaries and training of expert nurses as faculty in partner academic
institutions to increase the number of graduates prepared to meet the unique health care
needs of veterans in acute and primary care settings (158).
In Rwanda, the capacity of nursing faculty was strengthened through continuous education
focused on advanced teaching methodologies and curriculum development, among other
approaches (159). This initiative was supported by an international academic partnership,
recognizing that the programme had to be owned by Rwanda, and that cultural humility
needed to be practised through the collaboration (159).

remission and access to additional 4.2 Workforce inflows and outflows
training opportunities. The success of
these partnerships often rests on clinical 51. The number of active nurses (or nursing
sites providing adequate release time workforce “stock”) is determined by
for expert clinical nurses to supervise or many elements. “Inflows” comprise
engage with students on site. Examples graduates from domestic nursing
within and across countries are provided programmes who enter practice, nurses
in Box 4.3. who immigrate from other countries and
those returning to practice. “Outflows”
49. The shortage of faculty prepared at include nurse graduates who fail to
the master’s and doctorate levels is maintain employment in the domestic
an impediment to establishing higher health sector, nurses who choose
degree nursing education programmes, to work outside the health sector,
especially when educators’ requirements retirements and those who
are specified in accreditation or approval migrate abroad.
criteria. The lack of faculty trained at
doctoral level also impacts the ability 52. A fundamental determinant of the
of the profession to conduct research inflows of health workers into the
needed to develop evidence to inform health labour market is the country’s
practice, and to assume leadership roles economic capacity to create funded
in academic and health care sectors (20, employment positions (whether in the
154, 160). public or private sector) or opportunities
for income through the provision
50. Among all health care disciplines, nursing of health services. Job creation is
has been shown to make the most use therefore directly correlated with the
of interprofessional education (161). This socioeconomic level of the country, and
approach to education is also valued – within that – the level of prioritization
by nursing students, who perceive awarded by public sector policy-makers
it as facilitating their achievement to investments in the health sector and
of interprofessional collaboration in the health workforce in particular.
competencies (149, 162). Additionally, Other factors that impact demand
the integration of educators from are demographic changes, such as
different disciplines into the teaching ageing populations; changing disease
of nursing has the potential to bring profiles, such as growth in chronic
specialized knowledge from other disease and multiple morbidities; high
disciplines into nurse education, and rates of nurses leaving employment or
may enhance nurses’ competencies shortages of other health professionals;
required for team-based patient care a growth in health facilities, for example
(163). Currently, this teaching approach is through hospital construction or a
utilized more in high-income than in low- change in hospital hiring policies; or
and middle-income countries (159), but changes in legislation, such as staffing
the increasing use of technology, even norms for nurse-to-patient ratios (140,
in low-resource settings, creates a real 164). Factors that can reduce demand
opportunity to enhance interdisciplinary for nurses include new technologies
learning (162). that affect the need for inpatient or
provider care, high levels of retention,

greater productivity (for example, working conditions, health infrastructure,
through use of evidence-based practice clinic or hospital resources, and
or greater use of technology), and role education opportunities. In addition to
delegation from a nurse to a different these pull factors, destination countries’
occupational group (164). visa provisions for family petitions
may also be an incentive to migrate.
53. The international mobility of the nursing Push factors include absence of job
workforce is increasing, with significant opportunities, poor working conditions
effects on the pool of health workers in and terms of service, and insecurity in
countries. Reasons for nurse migration source countries. Remittances from
include availability of better jobs, salary, nurses working abroad can account for a
Box 4.4 Global skills partnerships
Adoption of the Global Compact for Safe, Orderly and Regular Migration in December
2018 by 152 States Members of the United Nations advanced a comprehensive approach
to addressing international migration. A central tenet of the Global Compact is building
global skills partnerships – bilateral agreements to leverage opportunities from migration
through matching the demand for and supply of workers with targeted educational support in
countries of origin (166). The format of the partnerships is designed to channel the pressures
of migration into tangible, mutual and fairly shared benefits for both source and destination
countries, which is consistent with the principles of the WHO Global Code of Practice.
Through such an agreement, the country of destination agrees to provide technology and
finance to train potential migrants with targeted skills in the country of origin, prior to
migration, while the country of origin agrees to provide that training, and also receives
support for the training of non-migrants (166). As part of this partnership, nurses may for
example be trained on a “home track” and an “away track”, where the home track nurses
receive skills training appropriate to the needs of the country of origin, while the away
track nurses are prepared for working in the destination country. Depending on the needs
of each partner, this partnership may not be limited to single occupations. The partnership
between Health Education England (of the United Kingdom National Health Service) and
the Government of Jamaica is intended to improve Jamaica’s specialist nursing workforce.
Jamaican nurses train in critical care in United Kingdom hospitals for a period of two years,
then return to Jamaica to transition into specialist roles. In parallel, United Kingdom nurses
will spend time in Jamaica to support health system strengthening activities, including
service delivery, quality improvement and training. The exchange programme was
initiated in 2019.
The International Organization for Migration has similar projects across the globe, linking
countries of origin and destination countries through programmes that promote effective
management of health worker migration, health systems capacity-building in countries of
origin, and skill and knowledge transfer from the diaspora (167). It does so in collaboration
with national governments and other stakeholders. The International Organization for
Migration is a key partner to the efforts of WHO, endorsing the WHO Global Code of
Practice as well as relevant policies and World Health Assembly resolutions (167).

substantial source of revenue for families 4.3 Equitable distribution and
and a sizable contribution to some efficiency
source countries’ economies. Policy
solutions, such as agreements between 55. Once in the health sector, nurses are
countries (bilateral agreements), must employed in a range of settings across
be mutually beneficial to source and the continuum of health service delivery
destination countries, consistent with points, both public and private (175–178).
the policy provisions of the WHO Global The distribution of nurses in different
Code of Practice on the International types of facilities and facility ownership
Recruitment of Health Personnel (165) is not systematically documented.
on support and safeguards (see Box 4.4 However, nurses may prefer to work
on global skills partnerships). in hospital and acute care settings as
opposed to primary care settings, and
54. The number of foreign-trained nurses in some contexts, nurses choose to
working in OECD countries increased work in the private sector due to the
by 20% over the five-year period from better remuneration compared to public
2011 to 2016, outpacing doctors to facilities (175, 177).
reach nearly 550 000 (168). The vastly
improved data indicate a blurring of 56. Care models should strive for the optimal
traditionally recognized “source” and skill mix in integrated primary health care
“destination” countries (169). While teams (179), allowing nurses to work to
there is still high economic demand the full scope of their nursing education
for nurses in high-income countries (180, 181). Nurses are a cornerstone
(see Box 4.5 for examples), there are of integrated care teams, often leading
emerging migration patterns from care provision and taking on expanded
Asia, Africa and the Caribbean to other practice roles, including, where relevant,
regions and countries (such as the Gulf collaboration with and oversight of
States) (170), as well as South–South community health workers (182–193).
migration amongst countries within Allowing nurses to practise at the top of
the same region. their education and experience can result
Box 4.5 Examples of economic demand for nurses in

high-income countries
Demographic, epidemiological and health policy shifts point to a growing demand for
nurses in high-income countries. Examples include:
• The Health Foundation in the United Kingdom estimates a need to recruit at least 5000
nurses per year from abroad until 2024 (171).
• In Japan, a new visa programme was enacted to attract up to 245 000 foreign workers,
including 60 000 nursing aides (172).
• The German Government reported approximately 36 000 vacancies in elderly and sick
care (173), noting that they would need to recruit from abroad (174).

in greater job satisfaction and greater medication compliance, monitoring
patient satisfaction with care (194). prescription decisions and reducing
Enabling factors are training in primary prescribing errors (203, 204).
health care, development of standardized
practice guidelines or standing orders, 58. The advanced practice registered nurse
and data systems to track patient care role was developed to increase access
outcomes (195, 196). for underserved and remote populations
and to address understaffing in primary
57. Many countries have prescribing as care settings (192, 207). The most
part of the professional or registered common type of advanced practice
nurse’s scope of practice (197, 198). nurse role is the nurse practitioner,
Nurse prescribing can be restricted to with a clinical scope that includes
specific groups or medication schedules the authority to autonomously order
established in legislation or the diagnostic tests, make diagnoses, and
professional regulatory framework (199). prescribe treatments and medications
In other circumstances, the prescribing (207). Certification by professional
of drugs is specific to population health organizations and master’s level
priorities, such as first-line antiretroviral education are usually required (208). In a
treatment in high-burden HIV countries small number of high-income countries,
in sub-Saharan Africa, antimicrobial there is strong evidence on the
resistance, or addressing chronic effectiveness of nurse practitioners and
conditions (200–202) (see Box 4.6 on advanced practice nurses in providing
prescribing in Poland). Nurses also quality care, enhancing access to care
play an important role in encouraging and improving patient satisfaction with
Box 4.6 Expanding access via nurse prescribing in Poland
Among the national health priorities for Poland was to improve community-level
management of chronic conditions and to increase accessibility to treatment and medicines
in primary health care settings. Policy decisions around nursing education and regulatory
mechanisms effectively expanded the function of nurses in the health care system, and
increased patients’ access to health services (205).
In 2016, nurses with specific qualifications were granted authority to prescribe medications
under certain conditions. To prepare graduating nurses for this role, prescribing was
incorporated into every initial nursing and midwifery education programme, and
regulations allowed all nurses graduating with a Bachelor of Nursing degree to prescribe
a predetermined list of medications (206). In parallel with this, a new national strategy on
developing nursing and midwifery introduced organizational standards for the different
roles and professional competencies of nurses and improved working conditions.
Since 2016, 10 287 nurses and 4799 midwives have completed training enabling them
to prescribe. By December 2018, nurses and midwives had independently issued 2538
prescriptions and authorized the continuation of 363 288 previous prescriptions.

care, when adequately trained (208, may also be eligible for certification as
209), though data on cost-effectiveness a specialist, though not licensed as an
are limited (208–210). The number advanced practice nurse (see Box 4.7 for
of masters in nursing programmes an example of a specialist nursing role).
and nurse practitioners is growing in
other countries as well (159, 211–214), 59. The geographical maldistribution
though regulations affecting educational of the health workforce between
preparation and certification or licensing rural and urban areas is a universal
vary significantly (192). Recognition of challenge. Countries employ a variety
the definition of the advanced practice of policy measures in multiple domains
nurse role and the related competencies (education, regulatory, financial and
also differ widely by country (192, 215), professional) in attempts to equitably
though country experience suggests deploy and retain health workers in
that advanced practice roles increase rural or remote areas (217) (see Box
the attractiveness of nursing as a career 4.8 on rural retention). Given that a
(211, 214). A nurse prepared at the multipronged approach is required to
baccalaureate level with expertise in address this multifaceted problem,
the care of defined patient populations understanding the impact of various
Box 4.7 Example of a specialist nursing role in the African Region
A growing number of governments in eastern and southern Africa are investing in a

specialist nurse role for children’s health as part of strategies to reduce child mortality.
A children’s health specialist is a registered nurse who has undertaken post-basic training
leading to an additional recognized qualification as a specialist paediatric or child
health nurse.
The most common route is to specialize after completing basic training (an advanced
diploma or baccalaureate degree in nursing) by undertaking a 12-month postgraduate
diploma in paediatric nursing. The resulting title and credentials vary by country – typical
formulations include registered nurse paediatric specialist, or professional nurse with
paediatric specialization.
There are approximately 3650 registered children’s nurses in the region, including
approximately 750 in Kenya, Malawi, Uganda and Zambia, and 2900 in South Africa (216).
The 12 different educational programmes (the majority in South Africa) graduate around
205 children’s nurse specialists annually. Three more programmes (Botswana, United
Republic of Tanzania and Zimbabwe) are in development (216).
Few country information systems in the region are currently set up to disaggregate by
nurse specialism. The Children’s Nursing Workforce Observatory supports national planning
for an optimized skill mix that meets the special health needs of children in the region.
Since 2015, researchers, nursing educators and other stakeholders have been collaborating
to capture and report on the role of the children’s nursing workforce in eastern and
southern Africa.

interventions is key to scaling up and 225). Organizational factors that affect
sharing such strategies in different retention include work environment,
practice settings and geographies working relationships, working conditions,
(144). In a country study, additional salary, managerial style and effective
measures were found to be important supervision (226). In studies covering
for rural providers, most notably Australia, Egypt, Islamic Republic of Iran,
fairness, transparency, predictability of Jordan and the Philippines, research
management of human resources for found that leadership styles of clinical
health by the Ministry of Health, and managers and organizational culture
employment status (permanent versus directly impact nurses’ job satisfaction
contract) (218). Studies in middle- and and turnover, and may affect quality of
high-income countries found that care, in both hospital settings (227–229)
organizational commitment, as well as and rural settings (219, 220).
intensive support from nurse managers,
was linked with nurse retention in
Decent work
rural practice (219, 220). Recruiting
nursing students from hard-to-reach 62. According to the ILO, decent work
communities may result in better “involves opportunities for work that is
retention if they return to work in their productive and delivers a fair income,
community (146, 221). security in the workplace and social
protection for families, better prospects
60. The retention of nurses in their practice for personal development and social
settings can be challenging. Nurse integration, freedom for people to
turnover is an inevitable consequence express their concerns, organize and
of market forces that can have both participate in the decisions that affect
positive and negative effects on health their lives and equality of opportunity and
care organizations, patients, and the treatment for all women and men” (230).
nurses themselves (220, 222). For Typical challenges to the decent work
instance, modest turnover rates can be agenda in the context of the nursing
beneficial for professional competency profession include gender issues, risk
development and organizational of attacks, excessive working hours and
alignment, for example when nurses exit unfair treatment of migrant nurses.
their roles to pursue career advancement
within an organization or health 63. Female nurses, together with other
system (223). On the other hand, job women in the health workforce, face
resignations and turnover almost always more barriers at work than their male
involve organizational costs and can have colleagues (21, 231). These include
negative impacts on patient care. biased perceptions of women’s roles in
caregiving, social gender norms, gender
61. Both organizational and individual factors bias and stereotyping, all of which
impact a nurse’s intention to leave or stay undermine nurses’ ability to obtain good
in a given job. Individual factors include working conditions, receive fair pay and
changes in personal or family life or equal treatment, participate in decision-
health, educational goals, work stress, job making, and become leaders within
dissatisfaction or, conversely, a sense of health care (21, 22, 122). A 2019 WHO
empowerment in decision-making (224, report, Delivered by women, led by men,

found that there is often a greater burden 65. Health service delivery requires constant
of discrimination in jobs where women responsiveness to patients, which
are in the majority: 36% of nurses in poses particular challenges in relation to
one context reported that they were not long and irregular hours, with potential
being respected by their seniors, while negative repercussions for the nurses
32% of nurses said they would like to themselves (including burnout) and for
be heard or listened to (21). These patients (including increased medical
barriers undermine the well-being and errors) (235). The ILO Nursing Personnel
livelihoods of female health workers, Convention, 1977 (No. 149), commits
and constrain progress on gender signatories to ensuring that nurses
equality (21). Gender discrimination enjoy working hours equivalent to other
also has a direct impact on care, as workers, and that overtime, inconvenient
institutional support and respect for hours and shift work are regulated
nurses improves the quality of care (232). and compensated.
Sexual harassment in the workplace is
a problem faced by women across the 66. Migrant nurses are also at particular risk
health workforce, including nurses (25%) of not having decent working conditions.
(233) and midwives (37%) (21). Migrant nurses and nurses from ethnic
minorities are at higher risk of work-
64. In some settings, nurses and health related injuries and discrimination than
workers are at risk of attack. Between nurses from the destination country
1 January 2019 and 1 January 2020, or from the ethnic majority (236).
WHO, through its Surveillance System Discrimination is reported as the leading
for Attacks on Health Care, recorded cause of impaired health amongst
1005 attacks on health care, resulting migrant and minority nurses (236).
in 198 deaths and 626 injuries of health However, a lack of decent work at home
care workers and patients in 11 countries may also be a push factor in encouraging
facing complex emergencies (234). nurses to migrate (237–240).
Box 4.8 Rural retention guidelines
Attraction, recruitment and retention of nursing staff in rural and remote areas is
a growing concern in many countries. In 2010, WHO produced the global policy
recommendations on increasing access to health workers in remote and rural areas
through improved retention (217).4
The recommendations cover four main intervention areas: education, regulations,

financial incentives, and personal and professional support. Although research specific
to rural nursing is growing, it is still very limited. This evidence comes mostly from high-
income countries (notably, Australia, Canada and the United States), but it suggests that
financial incentives, personal and professional support, and accelerated health career
pathways influence the retention of nurses in rural areas.
4 Note that these guidelines are currently being updated.

4.4 Regulation programmes than private ones (247).
In some cases, the private sector
67. Regulation serves to protect the public has challenged accreditation findings
through setting and enforcing conduct, on the basis that those making the
education and practice standards. It can decisions have a conflict of interest; as
also benefit providers and help advance a result, governments are changing the
quality in nursing education (241, 242) composition of decision-making bodies to
and practice across the public and private increase lay member participation (248).
sectors. Regulatory bodies are also
increasingly generating and maintaining 69. Within countries, accreditation can vary
health workforce data and evidence by type of programme (249). In some
(243): in the past 15 years there has been countries, government agencies establish
a marked increase in the generation of and oversee public universities, and
regulatory research evidence across only private institutions are required to
several disciplines, with nursing being be accredited; elsewhere, if there is no
the most prolific (244, 245). government mandate, private institutions
may not have to be accredited at all.
68. Education regulation can include setting Accreditation can be mandated directly
national standards for nursing education, by law or indirectly by requiring that
approval of nursing education and graduates applying for enrolment or
training programmes by the nursing registration with the council or sitting for
regulatory body, and accreditation licensure exams have graduated from
of institutions by external agencies. a programme that was approved by
Accreditation, whereby institutions are the nursing council or accredited by an
evaluated against the standards for appropriate organization.
the delivery of education, incentivizes
institutions to produce graduates that 70. Most standards for nursing education
can enhance quality, equity, relevance specify the minimum number of clinical
and effectiveness of health services for hours and minimum competencies to
the population (246). However, standards ensure the integrity and breadth of the
and accreditation cycles must keep pace programme content. The standards for
with changes in health care science and nursing education are often specific to
delivery models and be affordable or an individual jurisdiction (for example,
cost neutral for institutions. Enforcement a country, state, or other area where
of standards is needed to remediate a particular set of laws or rules must
programme deficiencies or, as an extreme be upheld), which can impact the
but sometimes necessary measure, mobility of nurse graduates. Mutual
discontinue programmes that cannot be recognition agreements and harmonized
brought up to acceptable standards. A education requirements are increasing
2013 study in 17 sub-Saharan African standardization and the safe and efficient
countries found that there was a strong mobility of practitioners. Examples
legal mandate for nursing education include the United States Nurse Licensure
accreditation; however, accreditation Compact (250, 251), the Caribbean
levels were low in the programmes that Regional Examination for Nurse
produced the majority of the nurses Registration (252), the European Union
in the region and were higher in public Professional Directive (253, 254), the

Association of Southeast Asian Nations also increasingly have a mandate and
agreement (255), and the Trans-Tasman responsibility to maintain an up-to-date
agreement (256). Box 4.9 presents registry of the active nursing workforce.
examples of harmonization of education
standards and licensure examination. 72. Over 60% of countries use a licensure
examination to assess and enforce a
71. With respect to the individual nurse, minimum level of initial knowledge
professional regulation involves or “fitness for practice” of nursing
(a) establishing the requirements for graduates before credentialing them to
initial recognition for the title of “nurse” enter practice (29). Another assessment
(that is, registered or registered and method for initial fitness for practice
licensed), which could include a licensure is the objective structured clinical
examination; (b) the requirements for examination, which attempts to directly
re-enrolment, registration or licensure, observe competence in a simulated
which could include a requirement for clinical environment; however, this can
continued professional development; be expensive and labour intensive to
(c) setting the scope of practice for administer (260–262). There is debate
nurses and the code of conduct and about whether fitness for practice
ethics; and (d) facilitating the investigation examinations should be used for re-
of and potential disciplinary action licensure, for re-entry into the profession,
against nurses (259). Regulatory bodies or for foreign-trained nurses.
Box 4.9 Examples of harmonization of education standards and

licensure examination
In 1972, the territories of the Caribbean Community created the Regional Nursing Body with the
initial task of establishing a shared pool of qualified educators to alleviate bottlenecks in holding
competency assessments for graduate nurses (252). When analyses indicated that nursing
education curricula objectives, content and methods of teaching were similar throughout
the subregion, countries agreed to a singular and shared examination for nurses, which
began in 1990. The Regional Nursing Body coordinates the examination, which is based
on mutually agreed competencies for a registered nurse to practise; governance is shared
between the chief or principal nursing officers, nurse tutors, and nursing council of each
country, as well as educators from the universities of the subregion (257). The examination
allows for standardization and improvement of nursing education, as well as reciprocity and
ease of movement for registered nurses among the countries of the subregion.
In the European Union, efforts to harmonize the diversity and complexity in nursing degree
structures and curricular programmes started with the introduction of the sectoral directives
in the late 1970s, and has accelerated with revisions in 2005 (Directive 36) and subsequent
updates that introduced a standard set of competencies (Directive 55) (253, 254). These
changes, coupled with the Bologna Agreement (1999), resulted in a three-cycle educational
structure of bachelor’s, master’s and doctoral qualifications, with harmonized academic
qualifications across all disciplines (258).

© WHO/Sergey Volkov

CHAPTER
5
Current status of
evidence and data on
the nursing workforce
73. This chapter reports, for the first time through a single system for data
in WHO history, data on the nursing definition and reporting, the NHWA
workforce for over 190 countries based platform, which serves as an online
on a set of standardized indicators and repository for Member States to report,
one data reporting process, following monitor and use their human resources
the National Health Workforce Accounts for health data. Detailed methods are
(NHWA) approach. presented in Annex 2.
74. Data were collected on the availability, 75. The focus of the analysis was on the
composition, distribution, education and current nursing workforce, but the last
training, skills, management, regulation, part of this chapter considers future
financing, and leadership of the nursing possible scenarios of the nursing
workforce.5 In total, data for over 30 workforce under different assumptions
indicators were collected and analysed. to assess progress towards the
The data collection efforts included objectives outlined in the WHO Global
various stakeholders such as ministries Strategy on Human Resources for
of health, other ministries such as labour Health: Workforce 2030, and in relation
and education, human resources for to the 2030 Sustainable Development
health observatories, national public Goal (SDG) and universal health
health institutes, nursing professional coverage agendas (16).
organizations, government chief nursing
and midwifery officers, and other 76. The number of countries reporting
national, regional and international on nursing stock is unprecedented,
organizations. Data were collected representing the most comprehensive
5 Using the ILO definition of the nursing workforce: see Annex 1.
Current status of evidence and data on the nursing workforce 35

and updated data set on the nursing estimates to be updated retrospectively,
workforce ever compiled (Figure 5.1). The and the data limitations of prior analyses
information on nursing has particularly and reports to be addressed.
increased for the period 2013–2018
as compared to other occupations 77. Of 36 indicators on the nursing
thanks to the momentum created by workforce used for this report (see
designating 2020 the International Year Table A2.1 in Annex 2), almost all WHO
of the Nurse and the Midwife. Data Member States were able to report data
on the stock of the health workforce on their nursing stock and the majority
have increased in recent years, not on other key indicators, such as age
only in quantity of information but also distribution, gender composition and
in the timeliness of reporting, with a duration of training. Around 80% of
majority of countries having reported countries provided data for at least 15
data on the five occupations included indicators, and 23% of countries for at
in SDG indicator 3.c.1 (medical doctors, least 25 indicators. This chapter reports
nursing and midwifery personnel, on selected indicators with a large
dentists, pharmacists) within the last response rate by Member States (the
five years. The availability of actual and full list is available in Annex 2).
retrospective data has enabled previous
Figure 5.1 Number of countries with workforce data available in the WHO NHWA (1990–2018)
Countries with dentistry Countries with nursing and Countries with pharmaceutical Countries with
personnel data midwifery personnel data personnel data physicians data
191 countries with recent data

83% for years 2017 and 2018
160
140
120
100
Number of countries
80
60
40
20
0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Notes: (a) Considering the last five years, nursing stock data were collected for 191 countries. The latest data point may refer to different years; most
countries (83%) provided headcount data from 2017 or 2018. (b) The lag time in data availability and reporting explains the apparent downward trend in
recent years; more data points are expected to become available for 2014–2018, maintaining a positive upward trend for nursing workforce stock data.
Source: NHWA 2019.

5.1 Nursing workforce availability, composition and distribution
5.1.1 Key findings
Data from 191 countries indicate a global nursing stock of approximately 28 million
in 2018, predominantly (69%) professional nurses.
There was a 4.7 million actual increase globally in nursing stock between 2013 and
2018, even after accounting for better availability and quality of data.
Professional and associate professional nurses represent approximately 59% of

health professionals (medical doctors, nursing personnel, midwifery personnel,
dentists, pharmacists) in 172 countries with available data.
Nine out of 10 nurses globally are female, with important regional variations: in
the African Region the female–male ratio is 3:1. Male nurses outnumber females
in 13 countries.
There are also large variations in distribution within regions. In the Region of the
Americas, more than eight out of 10 nurses work in three countries (Brazil, Canada
and the United States), which host 57% of the population. In the African and
Eastern Mediterranean regions, the nurse density per population varies 100-fold
across countries.
One out of six of the world’s nurses are expected to retire in the next 10 years; this
percentage is substantially higher in the Region of the Americas (24%), posing a
further replenishment challenge.
5.1.2 Global and regional stocks numbers, there are almost 10 times
of nurses more nurses in the Americas than in the
African Region, with 83.4 and 8.7 nurses
78. Data for 191 countries indicate a global per 10 000 population, respectively. The
stock of almost 28 million nursing Eastern Mediterranean and South-East
personnel, comprising both the public and Asia regions have the second and third
private sectors (Table 5.1). This translates lowest density (15.6 and 16.5 nurses
to a global density of 36.9 nurses per per 10 000 population, respectively), but
10 000 population. However, this global this is still almost double the density
figure masks deep variations within and observed in the African Region.
across regions.6
80. Around 81% of the world’s nurses work
79. While the Region of the Americas and the in three regions (Americas, Europe and
African Region have similar population Western Pacific), which collectively
6 See section 5.2 on equity.

account for 51% of the world’s midwives (of which 18.8 million were
population. nurses) using 2013 data. Part of the
increase in the number of nurses from
81. A cautious interpretation is required 2013 to 2018 is due to improvement
in comparing this total estimate of of data availability (accounting for 4.4
27.9 million nurses for 2018 with the million nurses), while the actual increase
estimation in the Global Strategy on is estimated at 4.7 million nurses
Human Resources for Health, which (Table 5.2), of which 3.6 million were
had estimated 20.7 million nurses and professional nurses, assuming a constant
Table 5.1 Number of nurses globally and density per 10 000 population, by WHO region, 2018
Number of Number of Density

countries reporting nursing personnela per 10,000
WHO REGION headcount/total in millions (%) population
Africa 44/47 0.9 (3%) 8.7
Americas 35/35 8.4 (30%) 83.4
South-East Asia 11/11 3.3 (12%) 16.5
Europe 53/53 7.3 (26%) 79.3
Eastern Mediterranean 21/21 1.1 (4%) 15.6
Western Pacific 27/27 6.9 (25%) 36.0
Global 191/194 27.9 (100%) 36.9
a
Includes nursing professionals and nursing associate professionals.
Note: stock data were not available for Cameroon, Comoros and South Sudan.
Source: NHWA 2019. Latest available density reported by countries between 2013 and 2018. For countries with a headcount reported between 2013 and 2017, to
standardize all countries to year 2018, the headcount was reported by applying their latest available density to 2018 populations.
The population size for each country and year used to compute density values was extracted from the 2019 revision of the World population prospects of the
United Nations, Department of Economic and Social Affairs (263).
Table 5.2 Changes in nursing stock due to better data and actual increase between 2013 and 2018
Nursing stock in 2013 Nursing stock in 2018

Change
Number of Number of due to
countries countries actual
with with increase
data for Stock data for Stock in stock
SOURCE 2009–2013 (millions) 2013–2018 (millions) (millions)
Estimate of Global Strategy on Human Resources for

102 18.8a
Health, 2016
Estimate of State of the world’s nursing 2020 174 23.2 191 27.9 4.7
Change due to improved data (millions) 4.4
a
The original publication includes midwives: 20.7 million nurses and midwives. This corresponds to 18.8 million nurses when corrected for share of nurses.
Source: NHWA 2019.

proportion of professionals to associate 84. Sixty-six countries were able to report
professionals (Figure 5.2). recent health workforce stock for at least
10 occupations; when considering nurses
82. The total stock of 27.9 million nurses compared to all of these possible health
reported for 2018 therefore highlights workers, the nursing stock represented
two separate positive trends: a share of the health workforce ranging
between 40% and 50%.
• improved availability of nursing workforce
data, which allow a better interpretation
5.1.3 Composition
and reappraisal of prior analyses;
85. Of the world’s 27.9 million nurses,
• an actual increase in the nursing 19.3 million (69%) are categorized as
workforce stock globally, reflecting professional nurses (ISCO code 2221),
growing labour market demand for and and 6.0 million (22%) as associate
Member States’ investment in this professional nurses (ISCO code 3221).
occupational group. This leaves 2.6 million (9%) not classified
either way, indicating possible challenges
83. When comparing the stock of nursing in alignment between national data
personnel with the aggregate stock of systems and the ISCO system. These
medical doctors, midwifery personnel, nurses are either nursing professionals
dentists and pharmacists in the 172 or nursing associates, and this category
countries with available data, nurses does not include nursing aides or health
represent on average 59% of health care assistants. The relative proportions
professionals, ranging between 49% in the of the different nursing workforce
Eastern Mediterranean Region and 68% in categories vary substantially by region,
the Western Pacific Region (Table 5.3). as illustrated in Figure 5.2.
Table 5.3 Nurses as a percentage of health professionals (medical doctors, nurses, midwives,
dentists and pharmacists), by WHO region
Nurse stocka compared to the stock of SDG 3.c.1 health professionals
Number of countries
WHO REGION reporting/ total Average share of nurses
Africa 45/47 66%
Americas 24/35 56%
South-East Asia 11/11 53%
Europe 50/53 57%
Eastern Mediterranean 20/21 49%
Western Pacific 22/27 68%
Global 172/194 59%
a
Includes nursing professionals and nursing associate professionals.
Note: SDG 3.c.1 is the indicator used to assess progress on SDG target 3.c.
Source: NHWA 2019.

Figure 5.2 Proportion of nursing headcount within each occupation group, by WHO region
WHO REGION Professional nurses Associate professional nurses Nurses not further defined
Africa
Americas
South-East Asia
Europe
Eastern Mediterranian
Western Pacific
Global
0% 20% 40% 60% 80% 100%
Percentage of total nursing personnel headcount
5.1.4 Nursing demography: AGE DISTRIBUTION

sex and age distribution
87. Global patterns of population and
SEX DISTRIBUTION workforce ageing make it necessary
86. Gender mainstreaming in health to factor in the age structure of the
workforce strategies is needed to workforce in projections. In many
ensure that evidence-based gender- countries, planners rely on a standard
sensitive approaches are undertaken retirement age, but this approach has
in health workforce planning and limitations, given differences in actual
management. The sex composition and retirement age across occupations,
ageing dimensions of nursing have long sex and grade levels. Data on the
been overlooked for various reasons, age profile from 106 countries were
including the lack of quality data for used to illustrate the current trends in
national planning and regional and global nursing demographics. Overall, available
comparison. Of 194 WHO Member information indicates a relatively young
States, 132 provided data disaggregated nursing workforce: 38% of nurses are
by sex, and 106 provided data on age. aged under 35 years,7 compared with
In these 132 countries, around nine 17% who are aged 55 years or above
nurses out of 10 (89%) are female, with (the latter group considered to be
significant regional disparities. The share retiring over the next decade) (Figure
of women in nursing is highest (95%) in 5.3). Regional variations are however
the Western Pacific Region, and lowest important: in the Eastern Mediterranean
(76%) in the African Region. Thirteen Region there are 14 young nurses for
countries reported more male nurses every one approaching retirement; by
than female (Table 5.4). contrast, in the Americas this ratio
7 Herewith called young nurses.

Table 5.4 Percentage of female nursing personnel, by WHO region
Number of countries
WHO REGION reporting/total % female % male
Africa 30/47 76% 24%
Americas 26/35 87% 13%
South-East Asia 9/11 89% 11%
Europe 32/53 89% 11%
Eastern Mediterranean 11/21 78% 22%
Western Pacific 24/27 95% 5%
Global 132/194 89% 11%
Note: “Nursing personnel” includes nursing professionals and nursing associate professionals.
Source: NHWA 2019. Most recent available headcount reported by countries between 2013 and 2018.
Figure 5.3 Percentage of nursing personnel aged below 35 years and 55 years or over,
by WHO region
WHO REGION <35 years ≥55 years

Africa
(n=20)
Americas
(n=25)
South-East Asia
(n=8)
Europe
(n=30)
Eastern Mediterranian
(n=5)
Western Pacific
(n=18)
Global (n=106)
80% 60% 40% 20% 0% 20% 40%

is 1.2:1, and in Europe and Africa it 89. To illustrate the ageing of the nursing
is 1.9:1, indicating a much smaller workforce, the ratio of the younger to
replacement pool. the older nursing workforce is reported
in Figure 5.4. While several countries
88. As 17% of nurses globally are aged 55 have a high proportion of young nurses,
years or over – and therefore expected several are barely at equilibrium (similar
to retire within the next 10 years – proportions of nurses aged less than
4.7 million new nurses will have to be 35 years and over 55 years, as indicated
educated and employed over the next by the green line in Figure 5.4), and
decade just to maintain the status quo. 18 countries (one in six of those with
To keep pace with population growth available data) face a particularly
and eliminate nursing workforce challenging situation, having an ageing
shortages, even more will be required workforce with fewer young nurses than
(see section 5.8). nurses approaching retirement.
Figure 5.4 Relative proportions of nurses aged over 55 years and below 35 years
Each dot represents a country Green line indicates where the number of nurses near retirement
equals the number of young nurses in the workforce.
70%
60%
18 countries at risk
of an ageing workforce
Percentage of nurses aged 55+ years
50%
40%
30%
20%
10%
0%
0% 10% 20% 30% 40% 50% 60% 70%
Percentage of nurses less than 35 years
Note: “Nursing workforce” includes nursing professionals and nursing associate professionals from 106 countries with data disaggregated by age.

5.2 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 Eastern Mediterranean Region, with a
requires addressing demographic, ratio of highest to lowest density of 121
geographical and skills disparities in to 1, and in the African Region, with a
availability of and access to the health ratio of 100 to 1. Also, in the Region
workforce. of the Americas a few large countries
have high densities of nursing personnel
while most of the other countries have
5.2.2 Equity across regions
relatively low densities: 87% of the
91. Figure 5.5 shows the global variation in nurses in this region are located in
nursing personnel density per 10 000 Brazil, Canada and the United States,
population, with the greatest gaps which account for around 57% of the
concentrated in the African, South-East population. Lower density disparities –
Asia and Eastern Mediterranean regions 10 to 1 – are observed in the European
and some countries in Latin America. Region. Countries in the African Region
are clustered at the lower end of the
column, indicating that only a few African
5.2.3 Equity in nursing availability
countries have a density of over 25
within regions
nurses per 10 000 population. Similar
92. Figure 5.6 illustrates the variation in patterns are observed in the South-
nurse density within regions: each dot East Asia and Eastern Mediterranean
represents a country. All regions show regions. The density variance is largely
significant variation in nursing density, driven by income levels, with a density
but the disparity is greatest in the of 9.1 nurses per 10 000 population

Figure 5.5 Density of nursing personnel per 10 000 population in 2018
< 10 10 to 19 20 to 29 30 to 39 40 to 49 50 to 74 75 to 99 100 +
0 500 1,000 2,000 3,000 4,000

km
Source: NHWA 2019. Latest available data over the period 2013–2018.
Figure 5.6 Regional disparities in density of nursing personnel per 10 000 population (2018)
Ratio maximum: minimum density

100:1 22:1 18:1 10:1 12:1 33:1
200
Number of nurses per 10 000 population
150
100
50
Africa Americas South-East Europe Eastern Western

Asia Mediterranean Pacific
WHO regions
Source: NHWA 2019. Latest available headcount reported by countries between 2013 and 2018.

in low-income countries versus 107.7 for low-income countries. The great
per 10 000 population in high-income majority of these countries are also
countries (Table 5.5 and Figure 5.7). considered as vulnerable (“high warning”
or “alert” categories) according to
93. When considering the 46 countries the Fragile States Index.8 Box 5.1
classified as least developed by presents further information on
the United Nations Committee for equity within countries.
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/.
Figure 5.7 Density of nursing personnel per 10 000 population by income group (2018)
200
Number of nurses per 10 000 population
150
100
50
Low-income Lower middle- Upper middle- High-income

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

Table 5.5 Density of nursing personnel per income group (2018)
Number of Density per 10 000 population

countries Ratio highest to
INCOME GROUP reporting/total Overall Low High lowest
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
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.
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.
9 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).

5.3 International nurse migration and mobility
5.3.1 Key findings
Based on data from 86 countries, one nurse out of eight (13%) was born or trained
in a country other than the one in which they currently practise.
Among the responding countries, there was significant reliance on foreign-born

nurses in high-income countries, where 15.2% of nurses were reported to be
foreign born or foreign trained.
Despite improvement in availability, data on migration and mobility are still

insufficient to enable a comprehensive assessment of the complexity of
migration patterns.
5.3.2 Challenges in quantifying global North) countries than previously

international nurse mobility thought.
94. Demographic, epidemiological, financial
and health policy trends have driven an 96. As of 2018, a total of 86 countries
acceleration in the international mobility had provided data on the proportion
of health workers in recent decades, and of nurses who are foreign born or
this mobility is expected to increase (18). foreign trained as a proxy indicator
The WHO Global Code of Practice on of the magnitude of the migratory
the International Recruitment of Health phenomenon (Table 5.6) through the
Personnel, adopted by the World Health NHWA and the OECD, Eurostat and
Assembly in 2010, is a key international WHO Regional Office for Europe
legal instrument to strengthen ethical reporting systems. Among countries
management of international health reporting, one in every eight nurses
worker mobility. (13%) was born or trained in a country
other than the one in which they
95. The movement of health workers currently practise. Applying this share
from lower-income to higher-income to the stock of nursing personnel gives
countries, as well as associated an estimated 3.7 million nurses foreign
challenges, has long been recognized born or trained globally. Foreign-born
and debated. Data to inform policy or foreign-trained nursing personnel are
decisions have however been mainly found in high-income countries,
largely limited to select high-income with a share of 15.2%, compared to a
countries. Recent improvements in share of less than 2% in countries of
data availability, particularly through the other income groups.
system of NHWA, suggest a less clear-
cut distinction between origin (in the
global South) and destination (in the

Table 5.6 Percentage of nursing personnel foreign born (or foreign trained) per income group
Number of countries % of nurses foreign born or

INCOME GROUP reporting/total trained
Low-income 3/31 NR
Lower middle-income 18/46 0.4%
Upper middle-income 27/60 0.7%
High-income 38/57 15.2%
Total 86/194 13.2%
Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. “Foreign trained” was used as a proxy for 30 countries that
could not provide data on the percentage who were foreign born.
Source: NHWA 2019. Latest available stock reported by countries between 2013 and 2018. Income grouping is from the World Bank classification as of 2018.
NR = not reported because of the small number of countries.
© Ian Miles-Flashpoint Pictures/Alamy

5.4 Regulation of nursing education and practice
5.4.1 Key findings
Nearly all countries reported on indicators for regulation of nursing education,

and more than 50% of countries responded positively to each of the nine
related indicators.
The existence of regulatory mechanisms and processes was reported as high in

the African, American and European regions.
There is more attention to regulation of the contents of education (such as

standards for duration and content or education institution accreditation
mechanisms) than to education leadership and governance.
Nursing education systems appear more regulated in the European Region and
less regulated in the South-East Asia, Eastern Mediterranean and Western Pacific
regions, particularly in relation to fitness for practice examination and standards
for faculty qualification.
5.4.2 Analysis of results reported having continuing professional

97. The Global Strategy on Human development systems. About two thirds
Resources for Health: Workforce 2030 of responding countries had standards
includes a milestone for the year 2020 for interprofessional education, fitness
stating that countries should have for practice examinations and a national
regulation and accreditation mechanisms association for pre-licensure students
for health workforce education. This (67%, 64% and 62%, respectively).
section provides a synthesis of nine self- Of 95 countries responding, 53%
reported indicators relating to regulation reported having advanced practice
of nursing education and training nursing roles. The existence of these
(Figure 5.8). regulatory processes or systems does
not necessarily mean, however, that
98. The vast majority of countries reported they function adequately.
having standards for the duration
and content of nursing education, 99. Table 5.7 presents data on the existence
accreditation mechanisms for education of regulatory mechanisms and systems
institutions and a master list of on education and training in the
accredited education institutions (91%, different WHO regions. Countries in
89% and 81% of responding countries, the African, American and European
respectively). Of responding countries, regions more frequently reported
77% reported having standards existence of regulations on education
for faculty qualifications and 73% than did countries in other regions. In

Figure 5.8 Percentage of responding countries indicating existence of nursing regulations
and standards
Standards for duration and content of education

91%
Accreditation mechanisms for education institutions
89%
Master list of accredited education institutions
81%
Standards for faculty qualifications
77%
(76 yes out of 99)
Continuing professional development
73%
(96 yes out of 132)
Standards for interprofessional education
67%
(66 yes out of 99)
Fitness for practice examination
64%
(73 yes out of 114)
National association for pre-licensure students
62%
(55 yes out of 89)
Existence of advanced nursing roles
53%
(50 yes out of 95)
0% 20% 40% 60% 80% 100%
Table 5.7 Percentage of responding countries reporting existence of nursing regulations on

education and training, by WHO region
National
Master list Standards for Accreditation Standards association
of accredited duration and mechanisms for interpro- Continuing Existence of Fitness for Standards for
education content of for education fessional professional advanced practice for faculty pre-licensure
WHO REGION institutions education institutions education development nursing roles examination qualifications students
Africa 91% 100% 90% 81% 68% 74% 68% 78% 66%
Americas 77% 91% 94% 49% 71% 55% 57% 75% 91%
South-East Asia 69% 85% 78% 60% 61% 75% 72% 64% 38%
Europe 85% 94% 98% 87% 91% 30% 64% 94% 67%
Eastern
80% 80% 70% 20% 50% 50% 70% 80% 30%
Mediterranean
Western Pacific 70% 77% 78% 52% 63% 52% 56% 71% 35%
Global 81% 91% 89% 67% 73% 53% 64% 77% 62%
Source: NHWA 2019, and State of the world’s nursing 2020 specific indicators for the last three factors. Latest available data reported by countries between
2013 and 2018.

the Eastern Mediterranean Region, could be scored from 0 (absence)
countries reported greater availability of to 1 (presence), with a value of 0.5
fitness for practice examinations for partial; missing answers were
and the existence of advanced nursing considered as 0. These scores were
roles. Fewer countries in the South- then summed up to a maximum of
East Asia Region reported existence of 9. Because the analysis implicitly
continuing professional development considers that a missing answer for an
systems, national associations for indicator gives a score of 0, a sensitivity
pre-licensure students or standards analysis was conducted to explore the
for interprofessional education than implications of classifying the missing
did countries in other regions. These values differently, and this did not
regional variations may to some extent change the interpretation of the results.
reflect different interpretations of Figure 5.9 reinforces the finding that
these indicators. the reported existence of regulatory
mechanisms examined in this report
100. Data for the nine indicators were used points towards a relatively stronger
to derive a composite “regulation of education regulatory environment in
education and practice” score for each North America, western Europe and
country (see Annex 2). Each indicator sub-Saharan Africa.
5.5 Education and nursing workforce supply
Figure 5.9 Map of nursing education regulation scores, by country
4 and less 5 6 7 8 9
Note: Combining education capacity questions, raw score from 0 to 9.

Source: NHWA 2019.

5.5.2 Education pipeline 104. A simulation based on the available data
101. Significant investment in education and and applying to the world population
5.5.1 Key findings
A total of 88 countries, mostly from South-East Asia and Europe, reported data on
the number of nursing workforce graduates per year.
Regions with the lowest density of nurses (African, Eastern Mediterranean and
South-East Asia regions) also had the lowest graduation rates (7.7, 7.1 and 12.2 per
100 000 population, respectively).
Relative to their population, the Region of the Americas had 10 times more
graduates than the African and Eastern Mediterranean regions.
Among countries reporting data, the average duration of nursing professional

education in the African and Western Pacific regions was two to three years for
approximately 75% of countries, while it was four to five years for over half of the
countries in the American, South-East Asia and Eastern Mediterranean regions.
training is required to match current and the overall density of 22.6 graduates
anticipated needs of health systems and per 100 000 population would yield an
meet national and subnational needs. estimate of 1.72 million nursing graduates
per year. This analysis should be viewed
102. To assess the adequacy of the education as a pure illustration, as stemming from
pipeline, countries were asked to provide a small number of countries per region,
the number of nursing graduates in the with the exception of the European
most recent available year. In total, 88 Region. However, the data, while limited in
countries, of which almost half (41) were coverage, did not show a wide variation in
in Europe, reported on this indicator. the ratio of graduates to nursing stock. In
The “total” figures in Table 5.8 should addition, these results estimated on stock
therefore be interpreted with the utmost were compared to the share of the age
caution, as they are skewed by the data group aged under 35 years, that is, roughly
from South-East Asia and Europe, and the workforce starting employment within
are not representative of the situation in the previous 10 years. Using one tenth of
other regions. this younger category as a proxy to stock
entering the market annually, this would
103. Similar to the association with nursing correspond to a stock of 1.06 million to be
density, the level of income was a factor compared with the present estimation of
associated with an increased number of 1.7 million graduates. As not all workers
graduates per 100 000 population. are employed, the order of magnitude
seems plausible.

Table 5.8 Production of graduate nurses, by WHO region and income group
Mean number of nursing graduates Number of

Number of per 100 active nurses graduates
countries per 100 000
BY WHO REGION reporting/total Overall Low High population
Africa 14/47 8.8 2.8 23.7 7.7
Americas 14/35 9.8 0.8 30.8 81.2
South-East Asia 8/11 7.5 3.9 13.8 12.2
Europe 41/53 4.0 1.0 31.9 31.9
Eastern Mediterranean 5/21 4.6 0.6 16.5 7.1
Western Pacific 6/27 5.7 3.4 12.0 20.6
BY INCOME GROUP
Low-income 8/31 13.8 4.1 31.9 10.4
Lower middle-income 15/46 7.7 2.8 13.8 12.8
Upper middle-income 26/60 6.4 0.6 30.8 22.7
High-income 40/57 3.6 1.5 7.6 38.7
Total 88/194 6.2 0.6 31.9 22.6
Source: NHWA 2019. Income grouping is from the World Bank classification as of 2018.

5.5.3 Duration of pre-service education almost three quarters of countries
105. Data on the duration of nursing pre-service have four-year programmes.
education programmes were obtained for
157 countries from various sources. A few 106. In an era of expanding nursing scopes
countries, mainly in the African, Eastern of practice, nursing education beyond
Mediterranean and Western Pacific regions, pre-service is important to consider, as
have two-year programmes, while the well as variable entries via direct entry
majority of countries in all regions have pathways (with defined prerequisites).
three- or four-year programmes; five- Reporting pre-service education
year programmes are rare across regions programme length is affected by these
(Figure 5.10). In the African and Western inherent limitations, constraining the
Pacific regions about three quarters of ability of the data presented to describe
countries have three-year programmes, the rich variety of nurse education
and in the South-East Asia Region globally, particularly for advanced
practice roles.
5.6 Regulation of employment and working conditions
Figure 5.10 Average duration (years) of education for nursing professionals, by WHO region
WHO REGION 2 years 3 years 4 years 5 years
Africa
Americas
South-East Asia
Europe
Eastern Mediterranean
Western Pacific
Global
0% 20% 40% 60% 80% 100%

Source: NHWA 2019 for 99 countries and Sigma database for 58 countries. Latest available data reported by countries between 2013 and 2018.

5.6.2 Analysis of results 108. Of the responding countries, more than
107. Employment characteristics and 80% reported having regulation on
5.6.1 Key findings
The African, American, European and Eastern Mediterranean regions reported

high levels of existence of regulatory mechanisms relating to working conditions
for nurses.
Some countries, mostly in the South-East Asia and Western Pacific regions,
but also in the African Region and South America, reported lower levels of
these regulations.
Just over a third of countries (37%) reported having in place measures to

prevent attacks on health workers, mostly in the South-East Asia and Eastern
Mediterranean regions.
The existence of an advanced nursing role (reported by 53% of the 95 responding

countries) is more frequent in countries with a low density of medical doctors,
suggesting that more professional autonomy for nurses might be a policy response
to mitigate the shortages of medical doctors.
working conditions are major drivers working hours and conditions, social
of attractiveness of employment, protection and minimum wage, and
performance and productivity, and having a nursing council or equivalent,
retention of the health workforce. The but fewer responding countries (53%)
Global Strategy on Human Resources had advanced nursing roles. A total of
for Health: Workforce 2030 calls for 55 countries responded to the indicator
upholding “the personal, employment on the existence of measures to prevent
and professional rights of all health attacks on health workers, of which
workers, including safe and decent just over a third (37%) said that such
working environments and freedom from measures were in place.
all kinds of discrimination, coercion and
violence”. To assess this dimension, 109. Table 5.9 indicates that countries in the
six indicators related to regulation of Eastern Mediterranean Region reported
employment characteristics and working higher levels of employment regulations
conditions were examined (Figure 5.11). for nurses examined for this report: over
It should be noted that three indicators 70% of countries responded positively
(regulation on working hours and to all six indicators. The South-East Asia
conditions, nursing council, existence and Eastern Mediterranean regions
of advanced nursing roles) are specific were the only two regions in which the
to nursing: the rest apply to the health majority of countries reported having
workforce as a whole, including nurses. measures in place to prevent attacks

Figure 5.11 Percentage of countries with regulatory provisions on working conditions
Regulation on working hours and conditions

94%
(133 yes out of 42)
Regulation on social protection

91%
(125 yes out of 37)
Regulation on minimum wage

89%
Nursing council
86%
Existence of advanced nursing roles

53%
(50 yes out of 95)
Measures to prevent attacks on health workers

(20 yes out of 55) 37%
0% 20% 40% 60% 80% 100%
Source: NHWA 2019.
Table 5.9 Percentage of countries responding on existence of nursing regulations on working

conditions, by WHO region
Measures
Regulation to prevent
on working Regulation Regulation attacks Existence of
hours and on minimum on social on health advanced Nursing
WHO REGION conditions wage protection workers nursing roles council
Africa 90% 90% 85% 41% 74% 78%
Americas 97% 85% 94% 37% 55% 91%
South-East Asia 75% 50% 50% 67% 50% 80%
Europe 98% 92% 100% 26% 30% 96%
Eastern Mediterranean 85% 100% 92% 73% 75% 85%
Western Pacific 100% 86% 57% 30% 52% 78%
Global 94% 89% 91% 37% 53% 86%
Source: NHWA 2019, and State of the world’s nursing 2020 specific indicators for the last factor. Latest available data reported by countries between 2013
and 2018.

on health workers, probably reflecting the countries in this region responded
the relatively high incidence of such positively to each of the six indicators.
attacks in these regions.10 The African, As noted in section 5.4, these regional
American and European regions also variations may to some extent reflect
reported positively on most indicators different perceptions of the meaning of
tracked; only 30% of responding these indicators, as well as the different
European countries, however, reported reporting rates across regions. The data
having advanced nursing roles and 26% collected do not provide information on
reported having measures in place to the adequacy of regulations or the level of
prevent attacks on health workers. implementation of the relevant provisions.
110. High proportions of countries in the 111. Data for the six indicators were used
Western Pacific Region reported to derive a composite “regulation of
having regulation on working hours working conditions” score for each
and conditions and a minimum wage, country using a similar methodology
and a nursing council or equivalent. to that used in section 5.4, and with
However, they reported lower levels of methods described in Annex 2. Figure
existence of the other three regulation 5.12 reinforces the finding that, as for the
mechanisms. The South-East Asia Region education system analysed in section
reported the lowest rate of positive 5.4, the regulatory environment was
responses to indicators assessing the reported to be relatively stronger in
regulatory environment, although half of
10 Surveillance System for Attacks on Health Care: https://publicspace.who.int/sites/ssa/SitePages/PublicDashboard.aspx.
Figure 5.12 Map of regulation of working conditions score
1 or no 2 3 4 5 6
Note: Combining working condition capacity questions, raw score from 0 to 6.

Source: NHWA 2019.

North America, sub-Saharan Africa, and Figure 5.13 Percentage of countries with
the European Region. advanced nursing role by level
of density of medical doctors per
112. Advanced nursing roles were found to 10 000 population
be more frequent in countries with lower 80%
density of medical doctors, as shown in
Figure 5.13.
65%
Percentage of countries with

60%
59%
advanced nursing role

40% 43%
20%
0%
<5 5-19 20+
Medical doctors density
per 10 000 population
Source: NHWA 2019.

5.7 Governance and leadership
5.7.1 Key findings
Of the 115 and 76 responding countries, respectively, 71% reported having

a government chief nursing or midwifery officer position and 53% a nursing
leadership development programme.
Both the presence of a government chief nursing officer (GCNO) position and
the existence of a nursing leadership programme are associated with a stronger
regulatory environment for nursing.
Neither GCNO positions nor leadership programmes are however associated with
increased rates of production of nurses.
5.7.2 Analysis of results leadership and governance environment.

113. The future development of the nursing Figure 5.14 shows that, on average,
profession requires strong nursing countries with a GCNO and a nursing
leadership and governance (264, 265). leadership programme achieved
Two State of the world’s nursing 2020 higher scores for regulation of working
indicators were used to assess the state conditions for nurses and regulation of
of nursing leadership and governance: the nursing education.
existence of a GCNO position within the
national government, and the existence 116. Although existence of a GCNO position
of nationally supported programmes to and a nursing leadership development
develop nursing leadership, research or programme are both associated with
policy literacy skills (115 and 76 countries a strong regulatory environment, the
responded, respectively). association is slightly stronger for
leadership programmes than for GCNOs.
114. Of the 115 responding countries, 71% In other words, the existence of a
reported having a GCNO position, ranging high-level nursing position within
from 54% in the Eastern Mediterranean the national government does not
Region to 86% in the European Region necessarily lead to actions such as the
(Table 5.10). Fewer countries (53% of introduction of leadership programmes:
the 76 responding countries) reported indeed, 37% of the countries with
having a nursing leadership development a GCNO did not have a leadership
programme, ranging from 40% in the development programme.
South-East Asia Region to 64% in the
African Region. 117. To test the hypothesis as to whether
leadership and governance in nursing
115. There are significant correlations also translate into increased investments,
between a strong reported regulatory as evidenced by acceleration of nursing
environment and the reported nursing graduation and subsequent recruitment

to tackle shortages, the ratio of graduates identified, suggesting that strong nursing
in countries with leadership and leadership and governance does not
governance measures was compared necessarily translate into accelerated
with that in countries without. No production of nursing graduates.
statistically significant association was
Table 5.10 Leadership and governance indicators: percentage of countries with chief nursing
officer position and nursing leadership development programme, by WHO region
Chief nursing officer position Nursing leadership development programme
Number of countries Number of countries

WHO REGION responding/total % yes responding/total % yes
Africa 26/47 60% 28/47 64%
Americas 26/35 79% 16/35 46%
South-East Asia 6/11 60% 4/11 40%
Europe 30/53 86% 10/53 56%
Eastern Mediterranean 7/21 54% 8/21 62%
Western Pacific 20/27 74% 10/27 43%
Global 115/194 71% 76/194 53%
Source: State of the world’s nursing 2020 specific indicators, 2019. Latest available data reported by countries between 2013 and 2018.
Figure 5.14 Association between GCNO and nursing leadership programme and the
regulatory environment
Working conditions
GCNO Leadership programme
6 10
Nursing working
8
Nursing working
condition score
condition score
4
6
4
2
2
0 0
No GCNO GCNO No leadership Leadership
programme programme
P=0.008 (Kruskal-Wallis test) P<0.001 (Kruskal-Wallis test)
Education regulations
GCNO Leadership programme
10 10
8 8
Nursing education
Nursing education
regulation score
regulation score
6 6
4 4
2 2
0 0
No GCNO GCNO No leadership Leadership
programme programme
P=0.007 (Kruskal-Wallis test) P<0.001 (Kruskal-Wallis test)
Source: State of the world’s nursing 2020 specific indicators, 2019.

5.8 Assessing the current trajectory towards 2030 SDG outcomes
5.8.1 Key findings
We estimate a shortage of 5.9 million nurses comparing 2018 data with benchmark
values defined in the Global Strategy on Human Resources for Health; the gaps
are mostly (89%) concentrated in low- and lower middle-income countries.
If all countries maintain their current level of production of graduate nurses,

the nurse headcount is projected to increase from nearly 28 million in 2018 to
approximately 36 million in 2030; 70% of this projected increase, however, is
expected to occur in upper middle- and high-income countries and not where
gaps are greatest.
Taking into account projected population growth and the ageing of the nursing
workforce, the African, South-East Asia and Eastern Mediterranean regions are
projected to remain in 2030 with a density below 25 nurses per 10 000 population.
Density in the African Region is projected to improve only marginally.
Addressing the shortage of nursing personnel in low-density countries would

require an average increase in the number of yearly graduates of 8.8% from 2018
to 2030 (range: 0.2–13.4%), and improving absorption capacity to at least 70%.
Scaling up education of nurses to address gaps may cost approximately US$ 10 per
capita for the period 2018–2030 in affected low- and lower middle-income countries.
118. To achieve the health-related SDGs, WHO account the current nursing headcount,
Member States will need to educate the estimated retirement rate (based
enough nurses to (a) compensate for on the age distribution of the nursing
losses to the profession (for example, workforce), the population growth, and
due to death, migration or retirement); assumptions on the entry in the labour
(b) meet the increased demands in many market (see Annex 2 for description of
parts of the world due to population scenarios). On current trends, the stock
growth and ageing and changing health of nursing personnel is projected to
care needs; and (c) eliminate the existing increase from 27.9 million in 2018 to
global shortage. 35.9 million nurses in 2030.
120. The increase of the nursing stock by

5.8.2 Projection of nursing stock and
2030 will be concentrated in high-
density to 2030
income countries, with very limited
119. A basic “stock and flow” model for growth in low-income countries (Figure
each country was developed, taking into 5.15). The disparities documented in

Figure 5.15 Projection of nursing personnel density per 10 000 population in 2030
(global distribution)
<10 10 to 19 20 to 29 30 to 39 40 to 49 50 to 74 75 to 99 100 +
0 550 1,100 2,200 3,300 4,400

km
2018 (see section 5.2) are projected to South-East Asia and Western Pacific
continue largely unabated to 2030. regions. When grouping by level of
income is considered, 88% of the
121. The growth trajectory of the projected increase in stock is projected in middle-
stock is not sufficient to fully address income countries (Figure 5.16).
the needs, particularly in the African
Region, where a population growth of
5.8.3 Nursing workforce shortage
34% is expected. Also, the Eastern
Mediterranean Region is projected to 124. The WHO Global Strategy on Human
see only marginal increases in nursing Resources for Health estimated in 2016
personnel stock (Table 5.11). that by 2030 there would be a global
shortage of 7.6 million nurses and
122. Projections were conducted with midwives in countries with a density
different assumptions and scenarios, below a benchmark of 4.45 physicians,
relying on data availability and data nurses and midwives per 1000
quality for factors used in the analysis. population; this threshold value excluded
Potential limitations are discussed in most high-income countries. Adopting
Annex 2. the same methodology and benchmark
values, but using more recent data,
123. In contrast, the nursing stock is projected a shortage of 5.9 million nurses was
to significantly increase in the American, estimated for 2018, and of 5.7 million

Table 5.11 Simulation of projected stock of nursing personnel from 2018 to 2030 under three
scenarios, by WHO region
Stock observed in Stock projected to 2030 (million)

2018 (million)
SCENARIO 3:
SCENARIO 2: ageing and
SCENARIO 1: ageing and graduation
ageing and stable graduation as of increasing by 50%
WHO REGION young age group recent years by 2030
Africa 0.9 1.2 1.5 2.0
Americas 8.4 9.2 12.4 17.7
South-East Asia 3.3 4.7 5.0 6.1
Europe 7.3 8.6 8.0 10.4
Eastern Mediterranean 1.1 1.9 1.5 1.7
Western Pacific 6.9 10.3 9.0 11.2
Global 27.9 35.9 37.4 49.3
Figure 5.16 Projected increase (to 2030) of nursing stock, by WHO region and by country income group
ENGLISH
Americas Eastern Mediterranean High income Low income
43% 4% 6% 6%
Africa
6% Lower middle
Europe income
7% 27%
BY REGION BY INCOME
South-East
Asia
18%
Western Pacific Upper middle income
22% 61%
Note: Income grouping is from the World Bank classification as of 2018.

by 2030. The countries accounting for countries above the benchmark are not
the largest shortages (in numerical experiencing shortages of nurses. Most
terms) in 2018 included Bangladesh, actually do experience a significant level
India, Indonesia, Nigeria and Pakistan. of shortage defined against nationally
Income level is strongly associated with identified service delivery targets and
shortages in the nursing workforce health system configurations. For
(Annex 2, Table A2.2), with 89% of the these countries, specific estimations
gaps in 2018 concentrated in low- and of shortages should be conducted.
lower middle-income countries. These should apply methodologies that
account for population and workforce
125. This estimation can be compared with ageing, changing epidemiological
the findings of the Global Strategy in patterns, implementation of retention
2016 by correcting the previous estimate strategies, and other labour market
to only display shortage of nurses (that dynamics. For instance, an analysis
is, excluding the midwife component) based on nationally defined population
and to account for improvement of data needs and health system requirements
(Figure 5.17). identified a potential shortfall of up to
3.2 million nurses in 31 high-income
126. The shortage was estimated considering OECD countries to 2030 (266). Similar
the benchmark value used in the Global estimates of future shortages of nurses
Strategy. As such, all countries above have been reported in Japan (270 000
the benchmark are excluded from this nursing staff by 2025) (267), Germany
estimation. This is not to suggest that (approximately 500 000 health workers
Figure 5.17 Estimation of shortages of nursing workforce in 2013, 2018 and 2030
Global Strategy on Human 9.0 million nurses and midwives 7.6 million nurses and midwives
Resources for Health 2016
1
Correcting for nurses only 8.2 million nurses 6.9 million nurses
2
Correcting for improved data 6.6 million nurses 5.6 million nurses Consistent
estimation
The State of world’s of shortage
5.9 million nurses 5.7 million nurses by 2030
nursing 2020
2013 2018 2030
Correction factors applied:

1
Removing the share of midwives from the stock of nurses and midwives combined in the Global Strategy using more recent share data (90% nurses out of
nurses + midwives).
2
Correcting for improved data, which results in higher stock estimates and lower shortages: 4.4 million nurses out of 27.8 million in 2018, being an effect of
improved data as compared to the Global Strategy.
Note: Shortage estimated by comparing nursing stock in each country in each year to a benchmark density.
Source: Global Strategy on Human Resources for Health 2016 and State of the world’s nursing 2020 report at global level.
The State of the world’s nursing 2020 estimate of nursing shortage by 2030, if the current trends are maintained, is consistent with (5.7 million nurses versus
5.6 million) the Global Strategy estimate.

by 2030, especially elder care personnel (80% of graduates), the required
and nurses) (268), and the United average increase in the graduation
Kingdom (shortage of over 108 000 rate would be 8.1% per year (from
nurses by 2030) (269), among others. 0.03% to 12.2%) to address the
nursing shortage by 2030.
5.8.4 Production and cost required to

128. To estimate the investment required
tackle nursing shortage by 2030
to eliminate the shortage by 2030, the
127. The required increase in graduation and additional number of nurses (projected
jobs to fully address the shortage by under the scenario of employment of
2030 was estimated under different 80% of graduates) from 2018 to 2030
hypotheses. was multiplied for each country by
an average cost to train a nurse (270).
• On current trends, an average of Based on published and grey literature
around a 10% increase per year in on education costs in low- and lower
number of graduates (ranging from middle-income countries, three different
1.5% to 14.9%) would be required. assumptions for average cost of training
per nurse were used: US$ 5000,
• If the labour market absorption US$ 10 000 and US$ 20 000 (271).
capacity of nursing graduates were The required investments to train
improved, using an absorption rate additional nurses to eliminate the
of 70% of graduates into the labour shortage were respectively US$ 5.2,
market, the average increase per year US$ 10.5 and US$ 21 per capita on
in graduates would be 8.8% (ranging average.11 Considering the sensitivity of
from 0.2% to 13.4%) to address the analysis to the assumptions made
the gap. and the paucity of the evidence, it can be
reasonable to adopt a central estimate
• In a scenario with a further improved of approximately US$ 10 per capita to
labour market absorption capacity develop illustrative simulations.
11 Figures quoted constitute a one-off investment in countries with shortages to cover the training of all graduates.


CHAPTER
6
Future directions
for nursing
workforce policy
129. The evidence presented in this report, 131. Harnessing this potential requires
building on both existing frameworks concerted efforts spanning different
and published literature (Chapters 2, 3 sectors at the local, national and global
and 4) and the analysis of the current levels. In this chapter, we discuss in
status of the nursing workforce (Chapter turn the main findings emerging from
5), provides a compelling case for a the global discourse and the specific
radical change in the way the nursing evidence collated for this report; on that
workforce is educated, deployed, basis, we outline the actions required to
managed and supported, as part of stimulate sustainable investments, build
broader health workforce and health institutional capacity, and catalyse policy
system policies. action in support of a fit-for-purpose and
fit-to-practise nursing workforce.
130. The investments required will be
substantial, but even bigger will be the 132. These policy options are addressed
returns for societies and economies in to both Member States and, where
terms of improved health outcomes for relevant, other stakeholders. Their
hundreds of millions of people, creation applicability and relevance should be
of millions of qualified employment considered by countries on a case-
opportunities, particularly for women by-case basis, depending on their
and young people, and enhanced global health system’s objectives, underlying
health security. conditions and implementation capacity.
Future directions for nursing workforce policy 67

6.1 Strengthening the evidence base education, financing and health labour
for planning, monitoring and market flows was substantially lower,
accountability hindering the capacity to conduct
comprehensive health labour market
Synthesis of results
analyses. For instance, only knowing
133. The State of the world’s nursing stock data without understanding in
2020 report represents the most quantitative terms production capacity,
comprehensive global data and vacancy rates, unemployment and
evidence specific to nursing. While attrition may leave policy-makers
80% of countries reported on at least uncertain about whether production
15 indicators, the data gaps identified should be scaled up or is already
reflect the varying capacity of countries’ adequate. Policy-makers and planners
health workforce information systems should know whether production by the
and represent valuable opportunities for education sector and absorption in the
focused attention moving forward. health labour market are evenly matched
or leading to any form of disequilibrium
134. Data availability was highest for (shortage versus unemployment) (see
indicators such as active nursing Box 6.1 on the health labour market
workforce stock and age composition in Scotland).
(191 and 132 countries, respectively),
but reporting of indicators relating to
Box 6.1 Scotland health labour market analysis
In December 2019, the Government of Scotland released an integrated health and social
care workforce plan for Scotland (272). The plan includes a vision to enable people to stay
at home rather than being hospitalized. However, implementation requires an increase in
the number of district nurses.
The Scottish Government used data from NHS National Services Scotland, Information
Services Division, to create modelled scenarios of how many additional nursing students
would be required. The government also considered the supply and shortages in other
health occupations, how the shortages impact what care needs to be delivered, and how
this may be addressed.
The data and findings were shared with the Nursing and Midwifery Student Intake
Reference Group and other stakeholders. This dialogue led to decisions to take a proactive
approach to training district nurses, increase investment in education and training of district
nurses, and consider staffing arrangements that will allow for nurses already in service to
receive such education and training.
This represents the government’s first attempt at addressing health and social workforce
issues in an integrated manner at the national level and shifting from planning for a single
profession towards planning for multidisciplinary team-based care.

135. Factors influencing the availability of and investment decisions at the national
data and ability of countries to report level (see Box 6.2 on nursing leadership
across these indicators include the level teams using NHWA indicators for a
of coordination across the ministries of nursing labour market analysis).
health, labour, education, and finance,
as well as engagement with other
6.2 Mobility and migration
stakeholders, such as professional
associations, councils and educational
institutions. 137. Approximately 3.7 million nurses (or one
in eight) are practising in a country
Policy options
other than the one in which they were
136. Countries should accelerate the born or trained as a nurse. The findings
implementation of their National Health indicate a high international mobility of
Workforce Accounts (NHWA), including nurses, fuelled by a strong dependence
disaggregated reporting for the nursing on migrant nurses in countries with
workforce. Of particular urgency is low domestic production. The demand
addressing gaps in essential data from high-income countries (where
elements to conduct national health over 15% of nurses are reportedly
labour market analyses. This should be foreign born or foreign trained) can
accomplished through a comprehensive attract the most qualified nurses from
effort at strengthening and building lower-income countries and deepen
the capacity of the human resources quality and distribution divides that are
for health information system (273). detrimental to population health (see
The description of the global nursing Box 6.3 on Germany’s approach to
workforce was feasible due to global managing migration).
efforts to implement NHWA and a
commitment to diversify data sources. 138. Very high levels of out-migration
Institutional capacity-building for human (when they are not the result of a
resources for health information systems deliberate policy to export the nursing
may entail establishing permanent workforce overseas) can be interpreted
mechanisms to convene stakeholders, as a symptom of unattractive labour
including nursing leaders, to establish conditions at home. The policy
clear mechanisms for collation and prescription should therefore focus
exchange of data, to discuss data on treating the underlying causes
availability, quality, and challenges, and to (in terms of improving the work
implement interoperable data systems. environment, support systems and
Coordination among different sectors remuneration), rather than attempting
and stakeholders may also present to address in isolation the migratory
opportunities to formalize the political phenomenon. Similarly, in the
mandate for data collection and sharing, preparation of nurses an appropriate
and for intersectoral policy dialogue to balance must be struck between the
translate the data into meaningful policy skills and competencies required to
changes. Countries should leverage prepare a nurse to work in their local
strengthened nursing and health context and in primary care, versus the
workforce data to be included in health interests of students to learn skills that
labour market analyses to guide policy will allow them to maximize income

Box 6.2 East, Central and Southern African Health Community:
national collaboration on nursing data reporting using
NHWA indicators
The East, Central and Southern African Health Community (ECSA-HC) is an inter-
governmental health organization that fosters and promotes regional cooperation in
health (274). Nursing shortages are common in the subregion. Poor working conditions
and high caseloads contribute to lack of incentives for nurses to enter the workforce and
high levels of out-migration. Often-fragmented education systems struggle with inadequate
faculty and regulatory capacity, resulting in a limited ability to train enough skilled nurses.
The World Bank Group collaborated with Jhpiego, the International Council of Nurses, and
the ECSA College of Nursing on a study to assess nursing labour and education markets.
The objective was to estimate the magnitude of the challenges in these systems and to
identify policies to scale up nursing education in the region through targeted public and
private investments. The study examined how the interaction between the education
system and the health system was mediated by the labour market for nurses, considering
governance and regulatory challenges. The data collected were indicators from the
WHO-developed NHWA (273) as well as additional qualitative data collected during regional
consultations. The country teams coordinating data reporting for the study were national
nursing leadership “quads” with additional support from WHO in the review process (see
also subsection 6.3.3).
Results revealed an imbalanced market, and a critical misalignment of demand for and
supply of nurses in the subregion. While nursing supply has grown faster than population
growth over the past 10 years, it coexists with low absorption rates of nurses into public
sector positions (often due to recruitment inefficiencies or undesirable working conditions)
in many countries, and large needs-based shortages. The projections analysis estimated
that effective demand would grow by 33% between 2019 and 2039, but still leaving a
surplus of over 220 000 nurses that the public and private sector were not able or willing to
employ. In contrast, needs-based shortages are estimated to reach 841 000 nurses by 2030,
expanding the current imbalances in the nursing labour market.
The study concluded that increasing the supply of nurses to respond to the SDGs in
ECSA countries would require scaling up nursing education, improving the quality of
nursing schools (including enforcement of quality assurance mechanisms), and increasing
resources needed to absorb nurses into the local and regional labour markets. This can be
facilitated by adequate investments in physical and human resources, nursing governance,
regulation, and the production of data and analytical capacities to empower countries to
monitor the impact of investments.

Box 6.3 Germany’s approach to managing migration
On 9 November 2018, the German Parliament passed the Care Strengthening Act, which
aims to improve the attractiveness of health care and long-term care for employees and
care staff in hospitals and residential homes (275). Improving staffing in these facilities was
at the heart of the new government’s health policy. For many years health care and long-
term care had suffered from a severe shortage of nurses, with widespread understaffing in
hospitals and residential homes. Numbers of professionals leaving the health service due to
retirement and dissatisfaction were greater than the numbers entering the workforce upon
graduation from vocational training. Furthermore, understaffing was perceived to lead to
deteriorating working conditions for staff and poor quality of care. In 2012 it was projected
that Germany would have a nursing care shortage of between 263 000 and 500 000 by 2030
(276). In its attempt to reduce staff shortages, Germany adopted a multipronged strategy
comprising a scale-up in education, the creation of new nursing jobs and the optimization
of international recruitment of migrant health workers, such as nurses from central and
south-eastern Europe (277). For this last element, Germany has taken steps to harness
opportunities for mutual benefits with source countries from international health worker
mobility, including through technical cooperation and bilateral agreements that create
training and investment opportunities in the source country (168).
opportunities and migrate to work Policy options

in a more specialized or global 140. Countries and regulators should
professional setting. strengthen the implementation
of regulations governing
139. With the vastly increasing numbers of international mobility of health
nurses migrating, the typical approach personnel, including the nursing
of single-jurisdictional solutions to public workforce. The regulators in the
protection are inadequate, and reformed destination jurisdictions need to
systems need to provide and enhance establish that the nurse’s preparation,
regional and global solutions (245, qualification and disciplinary history
278, 279). Furthermore, because many meets the required licensure,
countries are simultaneously countries of educational and ethical standards
both origin and destination, it is essential and codes of conduct, in the interest
to better understand the patterns of of public protection. Enhanced
movement in order to effectively manage models of regulation can facilitate
mobility and plan for future health mobility through harmonization of
workforce requirements. However, only requirements to enter a nursing
86 Member States reported on the programme and of the educational
percentage of foreign-born or foreign- content required to earn and maintain
trained nurses in their workforce, one nursing credentials. Regional
of the basic reporting requirements experiences of agreements on mutual
envisaged in the WHO Global Code of recognition of nursing professional
Practice on the International Recruitment qualifications provide a potential basis
of Health Personnel. for broader agreements in the future.

141. Countries and international of the world. However, countries
stakeholders should reinforce overwhelmingly (154 out of 169
the implementation of the WHO responding countries) reported standards
Global Code of Practice. The ability for the content and duration of education
to effectively monitor, govern and and training. Critical considerations
regulate international mobility of the when developing such standards include
nursing workforce may require capacity- whether they help educators provide
building, leveraging partnerships, and students with competencies required to
collaboration between regulatory bodies, meet population health needs, including
health workforce information systems, preparation for primary and preventive
employers, government ministries, and care services, disaster, emergency, and
other stakeholders such as professional conflict competencies where indicated,
associations. Countries experiencing an leadership skills, and appropriate use of
excessive loss of their nursing workforce technology (see Box 6.4 on technology
through out-migration should consider in nursing education and practice).
putting in place mitigating measures,
such as improving the salaries (and pay 144. Most countries (89%) also reported
equity) and working conditions, ensuring accreditation mechanisms in place for
decent work, and implementing tailored education institutions and maintaining
retention packages where warranted. a master list of accredited institutions.
This indicates, for most countries, an
opportunity to focus on strengthening
6.3 Developing and supporting the key areas of accreditation, including
nursing workforce efficient and affordable models, and
6.3.1 EDUCATION ensuring the social accountability and
relevance of programmes to population
Synthesis of results health priorities. Robust accreditation
142. The findings of this report illustrate mechanisms can cover content,
a complex situation with respect to curriculum, student clinical experiences,
the production of nursing programme faculty qualifications and interprofessional
graduates. The lowest proportion of learning. Our findings indicated that 67%
graduates in relation to existing stock of responding countries have standards
was in the European and Eastern for interprofessional learning, but in some
Mediterranean regions and high- regions this was less than half or as
income countries. Unless middle- and low as 20%.
high-income countries can increase
production, the data suggest a potential 145. Ensuring a representative health
continued reliance by high-income workforce, with a composition mirroring
countries on international recruitment, that of the population to be served,
potentially exacerbating existing requires diversity of those entering
shortages and raising related access and completing nursing programmes.
and equity issues. Findings from this report indicate that
that the nursing workforce is still largely
143. There is considerable variety in the female, particularly in the American and
duration of nursing education and Western Pacific regions. Fostering an
training programmes in different regions appropriate composition of the nursing

workforce will require not just increased countries. Addressing these challenges
enrolment of diverse student groups; it is required to make nursing an attractive
will also require addressing the structural career choice, especially in regions such
and organizational challenges that either as the Americas, where graduates are
exclude some students from nursing fewest relative to population.
(for example, completion of secondary
Policy options
education) or prevent the completion
of their studies (for example, excessive 146. Countries should ensure nursing
costs) (126). Demand for nursing education and training programmes
programmes may also be affected by equip nurses with competencies
the gendered occupational segregation to deliver high-quality, integrated,
and the low status of nursing in some people-centred services. A priority
Box 6.4 Technology in nursing education and practice
Technology is playing an increasing role in both education and practice of the

nursing workforce. Technology can be harnessed to access clinical decision support,
conduct provider-to-client telemedicine, and receive provider-to-provider training
and consultation (280) in ways that can enhance access, enable remote care, improve
primary health care service delivery and empower patients. Nurses should be equipped
and conversant with the digital determinants of health: these include their level of
digital literacy, access to technological equipment, and Internet infrastructure, including
broadband where available (281).
Digital health technologies, be it artificial intelligence or other forms such as augmented

reality and the use of robotics, are already transforming nursing and patient care (282).
Personalized medicine and genomics have the potential to better tailor patient care (283).
One of the greatest potentials for digital health lies in lifelong learning opportunities.
Technologies such as artificial intelligence can allow learning to be personalized,
relevant and up to date.
Findings from a Cochrane systematic review of health worker experiences of mHealth in

primary health care suggest that health workers, including nurses, have appreciated the
benefits of using mobile technology in their delivery of care, but have also encountered
challenges (284). The benefits described included being more connected to each other,
taking on new tasks, improving coordination and quality of care, improved communication
with clients, and accessing clients in hard-to-reach areas (284). Simultaneously, health
worker accounts described multiple and complex challenges, which could be personal
(such as poor digital literacy), relational (preferring face-to-face contact with clients
and colleagues), professional (feeling that their clinical skills were threatened by digital
clinical support tools), contextual (clients not being able to afford mobile phones), or
infrastructural (lack of electricity) (284). While technological advances offer many benefits,
health worker accounts included in this systematic review suggest that health system
decision-makers need to think carefully about how it is implemented in their context so as
to minimize the challenges experienced by health workers, including nurses.

issue is to critically appraise the skills 148. Health education institutions and
mix within the nursing profession and regulators should adopt competency-
decide whether the levels of nurses and based curricula and leverage
the types of specializations are relevant appropriate technology. Quality in
to the health system objectives, and nursing practice should be reflected
ensure availability of adequate numbers throughout the curricula. In addition to
of training posts based on health system the technical knowledge and procedural
needs and absorption capacity. Creating skills for individual clinical interventions,
or increasing the number of higher levels nurses should be equipped to work in
of nursing education – for example, interprofessional teams; to demonstrate
bachelor’s or master’s programmes, or empathy and compassion to patients; to
Doctor of Philosophy – has structural make decisions under pressure; and to
implications, such as developing new acquire the tools to keep learning over
educational programmes, staffing them a career spanning decades. Curricula
with appropriate faculty, and ensuring should be matched to both the scope
nurses with this type of educational of practice of graduating students and
pathway will have a defined role in the the population health needs. The digital
health system. provision of educational and training
content can usefully complement
147. Countries should consider traditional methods. The success of
mechanisms to increase the such efforts at “distributed learning” will
demographic and geographical require ensuring that students acquire a
diversity of students in nursing minimum level of digital health literacy
school. This may mean addressing as part of their education, that the
biases that negatively impact nursing curriculum design makes use of relevant
as a career choice for men, young digital and telehealth learning for the
people, or specific ethnic groups, and requisite competencies with support and
accommodating those wanting to enter supervision for clinical training (285), and
nursing as a second or subsequent that the institutional and infrastructural
career choice. Developing a “rural resources needed to enable a bridging of
pipeline” to foster a gender-balanced the digital divide are in place (286).
intake and appropriate number of
students from rural, remote and 149. Governments and stakeholders
otherwise underserved areas and should develop and leverage
communities may be required in some intersectoral partnerships and
contexts. Targeted financial support cooperation to advance the nursing
and incentive mechanisms can also be education agenda. Cooperation
used to increase opportunities for formal with regulatory bodies can facilitate
education for minority and vulnerable review of entry requirements to
groups and disadvantaged populations, nursing programmes and the minimum
and to attract faculty that reflects education standards for nurses (given
student and community populations. the current and future professional
Accreditation criteria that reinforce roles in the health system) and can
social accountability measures are promote harmonization of standards
one such mechanism. at regional level. Intersectoral dialogue

with accrediting bodies can help identify faculty numbers or competencies,
mechanisms to further the social infrastructure limitations, and
accountability aspects of accreditation, the availability of appropriate
for example by ensuring that nursing clinical practice sites (see Box 6.5
education institutions prioritize the on commitments from Pakistan on
production of graduates able to deliver producing more nurses). In order
quality health services, rather than to increase training posts while
their institutional income and status, preserving quality, investment in
through tuition fees and government faculty development programmes may
grants. Relevant line ministries be needed. High-income countries
(education, health) can strengthen or countries relying on international
formal coordination to promote science recruitment should increase the
and technology as fundamentals of the domestic production and deployment
nursing profession, to market nursing of nurses.
as a STEM (science, technology,
engineering, mathematics) field, and 151. Countries should consider applying
to put in place mechanisms to attract relevant financing levers to expand
a diverse range of secondary school (where needed) or strengthen
students to nursing. Public–private the quality of nurse education
partnerships can help source sites for to address health labour market
clinical training in primary health care failures. Financial mechanisms have
settings; engagement with other health great potential for increasing the
occupation education programmes diversity of the student pool, the
can help make these clinical faculty pool, or the number of seats in
practicums interprofessional. nursing programmes, and addressing
some of the current limitations in
150. Nursing education institutions clinical training. Financial subsidies for
should strengthen their capacity post-basic education programmes are
by addressing inadequacies in sometimes used to promote pathways
Box 6.5 Pakistan efforts to increase nurse education capacity
Pakistan is attempting to address its shortfall of 1 million health workers. In 2018 it launched
its national Human Resources for Health Vision for 2030, aimed at addressing the health
workforce skills mix and the nursing workforce. Nursing, which is regarded as the backbone
of the health sector, is key to this vision, with 2019 having been made the Year of Nursing in
Pakistan, highlighting the contributions of nursing to population health (287). In launching
the Year of Nursing, President Alvi announced that a nursing university would be established
in Islamabad, which aims to provide training to 25 000 students each year (287). The
country plans to double the size of the nursing sector within two years, to overcome the
national shortage of nurses. The shortage of nurses was described by Dr Nausheen Hamid,
Parliamentary Secretary for National Health Services, as an impediment to attaining universal
health coverage, with adequate numbers of well performing nurses needed for an effective
health system (288).

to higher levels of nursing practice. challenge. This report found significant
Governments, however, must be able differences in the distribution of nurses
to make informed decisions on whether across and within countries and regions.
it is a cost-effective investment to The findings of the report further indicate
subsidize nursing education, under that 53% of responding countries have
what circumstances, and in what advanced practice roles in nursing.
ways, prioritizing scarce resources on These roles are more frequently found
investments that can directly contribute in countries with low density of medical
to equity and efficiency objectives (289). doctors. This highlights the flexibility and
For example, a health labour market responsiveness of the nursing workforce
analysis should identify the settings in relation to the broader health workforce
where nurses are underproduced or situation of a country. These nurses
overproduced as compared to health may be well placed to provide care to
system needs. Where a systematic populations in rural and remote settings,
underproduction is documented, there if the existing skills mix suggests such a
is a case for government intervention move would increase efficiency.
to relax unnecessary barriers to entry
and if needed to subsidize pre-service 154. Within countries, the data point to a
education, particularly if priority is continued need to focus on addressing
awarded to the group of disadvantaged the maldistribution of nurses located
students, in order to facilitate education in rural versus urban areas to improve
pathways leading to a preferential career equity of access. The retention of
in the primary health care setting, and health workers is related to a variety of
in exchange for a minimum guaranteed complex and interrelated factors such
period of exclusive service within the as working conditions, occupational
public sector (140). safety, remuneration levels and non-
monetary incentives. Sustained success
6.3.2 NURSING PRACTICE in improving nurse retention is likely to
be the result of planned, sequenced,
Synthesis of results multi-policy interventions tailored to
152. The report findings indicate a nursing the local context. Retention should not
workforce larger than previously be examined or addressed in isolation
estimated — nearly 28 million in from the context of other features of the
2018, comprising a minimum of 69% working and living conditions of nurses.
professional and at least 22% associate
professional nurses. The growth, Policy options
compared to previous 2016 estimates 155. Countries should enable nurses
in the Global Strategy on Human to work to the full extent of their
Resources for Health, is due in roughly education and training (180). This
equal portions to vastly improved nursing objective should be part of broader
workforce data availability and quality, national efforts to adopt care models
and to actual growth in stock. that optimize the division of tasks in
integrated primary health care teams
153. Even with the growth in stock, inequitable (179). This entails maximizing the
geographical distribution of health contribution of nurses to enhance
workers, including nurses, is a universal primary health care in priority areas

(see Box 6.6 on expanding access to technology. Embedding the required
community health services in Oman). reforms in relevant education, health,
Possible approaches could include labour and other policies requires
advanced practice roles, expansion institutional capacity for effective
of nurse-led clinics, and developed or collaboration and coordination;
expanded authority for prescribing, supportive institutional structures
with the commensurate development and dedicated resources; leadership
or strengthening of education and and political will; effective managerial
training required. Nurses with advanced oversight; and effective organizational
practice credentials should be in culture. It is also important that the
settings that optimize their productivity roles and functions of nurses based on
in providing patient care or leadership scope of practice and competencies
and management to other clinicians. are accurately communicated to other
Nurses functioning in advanced health care providers and the public.
practice roles or in nurse-led clinics
should be supported with mentorship 156. Countries should optimize their
or collaborative partnerships as modalities and mechanisms
needed, be provided with adequate for effective deployment and
supplies and medications, have management of their nursing
clear clinical and facility guidelines workforce. The efficiency, equity
for practice, and have access to the and transparency of hiring and
required resources, including online deployment are key elements of
reference materials and appropriate the decent work agenda (16).
Box 6.6 Expanding access to community health services in Oman
The country of Oman provides an example of reorienting nursing and midwifery education
and emphasizing primary care competencies, which was a component of the call for action to
strengthen the nursing workforce adopted by the 66th session of the Regional Committee for
the Eastern Mediterranean (October 2019) (290).
Oman has experienced a rapid growth in population and life expectancy. The improvements
in socioeconomic status, however, have come with an increase in the burden of chronic
illness. To address this population health issue, the government decided to invest in
community health nurses (291). The Department of Nursing and Midwifery at the Ministry of
Health initiated a 16-week on-the-job training programme, first piloted in the capital, Muscat,
and then extended to other governorates. Community health nursing services were integrated
into primary health care structures in line with the services provided in the primary health
centres (292).
Eventually, the 16-week training transformed into a bachelor’s degree in nursing with a focus
on community health nursing, and then to a post-basic diploma in community health nursing
specialty (291). This specialty programme has contributed to maintaining the supply of
qualified community health nurses to meet primary care service needs in the country.

Policy-makers and managers should based on seniority (years of service).
have access to reliable metrics that As for other occupational groups,
assess the efficiency and timeliness the limits of compulsory deployment
of the employment process, such and rotation schemes should be
as the percentage of new graduates taken into account when considering
that are employed three months, six such schemes. Wherever possible,
months or one year after licensure, deployment of nurses should be
the average time between graduation based on voluntary career choices and
and licensure, and the average time preferences in relation to duty station.
between licensure and employment. A Reconciling nurses’ preferences with
low rate of employment of graduates health system needs, in particular in
may be symptomatic of saturation of relation to geographical equity, can be
the labour market, but if concomitant challenging. When tensions emerge
with excessively long lag times between the two, a range of related
between graduation, licensure and and mutually reinforcing strategies
employment, it can instead suggest for rural deployment and retention is
rigidities and bureaucratic hurdles desirable from the perspective of both
in the administrative system. The effectiveness and workers’ rights (289).
modalities of deployment also
matter: unless the public sector can 157. Countries should explicitly and
guarantee the absorption of all qualified proactively anticipate challenges
candidates, competitive recruitment in the retention of nurses and put
following the publication of vacancies in place relevant policies. Evidence-
and a meritocratic assessment of based approaches to enhance retention
candidates’ competencies remains include opportunities for leadership
the modality of choice (289). development, mentorship (293, 294),
Career advancement and promotion flexible scheduling, non-monetary
opportunities should also be linked to incentives and lifelong learning. A
merit and capacity, rather than primarily formalized preceptorship for new
graduates entering the workforce can
improve their transition to practice,
clinical competence, job satisfaction and
professional socialization, all of which
may affect retention of new nurses
in the workforce (295). The effect of
preceptorship on role competence and
retention is similar for new nurses in
rural or urban settings (296). Specific
policies should be in place for increasing
the roles of women in leadership,
addressing gender discrimination, and
preventing sexual harassment, which, in
addition to being a violation of workers’
dignity and rights, is linked to increased
attrition (122, 297, 298).
© Kieran Dodds

6.3.3 REGULATION need to be established through new
or updated primary legislation that
establishes the role and functions
158. Nursing regulation plays an essential of the regulatory authority and key
role in protecting the public and provisions and standards for nursing
empowering health systems to respond education and practice. One recurring
to changing patient and population challenge is the need to strike the right
needs. It can also provide a framework balance — ensuring that regulations
for advancing the profession (243, 299). are the least restrictive while achieving
The findings of this report indicate that the desired public protection benefit
164 Member States (86%) have an (303–306). Countries should consider
authority responsible for the regulation establishing requirements for lifelong
of nursing education and practice. learning to ensure nurses at various
The strength and effectiveness of the levels are exposed to learning
regulations issued, however, must be opportunities appropriate to their role.
examined on an individual country level. The use of a licensure examination
For example, 73% of countries indicated to assess a minimum level of initial
they had a regulatory requirement knowledge before a nurse is allowed to
for lifelong learning, but fewer (64%) practise is increasingly common (255,
indicated presence of regulations 307). While stronger evidence of the
that required a licensure or fitness to comparative effectiveness of different
practise examination. approaches is still needed, there is a
broad consensus on the need for the
159. Professional regulations are also competency assessment to be valid,
important to preserve quality care fair, independent, and based on the
in a context of growing international knowledge and skills that nurses will
professional mobility, ensuring incoming need in a variety of practice settings.
health workers have competencies that
match the needs of the population, 161. Countries should invest in the
and the ability to practise without capacity of regulatory systems to
compromising public safety. Real-time, strengthen and enhance the quality
web-based systems that can facilitate of nursing education and practice.
expedited recognition of credentials A key aspect is to ensure regulators
and provide collated information on the have and maintain live registries that are
current licence status and professional interoperable with other databases in
history of the practitioner are emerging the health system and other regulators.
as useful tools on a regional basis and One way of maintaining up-to-date
could potentially be developed into registries is through the requirement
global solutions (168, 300–302). for re-registration or re-licensure, which
can also be instrumental in incentivizing
Policy options lifelong learning as well as generating
160. Countries should develop and income for the regulatory body. The
enhance nursing regulation to individual capacity of nurse regulators
support safe, sustainable, and also requires strengthening. Nurse
high-quality education and practice. regulators, as is also typical for other
The authority to regulate nursing may health occupations, may have received

Box 6.7 African Health Profession Regulatory Collaborative
The African Health Profession Regulatory Collaborative (ARC) was created to help countries
update nursing and midwifery regulations to facilitate safe and sustainable nurse-led
models of care and treatment for patients with HIV. The collaborative involved 17 countries,
comprising most members of the East, Central and Southern African College of Nursing
(ECSACON) (308).
ARC convened the government chief nurse, the president of the national nursing association,
a leader in academia, and the registrar of the national nursing and midwifery council from
each country and supported prioritization of and collaboration on nationally identified
regulatory challenges. The country leadership teams, who called themselves “quads”, worked
together on their regulatory priority (for example, scope of practice inclusive of HIV tasks,
continuing professional development requirements for HIV content) on annual cycles. Quads
met frequently in country as well as with regional colleagues working on similar priorities.
Progress was measured regularly and with diverse measures (309).
Over the course of five years (2011–2016) nursing and midwifery regulations were
strengthened, and quads reported substantial increases in leadership skills, organizational
capacity, and collaboration among national nursing and midwifery organizations (310).
While ARC was a donor-funded initiative, the “quad” arrangement has been institutionalized
in ECSACON countries and serves as a continuing mechanism to leverage nursing and
midwifery leadership to address national health priorities.
little or no formal training in professional workforce is inherently more prone to

regulation prior to assuming that facing gender bias and discrimination at
role. Regulators can learn from the work. Nurses are also subject to long
experience of other countries and working hours, risk of attack in some
regional-level efforts that have been settings, sexual harassment and unfair
successful at strengthening regulatory treatment as migrant workers. The
frameworks (see Box 6.7 on the existence of regulations on working hours
African Health Profession Regulatory and conditions was reported by 94% of
Collaborative). countries, on social protection by 91%,
and on minimum wage by 89%, although
6.3.4 DECENT WORK less is known about the adequacy and
actual level of implementation of such
Synthesis of results policies. A total of 55 countries (36%),
162. Ensuring decent work conditions is mostly in the South-East Asia and Eastern
relevant and necessary for all health Mediterranean regions, reported measures
occupations, but the nursing profession to prevent attacks on health workers.
faces particular challenges. As a mostly
female workforce and considering the Policy options
negative legacy in some contexts of a 163. Countries should implement the
traditionally subordinate role, the nursing Decent Work Agenda and invest

in enabling working conditions 164. Countries must protect and support
for nurses. Essential elements nurses who are directly affected by
include adequate remuneration, social humanitarian crises. Ministries of
protection, fair working conditions, health, professional nursing organizations
reasonable working hours, occupational and nongovernmental organizations
safety, non-monetary incentives, need to engage with relevant authorities
and transparent and merit-based and parties involved to ensure the
opportunities for career progression. protection of and support for nurses
These conditions are closely related who may be providing care in severely
to nurse retention and should apply to underresourced or harsh conditions
nurses irrespective of their gender, social (such as refugee camps or shelters),
background, country or region of origin, or who may be part themselves of a
ethnic group, or language, and should population displaced across a border and
be enforced through clear accountability providing care in jurisdictions where they
mechanisms. Health workers’ rights, are not formally recognized to practise.
including appropriate pay and adequate This will help ensure the security of
working conditions, are some of the all health workers and health facilities
most common reasons for industrial in all settings, particularly for women,
action or strikes by health workers (see who may be at greater risk of attack or
Box 6.8 on health worker strikes). harassment during the crises.
Box 6.8 Health worker strikes
In many countries across the globe, workers are legally entitled to strike, and this is widely
considered as a civil right (311). However, for health workers, exercising this right is
complicated because doing so creates a tension with patients’ rights to care, and with citizens’
rights to universal health coverage, and may or may not lead to increased mortality (311–314).
Notwithstanding, health worker strikes, including by nurses, take place across the world,
in high-, middle- and low-income countries (313, 314). An analysis of strikes in low-income
countries found that health workers were reported to be on strike for 875 working days, in 23
low-income countries, between 2009 and 2018 (311). The study reported that strikes could last
days or months, and could also be recurrent over months or years (311). The primary causal
factors leading to these strikes were complaints about remuneration and delayed payments,
followed by protest against the unsatisfactory implementation of a previously reached
agreement, or against the health sector’s governance and policies, as well as complaints
about working conditions and security issues. Reducing health worker strikes will require
multistakeholder, multifaceted and multisectoral approaches (311, 314, 315). More research
is needed to understand the causal factors in individual cases, as well as patterns across
regions, and which actors should be engaged to reach a positive resolution (311). However, it
is clear that multisectoral action, with the support of political leadership, is needed between
health and other sectors to address the upstream factors associated with health worker strikes
(314). Investment in decent working conditions for health workers, where they are assured
of a safe, enabling and effective working environment, is vital for the achievement and
protection of the right to universal health coverage (314).

6.3.5 GENDER AND WOMEN’S RIGHTS progressively implement a more
equitable and gender-neutral system of
remuneration among health workers.
165. Approximately 90% of the nursing It must include sound policies and a
workforce globally is made up of reconsideration of fiscal arrangements
women. The high level of gender with respect to health worker
segregation in nursing leads to remuneration. While recognizing the
complex patterns of remuneration: need for market forces to influence
in many countries there is a “gender pay levels, policies and laws addressing
pay gap”, although the evidence is the gender pay gap should apply as
largely from high-income countries relevant to the private sector as well.
(21). The effective implementation Nursing leadership must be included in
and monitoring of gender wage gap the assessments of remuneration equity
policies are required to deliberately and development of policies to redress
promote gender equity within the health the issue.
workforce, and overcome the historical
legacy that has undervalued nurses’ 167. Countries should prioritize and
work, including through gender bias enforce policies addressing sexual
(121, 232). Analyses by WHO found that harassment and discrimination
health leadership positions continue to within nursing and the overall health
be dominated by men, with only 25% workforce. This should include a zero
of leadership positions in health globally tolerance policy towards violence and
being held by women (21). A study of verbal, physical and sexual harassment;
leadership barriers and facilitators in policies that create decent working
nursing commissioned by the Nursing environments for women, including
Now campaign described not only a flexible and manageable working hours
“glass ceiling” for women, but also a that accommodate the changing needs
“glass elevator” for men, who hold a of nurses as women; and gender-
disproportionately high number of senior sensitive leadership development
nursing roles (122). This is just the most opportunities for women in the
visible manifestation of deep-seated nursing workforce.
gender imbalances that permeate
health systems at all levels and affect
all facets of the management of the 6.4 Building institutional capacity
nursing workforce. and leadership skills for effective
governance
Policy options
166. Countries should address the gender
pay gap affecting female nurses. 168. Over 80 countries reported a leadership
In some countries the inequitable position for nursing at the national
remuneration between genders may be level with responsibility for providing
driven by the high levels of occupational input into policy decisions related to
segregation in nursing as compared health and nursing. Government chief
to other occupations. Addressing this nurses should work as full partners with
can start with an analysis of national other health professional leadership in
pay scales and a commitment to making strategic decisions that impact

health service planning, care delivery and participate in decision-making
and working conditions (316). Capacity forums. Nurses should be considered,
in labour market and fiscal space on par with other health professions,
analysis, workforce policy, planning for appointment to leadership positions
and governance is needed to identify within national and state governments,
priorities and develop evidence-based as well as within local and other
solutions to strengthen education organizational structures. This effort will
capacity, create jobs and retain nurses. require budgetary allocation specifically
The findings of this report indicate for the development of nursing
that of 76 responding countries, leadership. Country-based award and
53% had national programmes for recognition mechanisms can be created
leadership development of nurses – to recognize nursing contributions to
though distribution was unequal as a the advancement of universal health
majority of the countries reporting coverage and serve as role models
such programmes were in the WHO to younger nurses (see Box 6.9 on a
regions of Africa and the Eastern leadership fellowship programme in
Mediterranean. the Western Pacific Region).
169. Governance capacity for sound design

and implementation of nursing and
health policies also requires institutions,
mechanisms, policies and procedures
to ensure that the nursing workforce
priorities are considered and embedded
in broader government actions in the
health sector and beyond. The findings
of this report have highlighted that a
chief nurse position and the presence of
leadership development programmes for
nurses were correlated with a stronger
regulatory environment for nursing.
However, the existence of a chief nursing
officer was not necessarily correlated
with the existence of leadership
programmes. This may be due to the
fact that leadership programmes have
often been driven by the professional
associations as either a service to
their members or as an income
generation opportunity.
Policy options
170. Nurse leadership must be developed
at country, regional and global
levels. Nurses must have opportunities
to develop their leadership potential
© Janice Mullings-George

171. National policy-making forums 6.5 Catalysing investment for the
should consider the nursing creation of nursing jobs
perspective in health system
decision-making. Policies should
ensure that nurses are represented 172. This report provides additional evidence
at all levels of decision-making and for the inclusion of a greater focus on
have a voice in influencing key health nursing as part of the broader investment
system decisions and public health case for the health workforce for
policy matters. Nurses should also be achieving universal health coverage.
included in population-level clinical Despite a positive trend recorded
decision-making, which implies, over the last few years, unless the
for instance, including nurses in production and absorption of nurses
guideline development teams and increase substantially, nursing density
guideline review panels to reflect will improve only marginally in most
nursing research and insight on the regions over the next decade, with
feasibility and acceptability of clinical substantial needs-based shortages
recommendations. persisting in low-income and lower
Box 6.9 Leadership fellowship in the Western Pacific Region
Health systems in the Western Pacific Region are managing a double burden of
noncommunicable and communicable diseases, while also facing significant economic, social
and environmental challenges. Nurses provide approximately 78% of the care in the Western
Pacific Region (317), so it is crucial that they are empowered and educated to a level that
gives them the influence they need to improve community health outcomes. However, the
Western Pacific Region has traditionally experienced a lack of leadership programmes (318,
319), including few for health professionals (320–322), and existing programmes have not
been culturally contextualized (317, 323, 324).
From 2009 to 2017, the University of Technology Sydney ran an Australia Awards Fellowships
leadership and mentorship programme in partnership with the South Pacific Chief Nursing
and Midwifery Officers Alliance (318). The leadership programme focused on human
resources for health, collective cultures, teaching mentorship, policy implementation and links
with universal health coverage. Impact assessment involved more than 300 stakeholders and
programme participants from 14 countries (318).
Initial findings show that 85% of the participants of the leadership model have had major
career developments and assumed senior roles in nursing and midwifery. They have
also implemented projects in their home countries in areas such as succession planning,
professional development, regulation and refresher training (319). Another major finding is
that these professions are now represented at global summits, influencing policy on global,
regional and national levels (325). Nine nursing and midwifery officers from the leadership
programme attended the Seventy-second World Health Assembly. Six have become
government chief nurses in their countries, and two are the health ministers of their countries.

middle-income countries, especially in
the African, South-East Asia and Eastern
Mediterranean regions.
173. Intersectoral policy dialogue will be

needed to identify and commit adequate
budgetary resources for investments
in education, skills and job creation,
recruitment, deployment and retention
policies, and capacity-building of
relevant national institutions, such as
licensure and accreditation bodies.
Expanding health labour markets
creates opportunities for employment,
particularly for women. Expanding jobs
in nursing could help bolster the female
labour force participation – which is only
48% globally for women, compared
to 75% for men – and the female
employment rate (326, 327). The benefit
of investing in the creation of nursing
jobs is supported by overwhelming
evidence that speaks to the “triple
dividend” – for health, gender equality,
and development (21).
Policy options
174. Countries should coordinate
intersectoral action and sustainable
financing to enable an expansion of
economic demand for the creation
of nursing jobs. The 5.9 million new
nursing jobs needed (only focusing
on those required to fill current gaps)
can be created in most countries with
existing domestic funds by effective health workers in most high- and
management of wage bill growth. middle-income countries (assuming
National planners should consider the normal fiscal growth and ability to
efficiency of nursing investments vis- prioritize health) (328). Some high- and
à-vis that of other occupational groups middle-income countries can address
and optimize the productivity of the shortages and unlock demand by
current and future nursing workforce lifting restrictions on the supply of
through appropriate incentives and health workers, while at the same time
management systems. Public funds reducing overreliance on international
can meet the recurrent costs of labour mobility and immigration.

175. Development partners should align for example in low-income countries
official development assistance for and in fragile, conflict-affected, and
nursing education and employment vulnerable contexts, and governance
with national health workforce and conditions allow it, mechanisms such as
health sector strategies. Some low- fund-pooling institutional arrangements
and lower middle-income countries will can be considered.
face challenges to create nursing jobs
due to insufficient fiscal space. The 176. Countries should address the
harmonization and alignment of donors’ question of how much nurses
and development partners’ support should be remunerated considering
can expand sustainable financing for prevalent local, national and
strengthening the health and social international labour market
workforce while ensuring that the wage conditions. Policy-makers and
bill can be expanded and sustained to regulators, such as the civil service
accelerate progress towards universal or health service commission, should
health coverage (see Box 6.10 on deliberately avoid some typical pitfalls.
investing in human capital). Where These may include keeping remuneration
domestic resources are estimated to be levels too low (which can lead to
insufficient in the medium and long term, demotivation, excessive turnover and
Box 6.10 Investing in human capital
To increase access to quality primary health care services, as the cornerstone for achieving
universal health coverage, substantial investments are needed in infrastructure (for example,
hospitals and health centres) and the associated human capital (the health workforce,
including knowledge and skills) (14, 328). A number of human capital initiatives are focused
on helping countries invest more — and more effectively — in their people to improve
outcomes in health, nutrition, quality education and skills.
• The World Bank committed to invest US$ 15 billion to support human capital reforms in
low- and lower middle-income countries, with a particular focus on Africa; 63 countries
have signed on as human capital project countries.
• The International Monetary Fund is reinforcing all programmes with a social spending
initiative as a core objective. They will provide additional technical assistance in the areas
of social spending, social protection, education and health.
• Within the context of universal health coverage, the European Investment Bank and WHO
are partnering on the human capital agenda through development of a financial instrument
that links European Investment Bank investments with targeted support for education,
skills and jobs in the health sector.
• The OECD, WHO and the ILO established a United Nations Multi-Partner Trust Fund to
pool resources for implementation of recommendations stemming from the United
Nations High-Level Commission on Health Employment and Economic Growth related to
transformative education, skills and job creation.

illicit coping strategies), too high (which information needed to comprehensively
can lead to wage inflation and problems understand the nursing workforce and
of sustainability of the wage bill), or conduct a health labour market analysis,
perpetuating gender pay disparities. The particularly in relation to production
modality of remuneration also matters: capacity, attrition, wage levels and
nurses are typically paid a fixed income absorption in the health labour market.
through a salary in most settings, and The support systems that underpin
the income through dual practice is less collation, analysis and use of this type of
substantial than for other occupational evidence need to be strengthened. The
groups. Attention should be paid to use of NHWA, which hinges on strong
avoiding the known drawbacks of intersectoral engagement, can support
disease-specific or programme-specific the policy dialogue and decision-making
top-up incentives that distort national on planned, sustainable investments to
priorities and tend not to be sustainable. catalyse progress in key areas for nursing.
Policy-makers should also consider the
coherence of the remuneration across 179. Evidence on nursing workforce
health professions in order to avoid, effectiveness in primary health care
for instance, creating disincentives for and universal health coverage. This
choosing a nursing career. Ultimately, report has summarized evidence on the
nurses should be remunerated at a level contribution of nurses across different
that attracts, retains and motivates them clinical interventions and public health
sufficiently to meet the country’s needs. areas. The strongest evidence comes
from a systematic review that included
18 randomized controlled trials that
6.6 Research and evidence agenda showed the effectiveness of nurse-led
interventions across a range of primary
177. This report has provided an care functions (30). However, 17 of the
unprecedented wealth of data and an 18 included studies were conducted
overview of the research evidence in high-income countries, with only
on the nursing workforce, allowing one from a middle-income country
the development of policy options for and none from low-income countries.
consideration by Member States and Further Cochrane and Campbell reviews
other stakeholders. At the same time, have also been conducted for specific
its development was affected by several clinical or programme areas, including
limitations in both data and evidence antiretroviral therapy, tobacco cessation,
of effectiveness. The main gaps we mental health and sexual assault
identified are reported below and can be examination. Among these, one included
considered as part of a forward-looking only randomized controlled trials, while
research agenda. the others included both experimental
and quasi-experimental studies, including
178. Nursing-specific quantitative and controlled trials (randomized or non-
semi-quantitative evidence. One of randomized), controlled before and after
the most important findings in the State studies, cohort studies (prospective
of the world’s nursing 2020 report is or retrospective), and interrupted time
not from the data, but about the data. series studies, thus enabling comparison
There are large and important gaps in between intervention and control (31, 33,

34). The Campbell review was focused 180. Leveraging different research
on practices in the United States and the settings and methodologies. While
United Kingdom and was thus limited the aforementioned evidence reviews
to studies from those countries. The are essential to establishing the
review on antiretroviral therapy only effectiveness of nursing interventions,
included studies from Africa. All studies the setting of the included studies
in the review on tobacco cessation were limits their generalizability and global
from high-income countries, mostly the applicability. Furthermore, experimental
United States. The mental health review and quasi-experimental investigations
only focused on low- and middle-income most typically compared nurses to other
countries, including seven studies from health professionals. While this may
low-income countries and 15 from low- offer useful insights, the method is ill
and middle-income countries (31, 33, suited to illustrate and fully understand
34). The overview also highlights specific the team-based nature of efforts and
gaps in the evidence on effectiveness, interconnected processes required
such as nursing interventions with for the successful delivery of quality
respect to the social determinants health care. A broader range of studies,
of health, including climate change, comprising quantitative (experimental
and nursing interventions in complex and non-experimental) and qualitative
emergency settings. primary studies, mixed methods

reviews, and field descriptions, provide understood and should be studied
a more comprehensive overview of in a variety of settings and policy
nursing policy issues across the globe contexts, including through studies
(see web annex). However, most of this of cost-effectiveness of nursing care,
evidence was generated in high-income particularly in primary care settings
country settings (30, 329), including the in low- and middle-income countries.
generation of research priorities (330). There is also room to strengthen the
evidence on effectiveness of policy
181. More needs to be done to support the interventions to retain nurses in practice
documentation of nursing interventions settings, regulatory and governance
in low- and middle-income countries and approaches to enable nurses to practise
to support nursing science within low- to their full scope in primary health
and middle-income countries, so that care service delivery, and effective
nurses themselves drive their research mechanisms to regulate private
agenda based on their own experience sector education and practice. A more
of working in health service delivery. robust evaluation of policies intended
Nurses already make a very substantial to address the negative effects of
contribution to health care science, migration would enable a better design
including developing innovative research and a more realistic targeting of policy
methods and using these methods to responses. Across all these areas, an
investigate issues of importance to explicit gender lens should be applied to
improving global health (331). Research the analysis. As most of the reviewed
has shown that the quality of evidence studies have typically a short time
for effective strategies to improve horizon, longer-term longitudinal studies
health worker practices in low- and might help develop a greater level of
middle-income countries is low (332). confidence in the relevance of the
Investment in nursing research must findings to real-life policy settings.
therefore focus not only on increasing
quantity of output, but also on increasing
the quality of the science, as this will
contribute to our overall health
workforce knowledge.
182. Evidence on effective policy and

system support to optimize the
role of nursing. This report has
highlighted the evidence on the
effectiveness of policy options to
optimize the contribution and impact of
nursing, including diverse areas such
as education, regulation, deployment,
practice and retention. At the same
time, the evidence on other areas was
less strong. For instance, the return on
investments in nursing and the broader
health workforce could be better


CHAPTER
7
CONCLUSION
183. This State of the world’s nursing 2020 primarily in the African, South-East Asia
report has underscored the centrality and Eastern Mediterranean regions.
of nurses as part of integrated teams This represents an improvement in the
in making critical contributions nursing workforce stock in the countries
towards universal health coverage affected by shortages, as compared with
and other national and global health the baseline situation identified by the
objectives. Nurses represent the largest Global Strategy.
occupational group, with a headcount
estimated for 2018 of approximately 185. Despite signs of progress, the report
28 million, representing a central element has also highlighted key areas of
of primary health care and health concern. In line with the projections
systems in countries of all levels of made by the Global Strategy in 2016,
socioeconomic development. an acceleration of progress will be
required in low- and lower middle-
184. The data and evidence collated for income countries and the African and
this report are stronger than ever Eastern Mediterranean regions in
before. A total of 191 countries reported order to address key gaps. The largest
on workforce stock — an all-time high shortfall in absolute numbers remains
and a 53% increase on the health in the South-East Asia Region. The
workforce data released in 2018. For the American and European regions face an
first time, 80% of countries provided additional threat in light of their ageing
WHO with data on at least 15 nursing nursing workforce. Several high-income
indicators spanning different workforce countries in the American, European and
policy dimensions. An analysis of stock Eastern Mediterranean regions appear
data trends indicates a shortage of 5.9 excessively reliant on international
million nurses in 2018, concentrated nursing mobility.
Conclusion 91
186. National governments, with support multiple development outcomes,
where relevant from their domestic including job creation, gender and
and international partners, should youth empowerment.
catalyse and lead an acceleration of
efforts to: 187. Translating the evidence of
this report, the policy options
• build leadership, stewardship and recommended, and the strategic
management capacity for the nursing directions above into concrete policy
workforce to advance the relevant and investment decisions will require
education, health, employment and coordination among government
gender agendas; sectors and collaboration with the
most critical stakeholders. The
• optimize return of current investments findings and data presented should
in nursing through adoption of be used to trigger policy dialogue
required policy options in education, opportunities in countries involving the
decent work, deployment, practice, most important stakeholders. These
productivity, regulation, and retention policy dialogue mechanisms should be
of the nursing workforce; leveraged to elicit the requisite decisions
in terms of both the adoption of sound
• generate massive investment in the and evidence-informed policies and
health workforce, and in nurses as appropriate investment levels.
part of this, and leverage them for
Let us seize this

opportunity to
commit to a
decade of action
that begins with
INVESTING IN
NURSING
education, jobs and
leadership.

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Annex 1. Who is a nurse?
Nurses provide a wide variety 2221) and nursing associate professional nurses and
of services for people in all professional (ISCO code 3221). associate professional nurses
health care settings, from Of note, the present section is blurred. Similarly, the
specialist hospitals to health reports on nursing personnel distinction between associate
posts and communities. Nurses as an occupational group professional nurses and nurse
hold a diverse set of job titles, defined above, but it should aides is not always clear.
roles and educational pathways. be noted that “nursing care”, In these cases, therefore,
The six most common nursing putting the nursing personnel an element of judgement
job titles are registered nurse, within a multidisciplinary was required from national
nurse, licensed practice nurse, health system, involves stakeholders. Countries were
advanced practice registered several other occupations advised to consider both the
nurse, nurse practitioner, and not described in the present roles and responsibilities
nursing assistant. However, section. For example, the ISCO and the duration of pre-
the role of a nurse in one classification and a country’s service education when
country may be different from system following ISCO would deciding whether to classify
the role of a nurse in another classify “nurse aids” as health an occupation group as
country, even if their job title care assistants, a broader professionals or associate
is the same. This makes it support occupational group.12 professionals, or not nurses
inappropriate to use job title as at all. For example, as a
a method of classification and ISCO guidance provides general rule, a professional
analysis at international level. detailed descriptions of which nurse will have completed
health workers should be a pre-service education course
This report aims to present the counted under each category lasting at least three years.
best available, internationally (Box A1.1). In summary, In case a country was not
comparable data on the nursing professional nurses assume able to decide which category
workforce, as defined by the responsibility for the planning to use, NHWA includes a
ILO 2008 International Standard and management of the nursing “nurses: not further defined”
Classification of Occupations care of patients, working option, and some countries
(ISCO-08) and reported and autonomously or in teams with opted to place some or all of
validated by WHO Member medical doctors and others. their nursing workforce into
States. To help achieve this Nursing associate professionals this category. This category
aim, National Health Workforce provide basic nursing and corresponds to either nursing
Accounts (NHWA) use the personal care and generally professionals or nursing
ISCO-08 system to categorize work under the supervision or associate professionals,
the health workforce. Countries in support of medical, nursing but it excludes nursing aides,
were asked to classify their or other health professionals. who belong to the health
nursing workforce into one care assistant occupational
of two main ISCO-08 codes: However, in some countries, group, not analysed in the
professional nurse (ISCO code the distinction between present report.
12 ILO International Standard Classification of Occupations: https://www.ilo.org/public/english/bureau/stat/isco/.

Box A1.1 ISCO definitions of nursing personnel
NURSING PROFESSIONAL TASKS INCLUDE: NURSING ASSOCIATE PROFESSIONAL TASKS INCLUDE:
• Planning, providing and evaluating nursing care • Providing nursing and personal care and treatment
for patients and health advice to patients according to care plans
established by health professionals
• Coordinating the care of patients in consultation with
other health professionals • Administering medications and other treatments
to patients, monitoring patients’ condition and
• Developing and implementing care plans for the responses to treatment, and referring patients and
treatment of patients in collaboration with other their families to a health professional for specialized
health professionals care as needed
• Planning and providing personal care, treatments and • Cleaning wounds and applying dressings
therapies, including administering medications and
monitoring responses to treatment or care • Updating information on patients’ conditions and
treatments received in record-keeping systems
• Cleaning wounds and applying dressings
• Assisting in planning and managing the care of
• Monitoring pain and discomfort in patients and individual patients
alleviating pain using therapies, including
painkilling drugs • Assisting in giving first-aid treatment in emergencies
• Planning and participating in health education

programmes, health promotions and nurse education
activities
• Answering questions from patients and families and

providing information about prevention of ill-health,
treatment and care
• Supervising and coordinating the work of other

health workers
• Conducting research on nursing practices and

procedures
Note: The distinction between professional and associate professional nurses should be made on the basis of the nature of the work performed in relation to
the tasks specified above. The qualifications held by individuals or that predominate in the country are not the main factor in making this distinction, as training
arrangements for nurses vary widely between countries and have varied over time within countries.
Source: Adapted from ISCO-08.
Annex 1 109
Annex 2. Methods
Indicators used in the State organizations, and focal points reporting and validation of the
of the world’s nursing 2020 were advised to review and relevant data.
report validate the data. The population
WHO member states were size for each country and Data reported
invited to submit from July 2019 year were extracted from the Of the 194 WHO Member
to November 2019 the most 2019 revision of the World States, 193 reported data
recent available data on the population prospects of the (191 reported on stock) either
nursing workforce through 36 United Nations Department of directly via the NHWA platform
indicators, 30 from the NHWA Economic and Social Affairs.14 or through regional offices and
and six additional specific Additional data on indicators other international processes
indicators (see list in Table A2.1). assessing the governance and such as OECD, Eurostat and
The 30 indicators are defined in policy environment through WHO Regional Office for Europe
the NHWA handbook,13 which binary questions (yes/no) on the joint data collection on non-
also provides detailed definitions existence of related mechanisms monetary health care statistics.
and metadata for each indicator. and processes, as well as on Figure A2.1 illustrates that 80%
the duration of education and of countries provided data for
Data collection process training, were also gathered at least 15 of the 36 selected
NHWA is a continuous process from the Sigma and the NCBSN indicators, and 23% of countries
with progressive improvement databases15 to complete did so for at least 25 indicators.
of availability, quality and use information for a small number
of health workforce data. As of countries. The main data gaps were
part of this process, countries for the indicators relating to
were encouraged to set up To support the data collection, wages, expenditure on nursing
multistakeholder working WHO conducted regional NHWA education and other education-
groups on all health workforce workshops in all six regions and related issues. For selected
data-related aspects to conduct provided tools and information in indicators, alternative sources
internal validation before several languages. In total, more were identified to supplement
submitting data; this was than 250 representatives from the NHWA data, such as
done in a substantial number around 80 countries attended duration of education and
of countries. The preparation these capacity-building events. training, wages and capacity
of the State of the world’s Data were submitted between indicators. For example, the
nursing 2020 report accelerated July and November 2019, and international nursing honours
this global effort of improved data cleaning and analysis were society, Sigma, manages a
monitoring and reporting of conducted between October and database on the status of
standardized data. Countries December 2019. The present nursing education globally,
were asked to nominate focal report is based on the data set including indicators on entry-
points, which were provided from the NHWA online platform level wages and educational
with access to the NHWA online as of 17 December 2019. programme duration for around
platform to enter or validate 50 additional countries. For the
the data. In addition, data for NHWA focal points were advised set of binary indicators relevant
OECD countries resulting from to involve nursing leaders and to policies and regulations of
the joint OECD, Eurostat and other national stakeholders. nursing practice and education,
WHO Regional Office for Europe The WHO country and regional the Global Regulatory Atlas was
data collection questionnaire offices supported the NHWA used to identify where licensure
were prepopulated to avoid implementation and reporting examinations are required and
double reporting to international process, including the collection, where regulatory bodies exist.
13 National Health Workforce Accounts: implementation guide. Geneva: World Health Organization; 2018.
14 Department of Economic and Social Affairs and Population Division. World population prospects 2019, online edition, revision 1. New York,
United States of America: United Nations; 2019.
15 Sigma data extracted from: https://www.sigmanursing.org/advance-elevate/research/research-resources. NCSBN data extracted from: https://
www.ncsbn.org/national-nursing-database.htm.

Table A2.1 List of 36 indicators used for the State of the world’s nursing 2020 report
Thirty indicators were derived from the NHWA handbook and six were specifically designed for the present report.
Response rate as of
Indicator name (NHWA abbreviated) NHWA number 17 December 2019
NURSE WORKFORCE STOCK Nurse density by type/level of nurse 1-01 98%

AND DISTRIBUTION
Nurse density at subnational level 1-02 31%
Nurse distribution by age group 1-03 55%
Female nurse workforce 1-04 68%
Nurse distribution by facility ownership 1-05 47%
Nurse distribution by facility type 1-06 34%
Share of foreign-born nurses 1-07 35%
Share of foreign-trained nurses 1-08 46%
EDUCATION AND TRAINING Master list of accredited education institutions 2-01 88%
Duration of education and training 2-02 56%
Number of applications for education and training 2-03 12%
Ratio of nursing students to qualified educators 2-05 10%
EDUCATION AND TRAINING Standards for duration and content of education 3-01 87%
REGULATION AND ACCREDITATION
Accreditation mechanisms for education institutions 3-02 84%
Standards for interprofessional education 3-06 80%
Continuing professional development 3-08 82%
EDUCATION FINANCES Expenditure per graduate on nursing education 4-05 7%
HEALTH LABOUR MARKET FLOWS Graduates starting practice within one year 5-01 14%
Replenishment rate from domestic efforts 5-02 45%
Entry rate of foreign nurses 5-03 11%
Voluntary exit rate from health labour market 5-04 9%
Unemployment rate 5-06 8%
EMPLOYMENT CHARACTERISTICS, Health workers with a part-time contract 6-02 6%
WORKING CONDITIONS
Regulation on working hours and conditions 6-03 86%
Regulation on minimum wage 6-04 86%
Regulation on social protection 6-05 86%
Measures to prevent attacks on health workers 6-09 80%
NURSING WORKFORCE SPENDING Entry-level wages and salaries 7-05 42%
AND REMUNERATION
Gender wage gap 7-07 3%
SKILL MIX COMPOSITION
FOR MODELS OF CARE Existence of advanced nursing roles 8-06 79%
ADDITIONAL STATE OF THE WORLD’S National chief nurse (or equivalent) role – 84%
NURSING 2020 SPECIFIC INDICATORS
National leadership development opportunities – 76%
National association for pre-licensure students – 76%
Authority that regulates nursing – 98%
Standards for faculty qualifications – 68%
Fitness for practice or licensure examination – 92%
Note: For further information on NHWA indicators, detailed information with metadata is available in the NHWA handbook:
https://www.who.int/hrh/documents/brief_nhwa_handbook/en/.
Metadata for the additional six non-NHWA indicators are available on request to [email protected].
Annex 2 111
Of the 191 countries, 83% statistics were analysed and indicator was considered as
provided nursing headcount presented. Additional data will “no”, hence 0 points.
data from 2017 or 2018. Others be made available progressively
were able to provide data only through a public portal for Multiple correspondence
from earlier years (from 2013 accessing NHWA data. analysis of education
to 2016). In such cases, the regulation and working
2018 headcount was estimated Composite score on conditions in sections 5.4
by applying the latest available education regulation and and 5.6
year’s density to the 2018 working conditions in Indicators on regulation of
population. For four countries sections 5.4 and 5.6 education and practice display
for which headcount was not Whilst most analyses a high level of correlation: if
reported, the corresponding were purely descriptive in one is answered “yes”, it is
regional densities were applied nature, focusing mainly on likely that some others will also
to their 2018 populations. percentages, composite scores be answered “yes”. To better
were used to summarize understand such patterns,
The fact that many countries regulation of education and a multiple correspondence
— most notably in west and working condition indicators. analysis was conducted, which
central Africa and in central Asia For both scores, a country simplifies the correlation
— were unable to provide data was awarded 1 point for every between many variables in a
for several indicators indicates indicator for which the answer single two-dimensional graph
a critical need to continue to was “yes”, 0.5 points if the (Figure A2.2). The analysis
strengthen human resources for answer was “partially”, and 0 enabled extraction of two
health information systems in points if the answer was “no”, dimensions (x and y axis). The
these regions. then the scores were added first “dimension” (the x axis)
to determine a composite can be interpreted as factors
Not all data collected are one. Thus, the maximum associated with the absence
presented in this report: only possible score was 9, and the of regulation on the right
indicators for which a significant minimum was 0. For indicators as opposed to presence of
number of countries reported with missing information, the regulation on the left. The first
Figure A2.1 Number of indicators reported globally for the State of the world’s nursing 2020 report
<5 5 to 9 10 to 14 15 to 19 20 to 24 25+
0 500 1,000 2,000 3,000 4,000

km
Note: includes 30 NHWA indicators and six capacity questions.

Source: NHWA 2019.

dimension explains 79.7% of The indicators on working Projected stock by 2030
the variation between variables. conditions were strongly For the assessment of the
The second dimension (the correlated, as evidenced by stock of nurses by 2030, three
y axis) can be interpreted as multiple correspondence scenarios were developed,
an absence of accreditation analysis (Figure A2.3). Two as follows.
mechanisms towards the top indicators showing a strong
of the axis as opposed to an correlation were measures to • Scenario 1: ageing (single
absence of education regulation prevent attacks and existence effect of ageing of the nursing
towards the bottom of the axis. of advanced nursing role: this workforce). A projection used
This dimension explains 2.1% of might suggest that in more the age distribution per country
the variation between indicators. risky environments nurses and a stable age group of less
The graph also includes regions may be awarded a greater than 35 years, considering a
to highlight to which indicators level of professional autonomy replenishment of one tenth the
they are more closely correlated. to continue ensuring patient size of this lowest age category.
The analysis confirmed that, care under challenging It considered an ageing
with the South-East Asia circumstances. The European workforce with retirement
Region, Eastern Mediterranean Region displayed a different of one tenth of the size of
Region and Western Pacific pattern than other regions, the group of nurses aged 55
Region on the right side of the indicating both fewer years and over. This scenario
graph, these regions are more measures to prevent attacks does not take into account
likely to be associated with on workers and fewer the graduation statistics and
a lower level of regulation of advanced nursing roles. considers the proportion of
nursing education. the younger age group as
constant for upcoming years.
Figure A2.2 Correlation of education indicators with a multiple correspondence analysis
4
AMR
Dimension 2 (2.1%)
3
No-M2-01 No-M3-02
2
Yes
Yes 1 No-M3-06
Yes EMR
Yes 0
Yes Yes
-2 -1 Yes 0 1 2 3 4 5
AFR No-M3-01
EUR -1 No-NN2
-2 No-M3-08
No-NN3
-3
SEAR
-4
WPR
-5 Dimension 1 (79.7%)
Type of analysis: multiple correspondence analysis of variables on regulation of nursing education system; regions are displayed as independent variables.
Variables summarized in the present graph: M2-01: master list of accredited education institutions; M3-01: standards for duration and content of education;
M3-02: accreditation mechanisms for education institutions; M3-06: standards for interprofessional education; M3-08: continuing professional development;
NN2: fitness for practice examination; NN3: standards for faculty qualifications.
AFR = African Region; AMR = Region of the Americas; SEAR = South-East Asia Region; EUR = European Region; EMR = Eastern Mediterranean Region;
WPR = Western Pacific Region.
Source: NHWA 2019. Latest available data reported by countries between 2013 and 2018.
Annex 2 113
• Scenario 2: replenishment. scenario also assumes a 60% Words of caution in
A scenario with similar ageing absorption into the health interpreting projections
as scenario 1 but using the labour market. Several limitations need to
most recent graduation rate be taken into account when
by region computed in section From these scenarios, estimated interpreting projections.
5.5 to which a correction projected densities for 2030
factor of 0.6 was applied, were calculated using population 1. Regarding the availability of
assuming that 60% of the estimates from the United data, not all countries were
new graduates will find a Nations population prospect able to report on age, used in
job in the health sector, to estimates for 2030. scenario 1, and on graduation
mimic the difference between rate, used in scenario 2. The
graduation and entry into the To assess the impact of scenario analysis showed consistent
active workforce as observed 3, various simulations with results for scenarios 1
in OECD countries. variations in the increase in and 2, therefore providing
graduates were used: 25% reassurance on the entry rate
• Scenario 3: accelerated increase, 50% increase and into the labour market of
replenishment. A similar 100% increase (a doubling of new graduates.
scenario as scenario 2 but production) (Figure A2.4). This
considering an acceleration shows that the choice of the 2. Several assumptions were
of graduation and absorption growth rate of the number of used on the attrition rate for
rate, with more graduates nursing graduates does not personnel aged 55 years and
per year by 2030, assuming drastically impact the estimated above. This could potentially
a growth of 50% from 2018 stock by 2030, with projected vary across regions and might
to 2030 of the graduation stocks of 38.0 million, 39.7 be optimistic, considering
capacity of countries million and 42.8 million nurses that the retirement age will be
(equivalent to an annual with total growth rates of 25%, up to 65 years. Similarly, the
increase of 3.44%). This 50% and 100%, respectively. analysis applied a ratio of 0.6
Figure A2.3 Correlation of working condition indicators with a multiple correspondence analysis
12
SEAR
10
Dimension 2 (2.6%)
8
EMR
6 No-M6-04
4 No-M6-03
No-NN1
AFR 2
Yes-M6-09 WPR
Yes-M8-06 AMR
Yes 0 Yes
-3 -2 -1 Yes 0 1 2 3 4 5 6
-2 No-M6-09 No-M8-06
-4
EUR
-6 Dimension 1 (80.1%)
Type of analysis: multiple correspondence analysis of variables on regulation of working conditions; regions are displayed as independent variables.
Variable summarized in the present graph: M6-03: existence of regulation on working hours and conditions; M6-04: regulation on minimum wage;
M6-09: existence of measures to prevent attacks; M8-06: existence of advanced nursing role; NN1: existence of nursing council.
AFR = African Region; AMR = Region of the Americas; SEAR = South-East Asia Region; EUR = European Region; EMR = Eastern Mediterranean Region;
WPR = Western Pacific Region.
Source: NHWA 2019. Latest available data reported by countries between 2013 and 2018.

for adding graduates who account of a wider range of countries. Based on the
were starting to practise, health workforce and other recent data available for the
based on the OECD ratio of indicators throughout the State of the world’s nursing
practising to licensed nursing health labour market and 2020 report, 174 countries
workforce. However, this more detailed economic had stock data for 2013 or the
could potentially vary by statistics, including fiscal previous five years (including
region. To test the impact of space. 130 countries with 2013 data),
all underlying assumptions and the revised stock for
for scenarios 1–3 a series Estimating shortage 2013 was estimated at 23.2
of sensitivity analyses were The estimation of the shortage million nurses. The stock for
conducted. Results only in nursing personnel followed 2018 is based on data for 191
varied marginally, and the a method similar to the one countries for the period 2013–
conclusions remained described in the Global Strategy 2018, including 89% with data
largely unchanged. on Human Resources for for 2017 and 2018. Therefore,
Health. However, because of the stock reported in the State
3. Projections only reflect the updated data, the shortage of the world’s nursing 2020
recent trends and provide a values cannot be directly report for 2018 can also be
broad understanding of the compared to those estimated in considered as a very
trajectory of the stock of the Global Strategy. robust estimate.
the nursing workforce. This
would need to be revised The analysis shows that For estimating the shortage,
in the future as more data the estimation in the Global the 2018 and 2030 densities
become available. Also, Strategy was based on 102 were compared to a benchmark
these projections do not countries with stock available value used in the Global
replace the conclusions for the period 2009–2013; Strategy on Human Resources
derived from national-level older or imputed data were for Health. That benchmark
modelling, which would take used for the remaining of 4.45 medical doctors,
Figure A2.4 Evolution of global nursing stock (millions) under a “business as usual” scenario and
three “increased production of graduate nurses” scenarios, 2018 to 2030
Nursing stock Nursing stock - 25% Nursing stock - 50% Nursing stock - 100%
graduation constant increase in graduation increase in graduation increase in graduation
45.0
Nursing personnel stock in millions
40.0
35.0
30.0
25.0
20.0
2016 2018 2020 2022 2024 2026 2028 2030 2032
Note: “Nursing stock” includes nursing professionals and nursing associate professionals.
Correction factors used, region specific: ageing factor (one tenth of age group aged 55 years and above in 2018 retiring per year), the graduation rate from
section 5.5 analysis corrected by 0.6 (OECD practising to licensed ratio) to account for activities outside nursing practice.
Annex 2 115
nurses and midwives per 1000 • Because densities on middle-income countries,
population was then converted the health workforce are where the shortages are
into a benchmark value for expressed per 10 000 mostly located. These range
nursing. population, the value of from US$ 5180 in Madagascar,
27.4 nurses per 10 000 US$ 5589 in the World Bank
• First, the share of nurses population was used as ECSA analysis,16 and US
and midwives in the Global benchmark. $5656 in Mozambique, to US$
Strategy was applied to 19 794 in Ghana.17 Therefore,
this benchmark: with 20.7 • This benchmark value computations of costs were
nurses and midwives per was then compared to the conducted with a lower-cost
10 000 population and 9.8 density observed in 2018 scenario of US$ 5000 per
medical doctors per 10 000 and projected for 2030 under graduate, an intermediate
population in 2013, the the three scenarios. scenario of US$ 10 000 per
benchmark is corrected to graduate, and a higher scenario
3.02 nurses and midwives The estimated shortage by of US$ 20 000 per graduate.
per 1000 population (4.45 x 2030 was estimated for the Note that available data on
(20.7/(9.8+20.7))). three projection scenarios these costs were from African
described above and showing countries and could not be
• Then, to calculate a that the shortages remain transposed to high-income
benchmark value for nurses high in low- and lower middle- countries, for which published
only, the share of nurses income countries under each data show much higher costs
among nurses and midwives scenario (Table A2.2). per graduate.
combined (90.7% from most
recent year) was applied Cost per graduate
to this benchmark, giving Multiple divergent sources
a benchmark value of 2.74 of costs per graduate were
nurses per 1000 population. identified for low- and lower
Table A2.2 Estimates of shortage of nursing personnel (millions) in countries below the Global
Strategy threshold by income level: 2018 and 2030 (three scenarios)
2018 2030
Ageing and graduation

Ageing and stable Ageing and graduation increasing by 50% by
INCOME GROUP young age group as of recent years 2030
Low-income 1.34 1.80 1.54 1.26
Lower middle-income 3.91 3.44 2.81 1.54
Upper middle-income 0.67 0.45 0.25 0.12
High-income (used as reference, all with

– – – –
density above threshold)
Global 5.91 5.69 4.60 2.92
Note: “Nursing personnel” includes nursing professionals and nursing associate professionals. Income grouping is from the World Bank classification as of 2018.
16 Araujo EC, Garcia-Meza AM. Nurse labour market analysis in 16 countries in east, central, and southern Africa (preliminary findings,
unpublished). Washington (DC): World Bank; 2020.
17 Beciu HA, Preker AS, Ayettey S, Antwi J, Lawson A, Adjey A. Scaling up education of health workers in Ghana. Washington (DC): World
Bank; 2009.

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S TAT E O F T H E

© World Health Organization 2020

Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris.

Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders.

CHAPTER 6 Future directions for nursing workforce policy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

ISBN 978-92-4-000329-3 (electronic version)

© World Health Organization 2020. Some rights reserved.

James Campbell Howard Catton Mary Watkins

viii State of the world’s nursing 2020

Contributors and acknowledgements ix

REFERENCES FOR GLOSSARY

5. Credentialing definitions. American Nurses Credentialing Center (https://www.nursingworld.org/education-events/faculty-

x State of the world’s nursing 2020

Central role of nurses in achieving

Nursing is the largest

Figure 1 Density of nursing personnel per 10 000 population in 2018

0 500 1,000 2,000 3,000 4,000

*Includes nursing professionals and associates.

60% 18 countries at risk

*Includes nursing professionals and nursing associate professionals.

xiv 4 StateState ofworld’s

Americas Eastern Mediterranean High income Low income

While the patterns are evolving,

WHO REGION 2 years 3 years 4 years 5 years

0% 20% 40% 60% 80% 100%

© Nazeer Al-Khatib/AFP via Getty

One nurse out of every eight practises in a

xvi 6 StateState ofworld’s

Figure 5 Percentage of countries with regulatory provisions on working conditions

Regulation on working hours and conditions

Regulation on social protection

Regulation on minimum wage 89%

Nursing council 86%

Existence of advanced nursing roles 53%

Measures to prevent attacks on health workers 37%

Source: National Health Workforce Accounts, World Health Organization 2019.

1 Countries affected by shortages will need to increase funding to educate

xviii 8 StateState ofworld’s

3 Nurse mobility and migration must be effectively monitored and responsibly

4 Nurse education and training programmes must graduate nurses

5 Nursing leadership and governance is critical to nursing workforce

7 Policy-makers, employers and regulators should coordinate actions in

8 Countries should deliberately plan for gender-sensitive nursing workforce

Figure 6 Percentage of female and male nursing personnel, by WHO region

WHO REGION Females Males

Africa 76% 24%

0% 20% 40% 60% 80% 100%

9 Professional nursing regulation must be modernized. Actions include

10 Collaboration is key. Actions include intersectoral dialogue led by ministries of

© Yoshinobu Oka via Sasakawa Health Foundation

build leadership, stewardship and management capacity for the

optimize return on current investments in nursing through adoption of

accelerate and sustain additional investment in nursing education,

© St Thomas’ Hospital, London

1. The nursing workforce, comprising standards and nurse professional

1 As defined by the International Labour Organization’s International Standard Classification of Occupations

CHAPTER 2 Nursing in a context of broader workforce and health priorities

CHAPTER 3 Nursing roles in 21st-century health systems

CHAPTER 4 Policy levers to enable the nursing workforce