110 The World Health Report 2003 WHO Member States. In many countries, especially the poorest, people in need of treatment for themselves or their families still pay for the bulk of health services out of pocke All efforts to improve health care systems in developing countries must confront several main challenges: workforce development and retention; health information management; financ ing; and government stewardship within a pluralistic health landscape. The remaining sec tions of this chapter consider these topics. Systems face difficulties in numerous other areas as well, but all four of these problems demand urgent action in order to scale up the system to meet health targets. If constraints in these areas are not overcome, little progress will be made in improving access to care among the poorest. The global health workforce crisis The most critical issue facing health care systems is the shortage of the people who make them work. Although this crisis is greatest in developing countries, particularly in sub-Saha- ran Africa, it affects all nations. It severely constrains the response to the aIds treatment emergency and the development of health systems driven by primary health care, even as AIDS reduces the available workforce. Botswana's commitment to provide free antiretroviral therapy to all eligible citizens is frustrated, not by financing, but by the severe lack of health personnel(12) Unfortunately, workforce issues are still considered to be relatively unimportant by both national governments and international agencies. Rapid and substantial strengthening of the workforce is urgently required to capitalize on the funds and pharmaceuticals that are The health workforce crisis has to be confronted in an economic and policy environment very different from that of 25 years ago. Traditional models in which the government directly recruits, trains, hires and deploys health professionals no longer reflect the reality of most developing countries. Most countries have undergone decentralization and reforms of the civil service and the health sector. There has been a great expansion in the health care roles of nongovernmental organizations and private providers. Furthermore, all countries are now part of the global marketplace for health professionals, and the effects of the demand-supply imbalance will only increase as trade in health services increases(13). Accordingly, new mod- els for health workforce strengthening must be developed and evaluated (14) Size, composition and distribution of the health workforce The number of health workers in a country is a key indicator of its capacity to scale up deli ery of interventions. This crisis is nowhere greater than in sub-Saharan Africa, where limita tions on staffing are now recognized as a major constraint to achieving national health goals and the MDGs(15). In Chad and the United Republic of Tanzania, for example, the current workforce is grossly insufficient for the extensive delivery of priority interventions(16).Coun tries facing such extreme personnel shortages urgently need a rapid increase in the numbers of health workers to perform key tasks, particularly the delivery of services at community level in underserved areas The number of health workers in a country is not the only determinant of access to primary health care. Figure 7. 1 shows that the number of births at which skilled attendants are present is only partially related to the number of health professionals in a country. Guinea, Indone- The term" health professionals"is defined for the WHO database as including physicians, nurses, midwives, dentists and pharmacists.110 The World Health Report 2003 WHO Member States. In many countries, especially the poorest, people in need of treatment for themselves or their families still pay for the bulk of health services out of pocket. All efforts to improve health care systems in developing countries must confront several main challenges: workforce development and retention; health information management; financ￾ing; and government stewardship within a pluralistic health landscape. The remaining sec￾tions of this chapter consider these topics. Systems face difficulties in numerous other areas as well, but all four of these problems demand urgent action in order to scale up the system to meet health targets. If constraints in these areas are not overcome, little progress will be made in improving access to care among the poorest. The global health workforce crisis The most critical issue facing health care systems is the shortage of the people who make them work. Although this crisis is greatest in developing countries, particularly in sub-Saha￾ran Africa, it affects all nations. It severely constrains the response to the AIDS treatment emergency and the development of health systems driven by primary health care, even as AIDS reduces the available workforce. Botswana’s commitment to provide free antiretroviral therapy to all eligible citizens is frustrated, not by financing, but by the severe lack of health personnel (12). Unfortunately, workforce issues are still considered to be relatively unimportant by both national governments and international agencies. Rapid and substantial strengthening of the workforce is urgently required to capitalize on the funds and pharmaceuticals that are now available. The health workforce crisis has to be confronted in an economic and policy environment very different from that of 25 years ago. Traditional models in which the government directly recruits, trains, hires and deploys health professionals no longer reflect the reality of most developing countries. Most countries have undergone decentralization and reforms of the civil service and the health sector. There has been a great expansion in the health care roles of nongovernmental organizations and private providers. Furthermore, all countries are now part of the global marketplace for health professionals, and the effects of the demand–supply imbalance will only increase as trade in health services increases (13). Accordingly, new mod￾els for health workforce strengthening must be developed and evaluated (14). Size, composition and distribution of the health workforce The number of health workers in a country is a key indicator of its capacity to scale up deliv￾ery of interventions. This crisis is nowhere greater than in sub-Saharan Africa, where limita￾tions on staffing are now recognized as a major constraint to achieving national health goals and the MDGs (15). In Chad and the United Republic of Tanzania, for example, the current workforce is grossly insufficient for the extensive delivery of priority interventions (16). Coun￾tries facing such extreme personnel shortages urgently need a rapid increase in the numbers of health workers to perform key tasks, particularly the delivery of services at community level in underserved areas. The number of health workers in a country is not the only determinant of access to primary health care. Figure 7.1 shows that the number of births at which skilled attendants are present is only partially related to the number of health professionals in a country.1 Guinea, Indone- 1 The term “health professionals” is defined for the WHO database as including physicians, nurses, midwives, dentists and pharmacists