ArticlePDF Available

Abstract and Figures

Human resources for health have been recognized as essential to the development of responsive and effective health systems. Low- and middle-income countries seeking to achieve universal health coverage face human resource constraints - whether in the form of health worker shortages, maldistribution of workers or poor worker performance - that seriously undermine their ability to achieve well-functioning health systems. Although much has been written about the human resource crisis in the health sector, labour economic frameworks have seldom been applied to analyse the situation and little is known or understood about the operation of labour markets in low- and middle-income countries. Traditional approaches to addressing human resource constraints have focused on workforce planning: estimating health workforce requirements based on a country's epidemiological and demographic profile and scaling up education and training capacities to narrow the gap between the "needed" number of health workers and the existing number. However, this approach neglects other important factors that influence human resource capacity, including labour market dynamics and the behavioural responses and preferences of the health workers themselves. This paper describes how labour market analysis can contribute to a better understanding of the factors behind human resource constraints in the health sector and to a more effective design of policies and interventions to address them. The premise is that a better understanding of the impact of health policies on health labour markets, and subsequently on the employment conditions of health workers, would be helpful in identifying an effective strategy towards the progressive attainment of universal health coverage.
Content may be subject to copyright.
A preview of the PDF is not available
... There are many factors causing the shortage of GPs and the inequality in their distribution, such as salary, career prospects and promotion, living condition, and job satisfaction Mathers and Huang, 2014;Lian et al., 2019;Zhu and Ariana, 2020). From the perspective of health labor market, the health labor market would be "clear" when the supply of labor matches the demand for it, but labor markets do not always "clear" in this way, and there are often situations where graduates cannot find a satisfactory job or labor shortage (McPake et al., 2013). A health labor market is a dynamic system that needs to be analyzed from both the demand and the supply of health workers. ...
... A health labor market is a dynamic system that needs to be analyzed from both the demand and the supply of health workers. The demand for health workers is influenced by people's need for health care and the government or the medical institutions' willingness to hire them, and the supply of qualified heal workers is determined by many factors, such as the number of graduates, training system, financial and non-financial incentives, and working environment (Chen et al., 2004;McPake et al., 2013;Liu et al., 2017). There are a number of reasons for an imbalance between the demand and supply for health workers, for example, price (i.e., wages or "compensation") may not be easily adjusted due to the regulations established by legislative or bureaucratic process. ...
Article
Full-text available
Aim: This paper aims to analyze the inequalities in general practitioner (GP) distribution in China. Background: GPs-based primary health care (PHC) has been implemented from 2011 in China, aiming to improve the accessibility and quality of basic medical and healthcare services. GPs in China, as the gatekeeper of people's health, mainly undertake integrated health services at the grass-roots level. Methods: The number of GPs and inequality in GPs distribution from 2012 to 2018 was analyzed by the Lorenz Curve/Gini coefficient and Theil L index. Data were extracted from China Health Statistical Yearbook 2013-2019. Findings: The demographic Gini coefficient of GPs changed from 2012 (0.234) to 2018 (0.167), showing high equality in China. In contrast, the Thiel L index from 2012 (0.372) to 2018 (0.345) showed less equality. The decomposition of Thiel L index implicated the inequalities within the divisions. The number of GPs in China shows a fast growth trend since the general practice system established, and the GPs distribution becomes more demographically equitable. However, the shortage of GPs and inequality in their distribution remains severe. More incentive and supportive policies need to be made to enhance the quantity, quality, and structure of GPs in China.
... The reforms have, however, fallen short of resolving the contextual challenges hospitals encounter in the human resource management (HRM) domain. First, the policy measures have been unable to resolve the labour market issues arising from an insufficient supply of skilled healthcare professionals and difficulties with retaining the qualified staff attracted [4,14,15]. Second, public hospital reform is hampered by a heritage of poor general and administrative performance [16][17][18]. Third, institutional health system issues hamper effective reform implementation, despite the robust regulatory framework put in place [16,17]. ...
... Our findings thus provide evidence of human resource shortages faced by low-and middle-income countries, causing the market to be eminently shaped by service supply [15]. Our data do not provide evidence of competitive mechanisms on the demand side, e.g., hospitals competing for patients by providing higher quality of care or additional services. ...
Article
Full-text available
Background In Ethiopia, public hospitals deal with a persistent human resource crisis, even by Sub-Saharan Africa (SSA) standards. Policy and hospital reforms, however, have thus far resulted in limited progress towards addressing the strategic human resource management (SHRM) challenges Ethiopia’s public hospitals face. Methods To explore the contextual factors influencing these SHRM challenges of Ethiopian public hospitals, we conducted a qualitative study based on the Contextual SHRM framework of Paauwe. A total of 19 structured interviews were conducted with Chief Executive Officers (CEOs) and HR managers from a purposive sample of 15 hospitals across Ethiopia. An additional four focus groups were held with professionals and managers. Results The study found that hospitals compete on the supply side for scarce resources, including skilled professionals. There was little reporting on demand-side competition for health services provided, service quality, and service innovation. Governmental regulations were the main institutional mechanism in place. These regulations also emphasized human resources and were perceived to tightly regulate employee numbers, salaries, and employment arrangements at detailed levels. These regulations were perceived to restrict the autonomy of hospitals regarding SHRM. Regulation-induced differences in allowances and external employment arrangements were among the concerns that decreased motivation and job satisfaction and caused employees to leave. The mismatch between regulation and workforce demands posed challenges for leadership and caused leaders to be perceived as incompetent and unable when they could not successfully address workforce needs. Conclusions Bottom-up involvement in SHRM may help resolve the aforementioned persistent problems. The Ethiopian government might better loosen regulations and provide more autonomy to hospitals to develop SHRM and implement mechanisms that emphasize the quality of the health services demanded rather than the quantity of human resources supplied.
... Health Labor Market Analysis (HLMA) has been used to identify and address workforce challenges in many countries over the last decade [4,[9][10][11][12][13]. HLMA can help countries to identify the gaps in their HRH policies which affects the dynamics of labour market including policies related to wages and retention, training, geographic distribution, skill mix, unemployment and gender inequities. ...
... HLMA studies in other LLMICs have also played an important role in clarifying this aspect [4,11]. Studies have shown that comprehensive policies informed by HLMA are needed to address health workforce issues and just addressing the supply side, i.e. increasing the production may not help [4,11,13,38,39]. ...
Article
Full-text available
Background Human Resources for Health (HRH) are essential for making meaningful progress towards universal health coverage (UHC), but health systems in most of the developing countries continue to suffer from serious gaps in health workforce. The Global Strategy on Human Resources for Health—Workforce 2030, adopted in 2016, includes Health Labor Market Analysis (HLMA) as a tool for evidence based health workforce improvements. HLMA offers certain advantages over the traditional approach of workforce planning. In 2018, WHO supported a HLMA exercise in Chhattisgarh, one of the predominantly rural states of India. Methods The HLMA included a stakeholder consultation for identifying policy questions relevant to the context. The HLMA focused on state HRH at district-level and below. Mixed methods were used for data collection and analysis. Detailed district-wise data on HRH availability were collected from state’s health department. Data were also collected on policies implemented on HRH during the 3 year period after the start of HLMA and changes in health workforce. Results The state had increased the production of doctors but vacancies persisted until 2018. The availability of doctors and other qualified health workers was uneven with severe shortages of private as well as public HRH in rural areas. In case of nurses, there was a substantial production of nurses, particularly from private schools, however there was a lack of trusted accreditation mechanism and vacancies in public sector persisted alongside unemployment among nurses. Based on the HLMA, pragmatic recommendations were decided and followed up. Over the past 3 years since the HLMA began an additional 4547 health workers including 1141 doctors have been absorbed by the public sector. The vacancies in most of the clinical cadres were brought below 20%. Conclusion The HLMA played an important role in identifying the key HRH gaps and clarifying the underlying issues. The HLMA and the pursuant recommendations were instrumental in development and implementation of appropriate policies to improve rural HRH in Chhattisgarh. This demonstrates important progress on key 2030 Global Strategy milestones of reducing inequalities in access to health workers and improving financing, retention and training of HRH.
... Workforce. Provision of quality nutrition services to all requires a ready health workforce trained to deliver nutrition services and available at sufficient number and distribution to reach people in communities where they are Crowley, Ball, and Hiddink 2019;King et al. 2020;Kruk et al. 2018;McPake et al. 2013;SUN 2020;WHO and UNICEF 2018b). However, there is a severe shortage of qualified health workers in LMICs, most especially in rural areas (Boerma et al. 2018;Perry, Zulliger, and Rogers 2014;Scheil-Adlung 2013). ...
... In particular, health workers at all levels are grossly ill-equipped to provide high-quality nutrition care, due in part to insufficient training, supervision, and integration (Boerma et al. 2018;Crowley, Ball, and Hiddink 2019;Kruk et al. 2018). In addition to the lack of basic commodities, supplies, and equipment, and poor infrastructure, health workers lose motivation because of heavy workloads and time commitments, inadequate pay, payment delays, and insufficient incentives McPake et al. 2013). ...
Technical Report
Full-text available
Achieving nutrition outcomes and movement toward UHC are inextricably interlinked. Countries have financing choices to make in their efforts to finance health priorities and pursuit of UHC. It will be critical to include and prioritize a costed and well-defined set of nutrition services in the UHC benefits package for countries to scale up nutrition, strengthen health systems, and achieve global nutrition and UHC goals.
... 1 Despite the enormous number within the health-care group, the shortage of nurses and midwives is estimated to be about 9 million in 2030. 2 Many countries are struggling in terms of the availability, distribution, and performance of health workers, including nurses. 3 Achievement of Sustainable Development Goals (SDGs) and universal health coverage (UHC) requires a sufficient number of competent nurses. According to the World Health Organization, an approximately 4.45 health workers including doctors, nurses and midwives are required to serve every 1000 population in order to achieve the SDGs. 1 The importance of nurses in the global market landscape shows us that the world needs investment in the nursing area, particularly amid the COVID-19 pandemic. ...
Article
Full-text available
Purpose: Resolving nursing resources constraints should rely on robust nursing labor market analysis; however, no current study analyzes the dynamics of nursing labor markets in Indonesia. This study aimed to investigate the production, inflow and outflow, maldistribution and inefficiencies, and private sector regulations of the nursing labor market in Indonesia. Patients and methods: This study used descriptive qualitative and document analysis approaches via focus group discussion (FGD) among various stakeholders in Indonesia. The FGD was conducted once attended by representatives from various sectors, including health, education, manpower, professional associations, and private. Policies on training, inflow and outflow, maldistribution and efficiencies, and private sector regulation were analyzed. Document analysis was used to triangulate the qualitative data. Results: There is a structured policy regarding production, inflow and outflow, distribution, and involvement of the private sector. The number of nursing production shows an excess when entering the labor markets; however, the health-care providers reported a nursing workforce shortage. Policies on outflow encourage the deployment of Indonesian nurses overseas despite various challenges. Private sector involvement cannot be denied, especially in the placement of Indonesian nurses abroad. In addition, there is an absence of an integrated nursing labor market platform which may lead to inaccurate supply and demand. Conclusion: Establishing an integrated and comprehensive platform of the nursing labor market in Indonesia is imperative. Addressing the surplus and shortage of nursing workforce requires reliable data to inform the policy. These analyses highlight the need to understand how the existing environment affects the market for Indonesian nurses nationally and globally.
... Nevertheless, this challenge is not limited to developing countries, so lowand middle-income countries like China and India, which have one of the largest and most diversified health labor markets, are faced with such problems despite major healthcare reforms and experiencing great progress. 36 The findings also revealed that the distribution of nurses was highly inequitable in all study years. Theoretically, the GC possibly ranges from 0 (maximum equality) to 1 (maximum inequality). ...
Article
Full-text available
Background Inequitable distribution of human resources in healthcare is one of the main obstacles to improve any health system. This study aimed to evaluate inequalities in the distribution of human resources in healthcare in South Khorasan Province, Iran. Methods We have investigated three types of health staff (i.e. nurses, general practitioners, and specialists) from 2013 to 2018. Data were collected from the annual reports of the Statistical Centre of Iran. The Gini coefficient and time trend regression were applied to measure the inequality. Results The distribution of specialists and general practitioners were the highest and lowest inequality, respectively. Inequalities in the distribution of nurses and specialists have decreased from 2013 to 2018, while the Gini coefficients of the general practitioners have increased from 0.31 to 0.38. According to the regression analysis, inequality in the distribution of nurses and specialists was decreasing over the time; however, the decline was only significant for specialists. While the coefficient B for general practitioners is positive, this indicates raised inequality, but the observed increase was not significant. Conclusions This study revealed that Iran, similar to several other low- and middle-income countries, is with faced the challenge of inequitable distribution of human resources in healthcare, which in turn indicates the necessity of reforms at national and regional levels to address inequalities in the distribution of healthcare human resources, particularly in South Khorasan Province. Hence, the main policy recommendation is to focus on continuous monitoring and evaluation of resource allocation in South Khorasan Province to reduce inequalities.
... However, the above studies mostly focus on subjects in adolescence to early adulthood (e.g., college students), and very few studies have explored differences in humor style tendencies among adults (Stanley et al., 2014), especially older adults (Greengross, 2013). Recent studies have warned that populations are aging worldwide (Huang, 2019;McPake et al., 2013). To manage the impacts of aging populations and maintain the physical and mental health of older adults, the humor style tendencies of older adults must be explored. ...
Article
Full-text available
Individual humor tendencies or behaviors may change with age, but most studies have focused on school-aged children to college students and have rarely explored differences in humor style tendencies from adulthood to older age. The present study examines humor style differences among participants of different ages. This study hypothesizes that older adults are more likely to prefer positive and self-focused humor styles (self-enhancing humor style). A total of 407 participants of different ages and genders were recruited to investigate their humor style tendencies. The results show that men tend to prefer aggressive humor, while women tend to prefer affiliative humor. Interactions between age and humor styles were found. Further analyses show that adolescent to college-aged participants tend to use affiliative humor, adult participants tend to prefer both affiliative and self-enhancing humor, and older adults tend to use self-enhancing humor. In addition, individuals increasingly tend to prefer self-enhancing humor with age, and this tendency was strongest among the older adults, supporting our hypothesis. This study reveals not only significant gender differences but also age differences in humor style tendencies. Our findings clarify the relationship between humor and age and can serve as a basis for future research.
... Others wonder about the overwhelming emphasis on medical education more generally. In an important piece, Barbara McPake et al. point out how much human resources depend on global labor markets and suggests that the conditions of these markets also requires major intervention and regulation [103]. This fits with the WHO's traditional workforce policy. ...
Article
Full-text available
Background This article presents a history of efforts by the World Health Organization and its most important ally, the World Federation for Medical Education, to strengthen and standardize international medical education. This aspect of WHO activity has been largely ignored in recent historical and sociological work on that organization and on global health generally. Methods Historical textual analysis is applied to the digitalized archives and publications of the World Health Organization and the World Federation for Medical Education, as well as to publications in the periodic literature commenting on the standardization of international medical training and the problems associated with it. Results Efforts to reform medical training occurred during three distinct chronological periods: the 1950s and 1960s characterized by efforts to disseminate western scientific norms; the 1970s and 1980s dominated by efforts to align medical training with the WHO’s Primary Healthcare Policy; and from the late 1980s to the present, the campaign to impose global standards and institutional accreditation on medical schools worldwide. A growing number of publications in the periodic literature comment on the standardization of international medical training and the problems associated with it, notably the difficulty of reconciling global standards with local needs and of demonstrating the effects of curricular change.
Article
Full-text available
Conhecer a inserção e a atuação dos profissionais de saúde depois de formados contribui para o aprimoramento das instituições formadoras e para o planejamento de políticas públicas de educação e saúde. O objetivo do presente estudo é avaliar a inserção no mercado de trabalho e no sistema de saúde dos médicos formados pela Faculdade de Medicina da Universidade de São Paulo nos anos de 1999, 2000, 2009 e 2010. Para as características demográficas e de formação dos médicos foi utilizada a base de dados do estudo Demografia Médica no Brasil. Os dados sobre vínculos de trabalho foram extraídos de 4 plataformas digitais, e permitiram caracterizar a inserção dessa população: Plataforma Lattes, Cadastro Nacional de Estabelecimentos de Saúde, LinkedIn e Doctoralia. Dos 602 médicos estudados, 63,1% eram homens, com idade média de 44,7 anos; a maioria trabalhava em dupla prática pública e privada, enquanto uma minoria, apenas no Sistema Único de Saúde. O vínculo mais frequente foi com hospitais e houve baixa frequência de médicos na atenção primária. Manter a capacidade de formar especialistas em áreas fundamentais, além de fomentar vocações para a atenção primária, essencial ao sistema de saúde, é um desafio curricular e institucional a ser repensado. O estudo pode ser reproduzido para acompanhar a inserção profissional e o retorno social dos recursos humanos em saúde egressos de instituições de ensino.
Article
Resumen Introducción La demanda de médicos especialistas es un tema de discusión y debate en Chile, existiendo brechas variables entre la atención y la oferta. El objetivo de este estudio es caracterizar y actualizar la información de la distribución geográfica y demográfica de los médicos dermatólogos en Chile a enero de 2019. Materiales y métodos Se realizó la búsqueda de información a través de la Superintendencia de Salud, Sociedad Chilena de Dermatología y Venereología y CONACEM. Se solicitó al Ministerio de Salud el número de dermatólogos y horas contratadas en el sistema público. Los datos fueron tabulados y analizados en Excel y en los softwares Stata 14 y GeoDA 1.18.0. Resultados Dermatólogos en Chile: 512, con una tasa de 2,9 dermatólogos cada 100.000 habitantes, el 64% está concentrado en la Región Metropolitana (RM), la cual posee la mayor proporción de dermatólogos por habitantes (4,7 cada 100.000 habitantes). El 56% registra títulos otorgados por una universidad chilena. Ciento sesenta y dos dermatólogos se desempeñan en el sistema público, principalmente en la RM (52%). La menor cantidad de horas contratadas (44 h semanales) corresponden a las regiones de Antofagasta y Arica y Parinacota. Conclusión Chile presenta una tasa similar a la de Ecuador, pero inferior a Brasil, Argentina y gran parte de los países europeos. Existe asimetría en la distribución de los dermatólogos. La mayor concentración se encuentra en la RM. Aún faltan más estudios que caractericen la atención dermatológica en Chile.
Technical Report
Full-text available
Worldwide the geographical distribution of health workers is skewed towards urban and wealthier areas. This pattern is found in nearly every country in the world, regardless of the level of economic development and health system organization, but the problem is especially acute in developing countries. The geographical imbalances in the health workforce further exacerbate inequities in the health sector, as the services are not available where needs are higher and impact greater. A variety of interventions have been applied in different contexts and for different types of health workers to address this problem. There is an emerging consensus that policies for recruitment and retention in rural and remote areas need to address two critical issues: i) to be effective, interventions need to be implemented in bundles, combining different packages of interventions according to the variety of factors influencing the health worker’s decision to work in rural or remote areas; ii) to match the interventions with health worker’s preferences and expectations, since the health worker’s employment decisions are a function of these preferences. In order to respond to these requirements, this paper proposes the application of Discrete Choice Experiments (DCEs) to allow for measurement of health workers’ preferences and quantitatively predicts the job uptake given a set of job characteristics. This paper has a two-fold objective: i) to give the reader an overview of the magnitude of unequal health workforce distribution in the developing countries, provide a summary of the evidence to date on the factors that contribute to these imbalances, and present a systematic set of policy interventions that are being implemented around the world to address the problem of recruitment and retention of health workers in rural and remote regions of the developing countries; and ii) to introduce the reader to the potential application of the DCE to elicit health workers’ preferences and determine the factors likely to increase their probability of taking up a rural or remote job.
Article
Full-text available
This paper analyzes how doctors' practices in Paraguay differ across patients, physicians, and facilities. In the absence of claims or chart data, we constructed a measure of "doctor effort" based on observations of doctor-patient interactions. There is little difference in effort for patients from different backgrounds, but large differences across physicians and facilities. Female doctors, doctors on temporary contracts, and doctors in certain types of facilities provide greater effort; those with higher salaries exert less effort. The results suggest that ensuring access to high-quality care is essential, but whether doctors will discriminate against patients might be less of a concern.
Chapter
The medical workforce is important based merely on its size and takes on even greater importance given the influence physicians, nurses, dentists, and pharmacists have on patient treatment. On the supply side, most governments regulate health professions to assure that the inputs into the health production function are of sufficiently high quality. But such regulation can also cause harm. This chapter examines the supply and demand for medical labor and the effects of the market failure and government intervention. We begin by examining the supply side, describing a medical labor market with no market failures. We enumerate the various market failures that justify government regulation and discuss the implications of regulation on medical labor and consumers. We then examine several possible explanations for the persistent variation in medical labor productivity across markets and organization forms, including government regulation, differences in reimbursement incentives, politics, the effect of incentives to manage people within organizations, human resources management, and motivated agents. We end by suggesting some potential areas for future research.
Article
Background: The Millennium Development Goal 4 (MDG 4) is to reduce by two-thirds the mortality rate of children younger than 5 years, between 1990 and 2015. The 2012 Countdown profile shows that Niger has achieved far greater reductions in child mortality and gains in coverage for interventions in child survival than neighbouring countries in west Africa. Countdown therefore invited Niger to do an in-depth analysis of their child survival programme between 1998 and 2009. Methods: We developed new estimates of child and neonatal mortality for 1998-2009 using a 2010 household survey. We recalculated coverage indicators using eight nationally-representative surveys for that period, and documented maternal, newborn, and child health programmes and policies since 1995. We used the Lives Saved Tool (LiST) to estimate the child lives saved in 2009. Findings: The mortality rate in children younger than 5 years declined significantly from 226 deaths per 1000 livebirths (95% CI 207-246) in 1998 to 128 deaths (117-140) in 2009, an annual rate of decline of 5·1%. Stunting prevalence decreased slightly in children aged 24-35 months, and wasting declined by about 50% with the largest decreases in children younger than 2 years. Coverage increased greatly for most child survival interventions in this period. Results from LiST show that about 59,000 lives were saved in children younger than 5 years in 2009, attributable to the introduction of insecticide-treated bednets (25%); improvements in nutritional status (19%); vitamin A supplementation (9%); treatment of diarrhoea with oral rehydration salts and zinc, and careseeking for fever, malaria, or childhood pneumonia (22%); and vaccinations (11%). Interpretation: Government policies supporting universal access, provision of free health care for pregnant women and children, and decentralised nutrition programmes permitted Niger to decrease child mortality at a pace that exceeds that needed to meet the MDG 4. Funding: Bill & Melinda Gates Foundation; World Bank; Governments of Australia, Canada, Norway, Sweden, and the UK; and UNICEF.
Article
The shortage of health workers in many low-income countries poses a threat to the quality of health services. When the number of patients per health worker grows sufficiently high, there will be insufficient time to diagnose and treat all patients adequately. This paper tests the hypothesis that high caseload reduces the level of effort per patient in the diagnostic process. We observed 159 clinicians in 2095 outpatient consultations at 126 health facilities in rural Tanzania. Surprisingly, we find no association between caseload and the level of effort per patient. Clinicians appear to have ample amounts of idle time. We conclude that health workers are not overworked and that scaling up the number of health workers is unlikely to raise the quality of health services. Training has a positive effect on quality but is not in itself sufficient to raise quality to adequate levels.
Article
Many doctors in developing countries provide considerably lower quality care to their patients than they have been trained to provide. The gap between best possible practice and actual performance (often referred to as the know-do gap) is difficult to measure among doctors who differ in levels of training and experience and who face very different types of patients. We exploit the Hawthorne effect–in which doctors change their behavior when a researcher comes to observe their practices–to measure the gap between best and actual performance. We analyze this gap for a sample of doctors and also examine the impact of the organization for which doctors work on their performance. We find that some organizations succeed in motivating doctors to work at levels of performance that are close to their best possible practice. This paper adds to recent evidence that motivation can be as important to health care quality as training and knowledge.
Article
The quality of medical care received by patients varies for two reasons: differences in doctors' competence or differences in doctors' practice. Using medical vignettes, we evaluated competence for a sample of doctors in Delhi. One month later, we observed the same doctors in their practice. We find three patterns in the data. First, doctors do less than what they know they should do. Second, the more competent the doctor, the greater the effort exerted. Third, competence and practice diverge in different ways in the public and private sectors. Urban India pays a lot of “Money for Nothing”: in the private sector there is a lot of expenditure on unnecessary drugs. In the public sector, education subsidies and salary payments translate into little (and in small clinics, very little) effort and care. Provider training has a small impact on the actual quality of advice; under the circumstances, awareness campaigns to create a more informed clientele may be the best option.
Article
This paper presents a framework for the health system with health workers at the core. We review existing health-system frameworks and the role they assign to health workers. Earlier frameworks either do not include health workers as a central feature of system functioning or treat them as one among several components of equal importance. As every function of the health system is either undertaken by or mediated through the health worker, we place the health worker at the center of the health system. Our framework is useful for structuring research on the health workforce and for identifying health-worker research issues. We describe six research issues on the health workforce: metrics to measure the capacity of a health system to deliver healthcare; the contribution of public- vs. private-sector health workers in meeting healthcare needs and demands; the appropriate size, composition and distribution of the health workforce; approaches to achieving health-worker requirements; the adoption and adaption of treatments by health workers; and the training of health workers for horizontally vs. vertically structured health systems.