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1 POLICY BRIEF - PRE-PUBLICATION VERSION TITLE Global estimates of the size of the health workforce contributing to the health economy: the potential for creating decent work in achieving universal health coverage AUTHORS Scheil-Adlung X a, Nove, A b. AFFILIATIONS a International Labour Organization b Novametrics Ltd This pre-publication version was submitted to inform the deliberations of the High-Level Commission on Health Employment and Economic Growth (the Commission). The manuscript has been peer-reviewed and is in process of being edited. It will be published as part a compendium of background papers that informed the Commission. The manuscript is likely to change and readers should consult the published version for accuracy and citation. World Health Organization All rights reserved. The designations employed and the presentation of the material in this manuscript do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this manuscript. However, the material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The manuscript does not necessarily represent the decisions or policies of the World Health Organization.

2 2 Global estimates of the size of the health workforce contributing to the health economy: The potential for creating decent work in achieving universal health coverage Xenia Scheil-Adlung 1, International Labour Organization (ILO), Geneva, Switzerland Andrea Nove, Novametrics Ltd, Derby, UK Key Messages The achievement of health objectives such as universal health coverage (UHC) requires both workers in health occupations (HO workers), such as doctors and nurses, and workers in non-health occupations (NHO workers) who produce goods such as pharmaceuticals and provide services such as cleaning. NHO workers are employed in the broader health economy within or outside the health sector. In this paper, family care workers who provide care informally, very often women, are also included in the NHO category. NHO workers contribute to economic growth and health goals, yet, so far, neither the size of the NHO workforce, nor their contribution to the economy, have been assessed. Without a sufficient number of NHO workers, the achievement of the health-related sustainable development goals (SDGs) will be jeopardized. With them, not only can countries achieve health targets, but the related job creation will bring economic and development benefits, especially in areas which have high levels of un(der)employment among lower-skilled workers and/or which are underserved by health services. Acknowledging the fact that the health sector is strongly linked into the wider economy, this paper takes a health economy perspective. It provides new insights and evidence which indicate that in meeting health needs consideration should be given to the large number of NHO workers. We estimate the number of NHO workers in the current global health economy workforce and the ratio of NHO workers to HO workers. This shows the wide impact that investments in HO workers is likely to have on employment within the health economy and more broadly. We estimate that NHO workers currently constitute 60 per cent of all health employment globally: When workers providing health care informally are included this rises to 70 per cent. Globally, we estimate that 2.3 NHO workers contribute to the achievement of health goals for every one HO worker. In low income countries for each HO worker is supported by many as 3.4 NHO workers. Population growth indicates that perhaps as many as 57 million decent jobs for NHO workers would be needed by 2030 to achieve UHC in the context of the SDGs. Policies for the strengthening of the health economy workforce must take into account NHO workers as well as HO workers, and all health economy workers must be viewed as an investment rather than as a drain on resources. Additionally, the lack of workers results in informal provision of crucial services that might be of poor quality and lead to health and financial problems for the workers providing care. Policies to address the need for NHO workers must also, therefore, consider how to transform these informal jobs into formal jobs where it is appropriate to do so. 1 The authors would like to thank ILO colleagues for their contributions: Amber Barth, Thorsten Behrendt, Ekkehard Ernst, David Hunter, Stephen Pursey, Dorothea Schmidt-Klau and Christiane Wiskow.

3 3 This requires strengthened policies to achieve returns on investments in both groups of workers in the form of inclusive and sustainable growth. They include enabling economic frameworks that provide fiscal space for UHC and related decent health economy employment as well as mainstreaming labour market and employment polices into macro-economic policies. Further, achieving the objectives of UHC in the context of the SDGs requires providing equitable access to quality health services for all in need thus core principles of social protection in health such as equity and solidarity in financing should be applied. Finally, it is of key importance to transform informal care work into formal jobs so as to ensure decent living conditions for informal care workers and inclusive and sustainable growth.

4 4 The role of workers in non-health occupations in achieving health objectives and contributing to inclusive economic growth In many countries, the health workforce accounts for a large share of total employment (e.g. 11 per cent of total employment in OECD countries 2 ), and globally this share is expected to grow significantly over the coming years due to population growth and ageing. 3 At the same time, investing in the health workforce has significant potential to boost economic growth. This will mainly be due to the creation of necessary jobs for the delivery of health care and the increased productivity of healthier labour. The related implementation of social protection policies is addressing the lack of access to health care and also contributes to attaining Sustainable Development Goal (SDG) 3 in the context of SDG 1 on national social protection floors as outlined in ILO Recommendation 202 (R The forgotten workforce: 202) 4 and SDG 8 on Female family members filling in for shortages of LTC workers economic growth and decent work. The health economy requires workers with a broad range of skills, including workers in health occupations (HO workers), e.g. doctors and nurses, but also those in non-health occupations (NHO workers) providing goods and services to support the work of HO workers. Achieving health objectives and realising the related potential for economic growth is not possible without the contribution of NHO workers: their work is essential, for example in administration to register patients, the provision of social and long-term care (LTC) services including from family members as outlined in the box, ensuring clean and sanitized lab coats, producing and packaging Given critical shortages of long-term care (LTC) workers estimated by ILO at 13.6 million globally*, large numbers of family members are providing LTC to their older relatives to fill the gap. In fact, family members provide up to 90 per cent of care work, e.g. in Europe and their numbers exceed by far the number of skilled LTC workers. In low and middle-income countries, these numbers are estimated to be even higher due to the nearly complete absence of LTC workers in these countries. Shortages of skilled LTC workers often result from the assumption that family care is a free service without a cost to the economy. The situation is worsened by age and gender discrimination that manifests itself in neglect of the need for paid LTC workers and the perception of such work as a financial burden. However, many family workers are giving up, reducing formal employment or retire early to provide care and thus are not available to contribute to the economy. The work provided is unpaid, physically and mentally demanding and carried out irrespective of national regulations on working time, vacation, occupational safety and health. Even if compensated by minor in kind or cash benefits, family workers risk poverty and ill health at later stages of their life and thereby increase the economic costs of family care. Finally, accepting the lack of formal LTC workers as normal fails to recognize the potential for physical and mental improvements made possible by services of skilled workers and foregoing the potential of economic growth through creating a sufficient number of LTC jobs. *Scheil-Adlung, X. Long-term care protection for older persons A review of 2 Chris James, Health and inclusive growth: Changing the Dialogue, Policy Brief No 8, UN Commission on Health Employment and Economic Growth, OECD, Paris, Scheil-Adlung, Xenia, What are the impacts of health workforce shortages and employment conditions on the population and economic growth, Policy Brief No 10, UN Commission on Health Employment and Economic Growth, ILO, Geneva, ILO Recommendation 202 concerning National Social Protection Floors

5 5 medicines, operating computers, delivering financial and legal advice, moving goods such as food in the production line and producing finished products for use in the health sector. 5 Without diminishing the importance of health occupations, the roles of other workers contributing to the health economy seem to be equally crucial for achieving health objectives. Thus, for this study we take a broad approach to identifying workers in the health economy, including workers providing unpaid LTC, and thereby cover a larger group than usually covered in the health sector alone. Projected increases in the number of HO workers due to demographic changes are likely to generate substantial numbers of NHO workers as well, both within and beyond the health sector. Thereby, significant returns of investments can be expected given improved health coverage, creation of jobs and associated economic growth. Despite NHO workers being an indispensable part of the health workforce, the debate and strategies about health workforce shortages generally do not take them into account. Similarly, the need for decent working conditions of NHO workers as highlighted in SDG 8 on the promotion of economic growth and decent work has not been central to the debate. This may be due to the fact that hardly any national or global statistics exist to quantify the current number of NHO workers contributing to achievement of the SDGs. This lack of data has a strong impact on countries ability to allocate resources efficiently and devise evidence-based employment policies. Against this background, this paper aims to assess the employment and multiplier effects of investments in health economy employment in NHO focusing on the following questions: 1. Globally, how many NHO workers are supporting HO workers to achieve health objectives? 2. How many decent jobs for NHO workers should be created by 2030 to achieve UHC in the context of SDGs 1, 3 and 8? 3. What is the ratio of NHO workers to HO workers today and how many could be needed by 2030 to attain the SDGs? Methodology Few data at global and national level are available on the number of NHO workers, and current data do not permit country-level comparisons to be made, due to differing definitions and categories of workers. We have therefore developed a new methodology to estimate the current ratio of HO workers to NHO workers. From this we can extrapolate the number of NHO workers and the number of NHO jobs that would be created in achieving UHC by 2030 in the health economy, assuming that the current ratio does not change. The methodology is based on a broad view of the health workforce taking into account health economy workers, i.e. all workers in the health sector as well as in other sectors that contribute to the health sector. For the purpose of this study, health economy workers consist of two groups of workers: HO workers and NHO workers. We identify both groups working within or beyond the health sector to provide goods and services financed through health expenditure or delivered unpaid, e.g. by family members. For the purposes of this study we define: 5 A detailed definition of NHO workers is provided in the next section of this paper.

6 6 HO workers as workers in occupations that require higher or vocational education in a health field based on the International Standard Classification of Occupations (ISCO 6 ), specifically workers in paid or self-employment in the public or private health sectors or in the broader health economy working as Health professionals, Health associate professionals and Personal care workers (ISCO codes 22, 32 and 532). NHO workers as paid or unpaid workers not in heath occupations within the health sector or in other sectors contributing through the delivery of goods and services to HO workers. They include LTC workers such as family members, friends or neighbours who provide unpaid services informally to persons needing long term care. We estimate the number of workers in each of these categories for 185 countries using the ILOSTAT database, WHO Global Health Observatory database 7 and national databases, with data taken for the most recent available year for each country. First, we calculate the number of HO workers based on ISCO codes and the WHO Global Health Observatory 8 and apply an upward adjustment to balance data of countries where the WHO Global Health Observatory data is likely to undercount certain professional categories, such as associate health professionals. 9 Then we calculate the number of workers in all service industries 10 and estimate the proportion of these who are formal NHO workers based on a proxy: total health expenditure as a percentage of GDP. Numbers of informal NHO workers are estimated based on long-term care requirements of the population aged 65 and over and recent ILO estimates 11. We assume that the majority of unpaid informal caregiving is carried out by family members and that such work should be converted into formal jobs if paid employment has been given up, working hours have been reduced or early retirement been taken to provide LTC in the absence of paid formal LTC workers. The reference country considered is the UK 12. We assume we are underestimating the situation in low- and middleincome countries where family members are more likely to provide LTC than in OECD countries. Using the total number of HO workers and (both formal and informal) NHO workers working across all sectors we compute the current global ratio of NHO workers to HO workers based on workforce weighted data for each country. For estimates of the number of HO workers and NHO workers needed to achieve UHC in the context of the SDGs by 2030 we follow earlier methodologies 13 applied to estimate health workforce deficits, i.e. set a threshold based on workforce-to-population ratios in low-vulnerability countries and compare the situation in each individual country against this threshold. Incomplete data necessitated the use of a methodology based on the use of assumptions derived from the limited evidence available. Besides the necessary use of a proxy variable to estimate the WHO Global Health Observatory Database 8 This refers to ISCO codes 22 (health professionals), 32 (health associate professionals) and 532 (personal care workers) 9 Further details are available in the methodological annex. 10 The calculations are based on ISIC Rev 4 categories G-U 11 Scheil-Adlung, Xenia, Long-term care protection for older persons A review of coverage deficits in 46 countries, ILO, Geneva Scheil-Adlung, Xenia, Health workforce benchmarks for universal health coverage and sustainable development, in: Bulletin of the World Health Organization, Vol. 91, No 11, Geneva 2013 and World Social Protection Report 2014/2015, ILO, Geneva 2014.

7 7 number of HO workers beyond the health sector, this concerns e.g. the exclusion of workers in manufacture of pharmaceutical products and construction workers both numbers are probably relatively small. Further, we assume that the ratio of workers wages to material costs is similar for all service industry sectors. Also we assume that informal NHO workers providing care consist largely of family members. Finally, we base our estimates on a limited number of countries and apply workforce weighted average ratios to others. This is likely to introduce inaccuracies at individual country level, but should not greatly affect the global total. Global estimates on the relative sizes of the workforce of HO and NHO workers The global estimates provide information on the number of NHO workers working inside or outside the health sector in activities including (but not limited to) 14 : Administration Social services including delivery of long-term care Insurance Finance Information technology Transportation Education Our analyses indicate that, globally, NHO workers account for 60% of all health economy employment and 70% of all paid and unpaid workers, including informal LTC workers in the health economy. (Figure 1). Figure 1: Composition of workers in the global health economy (thousands), 2015 Unpaid NHO workers: 56,665 HOs: 70,631 Paid NHO workers: 106, For details see annex.

8 8 Source: ILO calculations 2016 In more detail, worldwide we find - 71 million HO workers million paid NHO workers, mostly formal workers and - 57 million unpaid NHO workers, mostly female LTC workers providing care to older relatives. The global ratio of NHO workers to HO workers is 2.3, i.e., globally each HO worker is supported by 2.3 (paid or unpaid, formal or informal) NHO workers to achieve overall health objectives. Excluding unpaid NHO workers mostly female family members and the necessary transformation of the work into paid employment in formal jobs for LTC workers brings the ratio to 1.5, meaning that each HO worker is supported by 1.5 paid NHO workers. Figure 2 shows how the ratio of NHO workers to HO workers varies by income group. If we consider just paid NHO workers, high-income countries have a NHO to HO ratio of 1.7, compared with 1.4 for middle-income countries and 1.3 for low-income countries. Taking paid and unpaid, formal and informal workers into account, however, we see a much higher ratio in low-income countries, because these countries tend to have small numbers of HO workers relative to the size of their populations. The relatively high ratio in high-income countries, on the other hand, is likely a reflection of the higher proportion of older persons among the populations and therefore greater numbers of LTC workers. Figure 2: Ratio of NHO workers to HO workers, by income group, Our estimates of 70.6 million HO workers are different from and larger than earlier estimates from WHO as a result of different approaches, definitions, and data sources, e.g. including or excluding private health sector employment. Global estimation of HO workers is also a challenging task, as data from various sources differ in terms of the definitions used, and the scope and completeness of the data. The differences show the range of the size of the total health workforce depending on choices about which groups to include.

9 Number of workers (thousands) NHO workers per HO workers (current) All (n=185) High (n=57) Upper middle (n=50) Income group Lower middle (n=49) Low (n=27) Including informal non-medical workers Including unpaid NHO workers Excluding paid NHO workers Excluding informal non-medical workers Source: ILO calculations 2016 Figure 3 provides estimates that suggest the world is currently short of about 18 million HO workers and 32 million NHO workers to achieve UHC. However, the shortages of workers are not equitably distributed: While some countries have a surplus of HO workers and NHO workers particularly high-income countries others show gaps: 89 countries are observed with a shortage of HO workers and 95 countries with a shortage of formal NHO workers. Figure 3: Numbers of formal HO workers to NHO workers currently available and missing, HO workers Medical workers Paid NHO workers Formal non-medical workers Available Missing Source: ILO calculations 2016 Adding unpaid workers to the calculations, we find that currently 123 countries have a shortage, amounting to 38 million missing formal and informal NHO workers. Figure 4 shows that the shortages of HO workers and NHO workers predominantly affect Asia and the Pacific which reflects the fact that this region contains the most populous countries in the world followed by Africa. Relative to the population size, however, Africa has the most severe shortages.

10 Number of additional workers required by 2030 (thousands) Shortage of workers (thousands) 10 Figure 4: Numbers of formal HO workers and NHO workers missing in public and private employment, by region, Medical workers HO workers Formal non-medical workers Paid NHO workers Asia & Pacific Africa Americas Arab States Europe & Central Asia Source: ILO calculations 2016 By 2030, population growth means that it is estimated that the world will have to create jobs for an additional 27 million HO workers and 57 million NHO workers in order to achieve UHC. The vast majority of the additional jobs for HO workers and formal NHO workers will be in lower-middle income and low-income countries (Figure 5), and in the regions of Asia & the Pacific and Africa. Figure 5: Additional HO and NHO jobs to be created by 2030 in public and private employment, by income group Medical workers Formal non-medical workers Formal + informal non-medical workers HO jobs Paid NHO jobs Paid and unpaid NHO workers High income Upper middle income Lower middle income Low income Source: ILO calculations 2016 Assessment of economic effects from investments in health economy employment The evidence provided leads to some key observations:

11 11 1. By applying a health economy perspective, evidence is provided that the global number of NHO jobs required to achieve health objectives such as UHC, exceeds the number of HO jobs. This suggests that the size of the health workforce is underestimated, and the contribution of NHOs to economic growth and meeting health needs is overlooked. This also holds true for the provision of decent working conditions for NHO workers, who often work on low wages. Working conditions that do not respect human rights, including labour rights, social protection coverage, occupational safety and participatory processes through social dialogue, will not address challenges to economic growth such as poverty and inequality. Based on this analysis, investments in decent jobs for NHO workers should be considered alongside investments in HO workers. 2. In all countries, investments in HO workers have significant economic multiplier effects resulting, amongst other things, in the creation of new jobs for NHO workers both within and beyond the health sector The data suggest that economic returns of investments in HO workers or more generally in UHC yield impacts on job creation for NHO workers. Globally, the ratio of NHO workers to HO workers is estimated at 2.3. If this ratio were to be maintained, the creation of one HO job has the potential to result in 2.3 jobs for NHO workers. If only paid NHO work is considered, the ratio is still 1.5 meaning that each HO job could result in the creation of 1.5 NHO jobs. Thus, a direct effect of additional HO jobs is the generation of NHO employment, from which the resultant incomes are used and re-used to contribute to the broader economy, leading to further employment and economic growth. 3. High deficits of NHO workers are observed globally, especially in lower-income countries, and demand for NHO workers will increase significantly by 2030 Despite their importance, evidence suggests that the world is short of 32 million NHO workers, with larger shortages in lower-middle- and low-income countries. The demand for NHO workers will grow significantly by 2030, when 170 million NHO workers are likely to be required to provide goods and services to achieve UHC. These results suggest much potential economic growth is foregone due to the gaps in employment. Further, NHO shortages reduce the accessibility of health services. It is thus creating: (a) negative health and economic impacts as the unserved population cannot fully contribute to economic growth due to absenteeism, disability and reduced life expectancy, and (b) increased public expenditure due to higher morbidity. 4. The creation of NHO jobs can benefit workers with all levels of qualifications and areas with limited employment opportunities and thus has the potential to reduce un(der)employment and poverty Given the many occupations included in NHO work, they provide a wide range of job opportunities for workers at all skill levels. Thus, the creation of decent jobs in non-health occupations can play an important role in areas with high unemployment of low-skilled workers. It can also provide learning and career development opportunities to workers who have missed out on primary or secondary education. Further, NHO employment effects are likely to occur not only in affluent areas but also in poor and rural areas if investments in decent jobs are made in the context of UHC policies based on equitable access to services as implied in SDGs 1, 3 and 8. Thus, multiplier effects of investments in health economy employment might include poverty alleviation and reduced unemployment in such areas.

12 12 5. A large number of informal workers is filling in for the lack of jobs in formal employment often without decent working conditions and by reducing or withdrawing own employment Shortages of formal NHO workers result in informal work, particularly for the provision of LTC services. These estimates indicate that, globally, there are nearly as many unpaid informal NHO workers as HO workers. Often, these unpaid services are provided without decent working conditions, defined working hours, rights to breaks, holidays and social protection coverage for sickness, unemployment and old age. This may result in negative health impacts such as burnout and old age poverty among care workers. Against this background, it is crucial to ensure adequate staffing for LTC services which has been estimated at 4.2 full-time equivalent LTC workers per 100 persons aged Further, it is indispensable to provide adequate cash benefits and social protection coverage to informal care workers such as family members to alleviate their burden. Achieving inclusive growth by creating decent jobs: Policy considerations on investments in health economy employment for NHO workers Closing the identified gap of NHO workers will be essential for attaining the SDGs. It will help to address the large deficits in decent jobs in countries of all income levels. This should be considered as an asset for the economy through contributing to improved health, economic growth and development, and decreasing inequality. Closing the gaps requires a rethinking of current health employment policies that often focus on HO workers in the health sector rather than considering the macro-economic dimension of employment effects for all workers in sectors contributing to the broader health economy. Thus, it is important to evaluate where investments are best placed to achieve optimal health, social and economic returns on investment. Evidence from prior studies 17 indicates that investments in medically underserved rural areas in low income countries have most impacts in terms of improving health coverage and creating jobs. Policies should not be limited to achieving solely higher numbers of HO jobs, but should also consider decent work for NHO workers as an integral part of health employment. Only if the total health economy workforce and decent working conditions are considered can sustainable progress be achieved. 18 Addressing these issues and achieving inclusive growth requires strengthened policies that focus on: Integrated macro-economic, employment and labour market policies with the potential to realise inclusive and sustainable economic growth due to investments in decent health economy employment for NHO workers based on progress towards SDGs 1, 3 and Scheil-Adlung, Xenia, Long-term care protection for older persons A review of coverage deficits in 46 countries, ILO, Geneva, Scheil-Adlung, Xenia, Global evidence on inequities in rural health protection new data on rural deficits in health coverage for 174 countries, Geneva: 2015; International Labour Organization, World Social Protection Report 2014/2015, Geneva: Wiskow, Christiane (ILO), The role of decent work in the health sector, High level Commission on Health Employment and Economic Growth Policy Brief No.15.

13 13 Ensuring that sufficient funds are made available for the workforce to attain UHC. This requires fair social protection financing mechanisms aimed at financial, fiscal and economic sustainability with due regard to social justice and equity as highlighted in R 202. Guaranteeing to the population the delivery of services by providing equitable access in the context of SPF and UHC policies. Transforming the provision of informal LTC provision (obliged by the absence of formal LTC workers) into formal jobs. Policy Option 1: Address shortages of decent jobs for NHO workers through enabling macro-economic and labour market policies Macro-economic policies are often detached from employment and labour market policies and the need for decent working conditions, particularly concerning the health sector. No less important than fiscal and monetary policies are macro-economic policies that enable raising labour productivity or investments in decent jobs because of their important employment effects. Jobs providing decent working conditions such as social protection and decent incomes have immediate beneficial effects for the economy e.g. due to improved health and the related productive potential, and in the longer term stabilized consumption based on regular income. An essential foundation for policies to ensure that the health economy contributes fully to and benefits from progress towards decent work for all is improved national data on the size and composition of NHO workers. Against this background, it is important to unlock the positive effects of health economy employment and realize inclusive and sustainable growth based on investments in decent jobs for NHO workers. Labour market and employment policies should be closely linked to employmentfriendly macro-economic policies. Such enabling policies reverse the prioritization of fiscal policies aiming at reducing debts and financial deficits only. By using macro-economic frameworks allowing for higher budget deficits and inflation they have the potential to reduce unemployment, provide for education, training, skill development, poverty alleviation and investments in social protection in health. This can be achieved without jeopardizing macro-economic stability as they are linked to employment generating growth. Labour market policies such as public investments in employment and/or subsidised employment are needed to trigger economic growth through the health economy and to provide incentives for private sector investments. Decent working conditions should be established that include full and rights-based health economy employment, social protection coverage, freedom of association and collective bargaining resulting in equitable income distribution and thus inclusive growth. 19 The exclusion of groups such as women, migrant workers or youth is often rooted in the absence of such enabling policies. 19 ILO. ILO Recommendation concerning National Floors of Social Protection, 2012 (No. 202). Geneva: Available from:

14 14 Thus, major efforts are needed to mainstream labour market and employment policies based on decent work into macro-economic policies aiming at stimulating inclusive and sustainable economic growth. Policy Option 2: Invest in new and better jobs to enhance economic growth by extending health protection towards UHC It will be important to ensure sufficient investments for increasing the quality and quantity of health employment for workers in health and other occupations in both the public and private sectors. The generation of public funds requires fiscal space that needs to be created based on fair financing mechanisms including taxes and shared contributions to health protection systems providing for UHC. Resultant funds should be equitably distributed in terms of geography, age and gender, to avoid access deficits. Thus, increased health economy employment will be linked to the needs and demands of the population that can access affordable services and will in return be enabled to contribute to economic growth. Some prerequisites and principles should be met to enable the population to utilize services. They include the establishment of rights and legislation providing guarantees to access health care for the whole population rather than an approach based on charity. Such legislation should be based on the principles of universality, equity, social inclusion and non-discrimination. Further, it is indispensable to make quality services affordable and financially protected by e.g. minimizing out-of-pocket payments. An enabling framework for related policies is provided in ILO Recommendation 202, which also provides guidance on achieving coherence with social, economic and labour market policies and highlights the need to coordinate related policies with development policies such as rural development plans. Policy Option 3: Transform informal work into formal jobs to create inclusive and sustainable growth Currently, many policy and decision makers do not anticipate the need to transform informal LTC work into formal jobs due to free services being expected mainly from female family members. The reliance on LTC being provided informally is unsustainable in the context of global ageing, particularly given that many are not trained for care giving, yet the work can be very demanding, e.g. caring for persons with mental disorders. Further, informal care giving has the potential to aggravate gender inequality as it is often provided without any remuneration or social protection coverage. It is therefore crucial to transform informal work that is undertaken as a consequence of the absence of formal care workers, into formal jobs with decent working conditions. This will allow for acceptable living conditions for those who currently provide informal care as well as preventing poverty and promoting gender equality. Most efficient and effective forms of formalizing LTC relate to the creation of decent jobs that provide adequate wages as well as skills development for the provision of quality care. (See Transition from the Informal to the Formal Economy ILO Recommendation No. 204, 2015.)

15 15 Annex: Methodology The analyses are based on the conceptual framework illustrated in Table 1, i.e. that the workers of interest fall into five groups. Table 1: Conceptual framework Workers in Workers in nonhealth health occupations (HO workers) occupations (NHO workers) Health economy workers Employed in the health sector A C A+C Employed outside the health sector B D B+D Unpaid informal workers E E Total A+B C+D+E A+B+C+D+E The terms used in Table 1 are defined as follows: Workers in health occupations (HO workers) (groups A and B) = workers in occupations that require postsecondary education in a health field Workers in non-health occupations (NHO workers) (groups C, D and E) = workers providing goods or services which support the work of HO workers Health economy workers (HEWs) (groups A, B, C, D and E) = all HO workers and NHO workers contributing with or without pay to the provision of health services, whether within or outside the health sector Employed in the health sector (groups A and C) = employed by an organisation whose primary purpose is to deliver preventive, promotive or curative health services, or self-employed in a job with this primary purpose Employed outside the health sector (groups B and D) = employed by an organisation which provides goods or services to the health sector, or self-employed workers, in a job with this primary purpose Workers engaged in any activity to produce goods or provide services for pay or profit (groups A, B, C and D) Unpaid informal workers (group E) = Persons who worked without pay to provide health and LTC or to provide support to HO workers. In this study we specifically focus on unpaid informal care giving of family members providing long-term care. Throughout, we used data based on headcounts rather than numbers of full-time time equivalent workers. Three data sources were used: 1. ILO s central statistics database: ILOSTAT ( ) 2. WHO Global Health Observatory workforce statistics ( ) 3. National sources of data The steps followed are: 1. Estimate the size of the entire formal health economy workforce (A + B + C + D) for ILOSTAT countries At present, there is no global data source that will allow the number of NHO workers outside the health sector (group D) to be counted. Only NHO workers within the health sector (group C) usually appear in global estimates, which is a major limitation because NHO workers can and do work in non-health sectors, and without them the health sector would not be able to operate to its full scope. Therefore, rather than ignoring this important group of workers and their contribution to the health economy, it was judged to be important to attempt to estimate their numbers, as follows:

16 16 For the 68 countries in the ILOSTAT database, the number of workers in service industries (ISIC Rev 4 categories G-U or ISIC Rev 3 G-Q) was extracted for the most recent available year. This number includes most types of formal HO workers and NHO workers (groups A-D), as well as people working in other service industries. Five countries were excluded at this stage because their ILOSTAT data were not disaggregated by industry sector (Algeria, Japan, Madagascar, Maldives, and Ukraine). For the remaining 63 countries, workers in ISIC Rev 4 category Q (or ISIC Rev 3 category N) were assumed to represent workers employed in the health sector (groups A + C). Five countries were excluded at this stage because their data showed zero employees in the health sector (Albania, Belarus, Dominican Republic, Indonesia, and South Africa). For the remaining 58 countries, to estimate the number of workers in ISIC Rev 4 categories G-P and R-U (or ISIC Rev 3 categories G-M and O-Q) who are health workers outside the health sector (groups B + D), we used total health expenditure (THE) as a % of gross domestic product (GDP) as a proxy variable. Thus, the % of service workers in non-health sectors who provide health services was assumed to be the same as the % of GDP that is THE. Limitations: It was assumed that the numbers of workers recorded in the most recent year in ILOSTAT still apply. Although the data were fairly recent for most (49 out of 63 countries had data for 2014, 4 for 2013, 3 for 2012), the data for a few countries were slightly out of date (2009 or 2010). People working in the manufacture of pharmaceutical products are not counted (they are categorised under ISIC Rev 4 category C or ISIC Rev 3 category D). However, those involved in research and development and retail of pharmaceutical products are counted. People working in construction are not counted (they are categorised under ISIC Rev 4 category F or ISIC Rev 3 category F), so workers involved in construction of health facilities were not included in the counts of NHO workers. The lack of empirical data means that the assumption that THE/GDP is equal to NHO workers/all service workers cannot be verified and it should therefore be treated with an appropriate degree of caution. It is highly unlikely that the percentage of service industry workers who provide services to the health sector is constant across all service industry sectors G-P and R-U. The proxy variable assumes that, on average, the percentage who do is equal to the percentage of GDP that is THE. The use of THE/GDP as a proxy variable for estimating B + D means that we assume that the ratio of worker costs to goods/materials costs is similar for all service industry sectors, which may not be the case. 2. Estimate the number of formal HO workers (A + B) for ILOSTAT countries For the 58 remaining ILOSTAT countries, the number of workers with ISCO08 code 22 or 32 (or ISCO88 222, 223, 322, 323 or 324) was extracted for the most recent available year. However, these ISCO codes do not include personal care workers (ISCO08 code 532). ILOSTAT does not disaggregate ISCO codes to the 3-digit level, so it was not possible to identify numbers of personal care workers. Because personal care workers are HO workers as defined in this study, and in many countries represent a significant proportion of HO workers, it was necessary to estimate their numbers. This was done using OECD data 21, which showed that, for the 17 OECD countries with data from 2012, 2013 or 2014 about both total employment in health and social care and the number of personal care workers, on average 10% of all those employed in the health sector (groups A + C) are personal care workers (accessed 22 April 2016) (accessed 25 April 2016)

17 17 The size of the formal HO workforce (groups A + B) was therefore estimated by taking 10% of the number of workers in ISIC Rev 4 category Q (or ISIC Rev 3 category N) and adding this to the number of workers with ISCO08 code 22 or 32 (or ISCO88 222, 223, 322, 323 or 324). Four countries (Azerbaijan, Bhutan, Botswana and Brazil) were excluded at the stage because they had no data for the relevant ISCO codes, and two more (Russia and Sri Lanka) were excluded because the number of workers with these ISCO codes was larger than the number of service industry workers counted in step 1. These two situations were taken as indicators of poor quality data. This left a total of 52 countries with sufficient data in ILOSTAT to estimate the size of both the total number of health economy workers (groups A-D in Table 1) and the number of HO workers (Groups A + B). Limitations: The proportion of workers employed in the health sector who are personal care workers varies even within OECD countries, so the estimate of 10% on average may not be representative of all countries 22. The ISCO codes used to identify HO workers probably includes veterinary workers and some other categories that are not relevant for our study for at least some countries. Their numbers are much smaller than numbers of human health workers, so this is not thought to be a major limitation. 3. Estimate the number of formal NHO workers (C + D) for ILOSTAT countries For the 52 remaining ILOSTAT countries, the size of the paid NHO workforce (Groups C + D) was estimated by subtracting the number of HO workers (see step 2) from the number of service industry workers (see step 1). 4. Calculate the ratio of HO workers to NHO workers ((A + B) : (C + D)) for ILOSTAT countries The ratio of HO workers to NHO workers in each country was calculated by dividing the number of NHO workers (see Step 3) by the number of HO workers (see Step 2). Across all 52 countries, the median ratio was 1.62, i.e. for every HO worker in these countries, on average there were 1.62 NHO workers. The ratio was disaggregated by World Bank income group as shown in Table A.1: Table A.1: Median ratio of NHO workers to HO workers in 52 ILOSTAT countries Income group No of countries Median number of NHO workers per HO workers High Low and middle* All * The low and middle income categories were combined because there were very few low-income countries in ILOSTAT, and the medians for the low, lower middle and upper middle income countries were very similar. 5. Estimate the number of HO workers (A+B) in countries with other data sources ILOSTAT does not include data for enough countries to permit global and regional estimates of the number of HO workers. The WHO Global Health Observatory database contained data on health worker numbers for We tried to work out a method of adjusting for this by referring to the WHO Global Health Observatory database, which includes personal care workers within its counts of other health workers, but also provides separate counts of personal care workers as well as other health workers. However, only 15 countries had disaggregated data on personal care workers for a comparable year to the data on other health workers, of which 5 recorded more personal care workers than other health workers which caused us to doubt the quality of the data.

18 18 countries, of which 133 were not included in ILOSTAT. The WHO database uses cadre definitions that do not directly match the ISCO codes used for the ILOSTAT countries, so we assumed the following: Table A.2: WHO database categories and their ISCO code equivalents WHO category ISCO-08 equivalent Our classification Physician 221 HO Nursing & Midwifery 222, 322 HO Dentistry 226 HO Pharmaceutical 226 HO Laboratory 321 HO Environmental & public health 226 HO Community & traditional health 223 HO Other health workers (which not mentioned HO includes personal care workers) above Management & support various NHO As with ILOSTAT, data were taken from the WHO database for the most recent available year. For one of the WHO database countries (Tanzania), the data showed zero physicians, which was taken as an indicator of poor quality data. An alternative data source was therefore used for Tanzania 23, which used the same health worker categories as the WHO database (see Table A.2). Thus, estimates of the number of HO workers were made for 185 countries (52 from ILOSTAT, 132 from WHO and 1 from a national data source). The numbers of HO workers in the WHO database were systematically lower than the numbers in the ILOSTAT database. It seems likely that this was due to undercounting of certain categories of worker, most notably associate health professionals (our analyses indicated that the numbers of health professionals were similar across the two databases, whereas ILOSTAT tended to include many more associate health professionals). It is also possible that, for some countries with data provided by national governments 24, private sector workers are undercounted 25 due to public data systems focusing on the public sector. For this reason, an upward adjustment was made to the WHO numbers to make them more comparable with the ILOSTAT numbers. This was done by examining the 49 countries which had data on the number of HO workers in both ILOSTAT and the WHO database. For these countries, the median ratio of WHO to ILOSTAT estimates was 0.59 (i.e. on average, the number of HO workers in the WHO database was 0.59 the number in ILOSTAT). For each of the 133 non-ilostat countries, therefore, the number of HO workers in the database was divided by 0.59 to give an estimate of the actual number of HO workers. Limitations: The upward adjustment of HO numbers in the WHO database is based on an average, which is unlikely to apply to all individual countries. For this and other reasons, it is not appropriate to present individual country estimates. In all outputs relating to this study, aggregate estimates and regional and/global levels only should be presented. 6. Estimate the number of formal NHO workers in countries with other data sources The median ratio of HO to NHO workers in high-income ILOSTAT countries (1.72) was applied to high-income countries in the WHO database, and the median ratio in low- and middle-income ILOSTAT countries (1.38) was 23 (accessed 22 April 2016) 24 (accessed 10 May 2016) 25 (accessed 10 May 2016)