• In order to achieve effective coverage of high-quality PHC, the PHC workforce must be available, accessible, acceptable, and high-quality. 13 To achieve this, the PHC workforce should be equipped with the necessary competencies to deliver comprehensive, high-quality PHC and made up of the appropriate number and skill mix of occupations to meet population health needs and ensure that all communities have equitable access to the right care at the right time. 24

    • Competencies are the observable abilities--including knowledge, skills, and behaviors--of individual health workers that relate to specific work activities. Competencies are durable, trainable, and measurable. 56 All members of the PHC workforce should have competencies related to people-centeredness, communication, decision-making, collaboration, evidence-informed practice, and personal conduct to enable them to provide comprehensive PHC services which meet the majority of people’s needs. 5 Competencies should be evidence-based and adapted to the country-context to reflect the list of interventions at the PHC level and structure of the PHC workforce in-country. 456789 Standards for workforce education, training, and practice should be based on these defined competencies and instituted for all occupations of the PHC workforce. 
    • Skill mix describes the combination of different occupations of health workers delivering PHC in terms of numbers, diversity, and competencies. 10 PHC services are best provided by coordinated, multidisciplinary teams with the wide range of knowledge, skills, and expertise needed to provide comprehensive, holistic care that is accessible and acceptable to the local community. 4111213 The different occupations of providers that make up a country’s PHC workforce may include family medicine doctors, nurses, midwives, community health workers, physician assistants, social workers, or others depending on the local context. The optimal skill mix of the PHC workforce will depend on the needs of the population and the best way to meet those needs within the context of the health system. 291011121314 Some occupations of health workers, such as family medicine providers and some designations of general practitioners, are specifically trained in PHC and some countries have found having an approved medical specialty dedicated to comprehensive PHC to be a valuable and effective strategy. 1415 Additionally, integrating a diverse range of occupations, including mid-range and/or community-based workers, can help to support the realization of a diverse, sustainable workforce with the skills and reach needed to meet a comprehensive set of population health needs. 34 For example, given that PHC is often delivered in both communities and facilities, community-based health care workers may be integrated into the workforce plan to support proactive population outreach. 162 For more information on the characteristics of effective community health worker programs, see resources here and here

    To effectively meet the needs of the population, the skill mix, competencies, and distribution of the PHC workforce should be defined in relation to the needs of the population, taking into consideration dimensions such as access, population health needs, acceptability, and the context of the health system, including the service delivery model and health sector goals.

    In addition, the PHC workforce must be motivated and empowered to deliver high-quality care that is acceptable to the needs and expectations of the population. 3 Health systems should promote working conditions that enhance both the capacity and motivation of the health workforce to deliver quality care and continuously improve their performance, such as through appropriate remuneration and incentives, merit-based professional development opportunities, and occupational health and safety standards. 3

  • Countries should strive to align their workforce development strategy with an integrated, person-centered PHC delivery model that achieves “a diverse, sustainable skill mix... and harnesses the potential of community-based and mid-level health workers in interprofessional primary care teams” 3 in order to ensure that the workforce is cost-effective and responsive to community needs. Countries will need to continuously assess the ability of the PHC workforce to deliver on their defined competencies, addressing any challenges with skill mix imbalance, maldistribution, and interprofessional collaboration (see performance management section below). 

    Building an efficient and effective PHC workforce in practice relies on strong in-country capacity (systems, evidence, policies, and investments) to implement, assess, and improve effective strategies and policies for PHC workforce education, recruitment and deployment, retention, and quality assurance and regulation. 3  

    • Education: Appropriate education is essential for ensuring that the PHC workforce has and can demonstrate the competencies necessary for delivering high-quality PHC, including competencies related to evidence-informed practice, person-centeredness, and collaboration. 317 Achieving this requires that the relevant competencies for each PHC occupation are identified, that education standards are established based on these competencies, and that quality assurance systems are in place to ensure that educational institutions are adequately training on these competencies, for example by accrediting training institutions and/or licensing or certifying graduates. 5 It is critical that these quality assurance mechanisms be integrated into the overall workforce quality assurance system as described below to ensure consistency in quality standards from education through practice. 5 Additionally, in-service educational programs should be deployed to ensure continuous professional development and ongoing training as needed. 18
    • Recruitment and deployment: Policies and systems for recruitment and deployment should aim to ensure that the right people are placed in the right positions in order to ensure equitable access to quality care for all. 317 Evidence shows that in many countries there is a maldistribution of health workers, with too few serving in the public sector and/or rural areas or marginalized communities. This maldistribution often results from poor translation of policies and systems for recruitment and deployment into effective posting and transfer practice. 19 Reasons for ineffective posting and transfer include the politicization of the process, individual provider preferences for postings that are associated with greater income, prestige or personal convenience, and a lack of accurate and detailed data on the health workforce. 19 There has been a recent increase in efforts to better diagnose the underlying reasons for poor recruitment and deployment in order to identify solutions to support improvement.20212223 For example, evidence has shown that one way to address the shortage of health workers in rural or underserved areas is to recruit students and workers directly from these communities, as these individuals are more likely to desire returning to practice in their home areas and provide services that are accepted and trusted by the communities they serve. 16212425 You can find more information about these issues in underserved communities here and policy options for improving health worker deployment here.
    • Retention: Retaining a qualified workforce--whether at the country level, within the public sector, or within underserved areas--is essential to ensure that investments made in workforce education and deployment yield the expected benefits to service delivery quality and population health. Too often, though, PHC workers in general and particularly those in underserved areas often lack access to the training and resources needed to deliver up-to-date, effective care, build their skills and competencies, and advance their careers. 26 Many health workers then leave underserved areas for urban areas with better working conditions, access to professional development, and sufficient resources.26 National and institutional policies and regulations can support retention by promoting job security and providing pathways for professional growth and supportive supervision, improving living conditions, promoting work-life balance, providing appropriate remuneration and incentives such as loan repayment, and ensuring a positive, non-discriminatory practice environment. 3172122232728
    • Quality assurance and regulation: Quality assurance and regulatory systems are essential to ensure that the PHC workforce has and demonstrates the necessary competencies and is delivering high-quality care. There are three primary goals for such systems: to ensure that the practicing PHC workforce has the appropriate training and qualifications, that records of appropriately trained and qualified workforce are collected and maintained, and that appropriate measures are taken with respect to workforce members who do not meet the established standards. 5 Mechanisms for meeting these goals include ensuring that all practicing workforce be licensed and/or accredited, establishing systems for issuing and investigating complaints, instituting continuing professional development and periodic re-validation of credentials/registration/licensing, and creating systems for course-correcting members of the workforce who fail to meet standards--including removal if no improvements are made. 529 All occupations of the PHC workforce should be covered through such systems. 5 In addition, users can find more information about systems for monitoring and improving the performance of the health workforce, including supportive supervision, in Performance Measurement and Management while specifics around measuring and improving provider competence and motivation are addressed in Availability of Effective Primary Health Care Services.

    Achieving the above will require sufficient and appropriately targeted financing for the PHC workforce. 133031 Users can learn more about workforce financing here.

    To support sustainable investments, policies, and systems for health workforce development, countries need robust workforce-related data--including workforce characteristics, remuneration patterns, workforce competence, performance, absenteeism, etc.--from the public and private sectors as well as in-country capacity to analyze and use this data to inform policymaking and planning. 32 National Health Workforce Accounts (NHWA) is a system for supporting countries to produce and use quality health workforce data and evidence in order to guide evidence-based policymaking and planning. 31 The NHWA includes a set of indicators for monitoring education, labor market dynamics, financing, governance, policies, and regulations, and is accompanied by an implementation guide and an online platform to support data management, analysis, visualization, and reporting.

  • The PHC workforce is the primary implementer of primary health care; without a strong workforce it is impossible to deliver high-quality PHC services for all.1233 To develop a skilled and motivated workforce, countries will need to ensure alignment of policies, goals, and resources with the PHC service delivery model, alongside concentrated efforts to align workforce education and practice to embody the core principles of high-quality PHC: first-contact accessibility, continuity, comprehensiveness, coordination, and person-centeredness.3 By reorienting health systems toward person-centered integrated care models made up of interprofessional primary health care teams with a diverse skills-mix, countries have the potential to strengthen the quality of PHC service delivery and achieve better population health outcomes for all.3

  • Accreditation [of a training institution or program]: Accreditation is a form of quality assurance in which a training institution or program is assessed to determine whether it meets predetermined and agreed-upon standards. If so, the institution or program is given accredited status. 34

    Certification [of a profession or occupation]: Certification is, “the process whereby a profession or occupation voluntarily establishes competency standards for itself.” It is particularly useful in cases where the government has not regulated the profession or occupation through licensure. 34

    Community Health Workers: Community health workers are a type of community-based health worker whose primary responsibility is to conduct proactive outreach in the community to meet local population health needs. 16

    Competencies: “Competencies are the observable abilities of individual health workers relating to specified activities of work that integrate knowledge, skills, and behaviors. Competencies are durable, trainable and measurable.” 6

    Density [of the skilled workforce]: Density is measured as the ratio of active health workers per population in the given national and/or subnational area. 31 33 

    Incentives: Incentives refer to, “a particular form of payment which is intended to achieve some specific change in behaviour. Incentives come in a variety of forms, and can be either monetary or non-monetary.” 36

    Licensure [of an individual health worker]: Licensure is a process in which a governmental authority determines the competency of an individual health worker seeking to perform certain services and grants that individual the authority to engage in specific area(s) of practice based on demonstrated education, experience, and examination. Licensure also typically means that governments have the authority to both discipline licensees who fail to comply with statutes and regulations as well as to take disciplinary action against unlicensed individuals who practice within the scope of a licensed profession or occupation. 34

    Posting and transfer: Posting and transfer refers to geographic deployment of health workers. It encompasses both initial health worker posting and subsequent transfers of staff between health facilities. 1937

    Quality assurance: Quality assurance of the health workforce refers to systems for ensuring that the practicing primary health care workforce has the appropriate training and qualifications, that lists of those appropriately trained and qualified providers are maintained, and that appropriate measures are taken with respect to providers who do not meet established standards. 5

    Remuneration: Remuneration is traditionally seen as the total income of an individual that may take different forms, such as salary, stipend, honorarium, and/or monetary incentives. 316 A remuneration strategy determines this particular configuration or bundling of payments that make up an individual’s total income. 36 The World Health Organization recommends that all occupations of the health workforce be remunerated with a financial package in accordance with the employment status and applicable laws and regulations in the jurisdiction. 316

    Skill mix: Skill mix describes the combination of different occupations of health workers (i.e. doctors, nurses, and midwives) in a primary care practice in terms of numbers, diversity, and competencies. 10

Relevant resources

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Global strategy on human resources for health: workforce 2030 WHO, 2016

This resource from the Global Health Workforce Alliance lays outlines a policy agenda for member states on how to drive progress toward a global strategy on human resources for health for all. The agenda is organized into four objectives, under which countries can find a series of intersectoral policy options for taking action and milestones to help assess progress toward each objective. In particular, the agenda includes recommendations for how to build the institutional capacity and strengthen data to optimize the health workforce and accelerate progress towards UHC and the SDGs.
Tags: Key principles, Competencies, Skill mix, Quality assurance and regulation, Education and training, Recruitment, deployment, and retention

Guideline on health policy and system support to optimize community health worker programs WHO, 2018

This guideline was developed to provide countries with the best global evidence on optimizing community health workers programs as part of a comprehensive PHC workforce. It contains practical guidance on how to effectively improve the design, implementation, performance, and evaluation of community health worker programs. In particular, it details policy and system enablers required to strengthen education, deployment, performance, and integration into the broader health system.
Tags: Key principles, Competencies, Skill mix, Quality assurance and regulation, Education and training, Recruitment, deployment, and retention

Practitioner expertise to optimize community health systems: Harnessing operational insight Community Health Impact Coalition, 2017

This report examines a series of case studies from six organizations - Hope Through Health, Last Mile Health, Living Goods, Muso, Partners in Health, and Possible - and proposes a set of best principles for how community health workers can be successfully integrated into national health systems.
Tags: Skill mix, Education and training, Recruitment, deployment, and retention

Global Health Workforce Network WHO

The Global Health Workforce Network was established as a global platform for stakeholders to work collaboratively toward the effective implementation of comprehensive and coherent workforce policies in line with global best practices. In particular, the network focuses on the development and dissemination of products that facilitate better alignment of workforce education and deployment with population, health systems, and health labour market needs and the scale up of socially accountable education.
Tags: Key principles, Quality assurance and regulation, Education and training, Recruitment, deployment, and retention

Human Resources for Health 2030 Programme HRH2030, USAID, and PEPFAR

This website is the home of USAID and PEPFAR’s Human Resources for Health 2030 initiative, created to support countries in developing a workforce that is capacitated to improve health outcomes in their country context. It contains practical lessons and evidence-based solutions to workforce challenges in four areas: performance and productivity of the health workforce; number, skill mix, and competency of the health workforce; human resources for health leadership and governance capacity; and sustainability of investment in human resources for health.
Tags: Key principles, Skill mix, Education and training, Recruitment, deployment, and retention

Global standards for postgraduate medical education WONCA, 2013

This document provides a set of global standards for postgraduate family medicine education. While countries will need to adapt these global standards to their local environment and local needs, they may be used by institutions and education programs to support quality improvement in family medicine postgraduate education, including self-assessment and program quality improvement; new program development; peer review; and recognition and accreditation.
Tags: Quality assurance and regulation, Competencies, Education and training

Rural medical education guidebook WONCA, 2014

The World Organization of Family Doctors (WONCA) launched the Rural Medical Education Guidebook to provide a resource for stakeholders to obtain practical strategies and ideas for training health care workers for rural education and practice. In particular, the guide provides detailed information and implementation guidance related to resourcing rural medical education and practice, providing professional and technical support and development, and undergraduate and postgraduate medical education training and development models.
Tags: Quality assurance and regulation, Competencies, Education and training

Health workforce: monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies WHO, 2010

This document provides countries with a monitoring strategy to track progress and performance, evaluate impact, and ensure accountability for strengthening the health workforce using a set of core indicators and related measurement strategies. It also guides countries through a series of plans and actions for assessing and strengthening workforce recruitment, distribution, retention, and productivity that are paired with indicators for monitoring progress toward these goals.
Tags: Key principles, Quality assurance and regulation, Education and training, Recruitment, deployment, and retention

The labor market for health workers in Africa: a new look at the crisis The World Bank, 2013

This book draws on the lessons, knowledge, and data gathered by the World Bank’s Africa Region Human Resources for Health Program to examine the health human resource crisis in the context of Africa’s labor markets. The book’s four parts provide information and tools on health workforce analysis, the distribution of health workforce, performance of the health workforce, and education and training of health workers. The featured case studies offer tangible lessons from a variety of countries in the region that have achieved improvements in human resources for health.
Tags: Competencies, Quality assurance and regulation, Education and training, Recruitment, deployment, and retention

Handbook on monitoring and evaluation of human resources for health with special applications for low- and middle-income countries World Health Organization, The World Bank, and USAID, 2009

This handbook provides managers, researchers, and policymakers with a comprehensive and standardized reference for monitoring and evaluating human resources for health. Using an analytical framework, the handbook presents countries with strategic options for improving the health workforce information and evidence base, and uses country experiences to highlight approaches that have worked.
Tags: Key principles, Quality assurance and regulation

Human resources for health and universal health coverage: fostering equity and effective coverage Bulletin of the WHO, 2013

This paper examines human resources for health policy lessons from four countries that have achieved sustained improvements in accelerating progress toward universal health coverage - Brazil, Ghana, Mexico, and Thailand. For each country, the paper identifies the key actions and lessons that helped to accelerate progress toward universal health coverage through the lens of health workforce availability, accessibility, acceptability, and quality. The paper uses country experiences to demonstrate actions that support improvements in human resources for health, with special attention to equity and efficiency.
Tags: Key principles, Quality assurance and regulation, Recruitment, deployment, and retention

Five-year action plan for health employment and inclusive economic growth (2017 - 2021) WHO, 2018

This action plan was developed as a part of a joint intersectoral programme of work across the International Labor Organization, the Organization for Economic Cooperation and Development, and the World Health Organization to support countries in the effective implementation of the WHO’s global strategy on human resources for health. It provides detailed information and guidance related to the implementation of intersectoral, collaborative and integrated approaches and country-driven action for sustainable investments, institutional-capacity building, and transformative policy action and practice.
Tags: Key principles, Financing and policy, Data and evidence, Recruitment, deployment, and retention

Delivered by women, led by men: a gender and equity analysis of the global health and social workforce WHO, 2019

This report, produced by the WHO Global Health Workforce Network’s Gender Equity Hub, examines gender and equity in the health workforce. Four thematic areas guide countries in identifying and addressing issues of leadership; decent work free from all forms of discrimination, harassment, including sexual harassment; gender pay gap; and occupational segregation using gender-transformative policies and measures. The report concludes with key messages and policy recommendations that may be used to address gender inequity in the health workforce and support progress toward global targets such as UHC.
Tags: Key principles, Recruitment, deployment, and retention

Working for health and growth: investing in the health workforce WHO, 2016

This report, produced by the High-Level Commission on Health Employment and Economic Growth, was developed to call attention to the social and economic benefits of the health workforce. It proposes ten recommendations and five immediate actions to transform the health and social workforce and enable change for the achievement of the 2030 Agenda for Sustainable Development.
Tags: Key principles, Financing and policy

Building the primary health care workforce of the 21st century - technical series on primary health care WHO, 2018

This report was released as part of the Technical Series accompanying the Astana Declaration of 2018. It provides an updated definition for PHC workforce, describes the current state of the PHC workforce globally, outlines the challenges facing the workforce, and proposes a series of policy directions and levers for improving the PHC workforce. The document also includes a series of case studies highlight PHC workforce improvements in various countries.
Tags: Key principles, Financing and policy, Competencies

National health workforce accounts - handbook, implementation guide, and video WHO, 2016-2018

This set of tools was developed to facilitate the implementation of the National Health Workforce Accounts (NHWA), a system for improving the availability, quality, and use of health workforce data. It contains a set of 78 core indicators that provide a comprehensive overview of the dynamics of a country’s health workforce, described in detail in the NWHA Handbook, and an implementation guide that offers a series of recommendations for improved use and collection of relevant data.
Tags: Data and evidence

Gender equity in the health workforce: analysis of 104 countries WHO, 2019

This brief examines gender equity in the social and health workforce at the global level based on an analysis of WHO National Health Workforce Accounts data over the last 18 years and highlights key policy options for stakeholders to consider to achieve gender equity in health.
Tags: Key principles, Data and evidence, Financing and policy, Recruitment, deployment, and retention

Increasing access to health workers in remote and rural areas through improved retention: global policy recommendations WHO, 2010

To support the recruitment, deployment, and retention of workforce in remote and rural areas, this document outlines a series of 16 evidence-based recommendations. It also provides guidance for policymakers on how to choose and implement the most appropriate interventions for their context and how to monitor and evaluate impact over time.
Tags: Recruitment, deployment, and retention

HealthWISE - work improvement in health services action manual ILO and WHO, 2014

HealthWISE, produced by the International Labor Organization and WHO, is a participatory quality improvement tool for use in health facilities to improve occupational safety and health, personnel management, and environmental health.
Tags: Quality assurance and regulation

Workload indicators of staffing need - user’s manual WHO, 2015

This manual guides users through the methodology and process of applying the Workload Indicators of Staffing Need (WISN) method, a human resource management tool. The manual is designed to provide a wide range of managers with a systematic way to make staffing decisions that optimize management of their human resources. It contains practical guidance on defining the objectives and scope of using WISN, its implementation, and applying WISN to determine optimal staff requirements based on workloads.
Tags: Quality assurance and regulation, Recruitment, deployment, and retention

What questions should be considered to begin improvements?

The questions below may be a useful starting place for assessing the performance of workforce in your context, determining whether it is an appropriate area of focus for improvement efforts, and how one might begin to plan and enact reforms.

Do the competencies and skill mix of your PHC workforce meet population health needs?

The competencies and skill mix of the PHC workforce should be defined in relation to the comprehensive needs of the population, taking into consideration dimensions such as access, population health needs, acceptability, the service delivery model, and health sector goals. You might consider the following questions to determine whether PHC workforce competencies and skill mix meet population health needs: 

  • What are the different occupations of health workers that deliver PHC? How are these different occupations of providers organized and coordinated at the service delivery level? 

  • Is there a defined set of competencies for all PHC workforce that emphasizes the skills needed to provide comprehensive, coordinated, continuous, and person-centered care?

  • Are these competencies used to inform pre- and in-service education standards?

  • Is there an occupation of health worker in the country that provides proactive outreach and care to communities? If yes, are they integrated into care teams at the service delivery level?

  • Is there an approved medical specialty dedicated to comprehensive primary care, for example, family medicine or specialized general practitioners?

  • Collectively, is the PHC workforce able to meet the majority of population health needs? One way to know this is to determine whether or not large numbers of PHC-sensitive cases are being referred to specialty care due to a lack of competency and capacity at the PHC level.

How equitably is your PHC workforce distributed?

To effectively meet population health needs, the health workforce must be equitably distributed to be able to deliver the appropriate care at the right place and right time. To assess the distribution of your workforce, you might consider:

  • Does the distribution of PHC workforce mirror the distribution of your population, so that both rural and urban populations have equitable access to PHC

  • Are there variations in workforce distribution by geographic regions, types of facilities, types of occupations, and/or gender of providers?

  • Is the current health workforce available, acceptable, and accessible to the population it serves? If patients are not utilizing services, is this related to a lack of trust in services, geographic or financial access barriers, workforce shortages and/or absenteeism, or other factors? 

  • If there issues with workforce shortages and maldistribution in your country, are there mechanisms in place to improve future recruitment, distribution, and retention?

How strong are the PHC workforce quality assurance mechanisms in your country?

Quality assurance mechanisms that span from education to practice are critical to ensure that the PHC workforce is equipped with and demonstrates the knowledge and skills needed to deliver high-quality PHC services. As described above, mechanisms should ensure that education standards are established and enforced based on predefined PHC-specific workforce competencies, that all actively practicing workforce are qualified to do so, and that quality standards are being met in practice. To assess the strength of these mechanisms, you might consider:

  • Do the mechanisms cover all occupations of the PHC workforce?

  • Do the mechanisms consistently and reliably function as intended?

  • Do the responsible regulatory bodies have the staff and funding they need to perform their role?

Are you investing enough in your PHC workforce?

Achieving a high-quality PHC workforce requires significant financial investment.1303138 To assess whether sufficient funds have been invested in the PHC workforce, you might consider: 

  • In the context of competing demands for limited resources, do policies and plans target substantive and strategic investments in PHC? 

  • Are educational and training institutions able to enroll enough students to meet demand? Are they appropriately resourced such that instructors are well paid and delivering up-to-date curricula and facilities meet student/trainee needs?

  • Are there sufficient funds available to hire the number and skill mix of providers needed to meet community and population health needs?

  • Are provider payments and incentives aligned with labor market dynamics? Are there dependably sufficient funds available to ensure job security and that providers are paid in a manner that is reliable and consistent to maintain motivation and retention?

  • Are regulatory bodies sufficiently staffed to be able to consistently carry out their essential functions?

  • Are facilities sufficiently resourced to ensure safe working conditions?

What data do you have about your workforce?

To support sustainable investments, policies, and systems for health workforce development, countries need robust workforce-related data--including on workforce characteristics, remuneration patterns, workforce competence, performance, absenteeism, etc.--from the public and private sectors as well as in-country capacity to analyze and use this data for local decision-making. To assess the quality and reliability of data on the health workforce in your country, you might consider:

  • What types of data are needed and collected on the health workforce? 

  • How comprehensive and timely is this data? 

    • Does it include workforce characteristics, remuneration patterns, performance data, and lists of certified/accredited workforce?

    • Is it collected from both the private and public sector? 

    • Can it be disaggregated by sector, geography, and sex and age of the workforce?

  • How up to date is the data?

  • How is workforce-related data collected, analyzed, reported, and used?


In 2013, the Ministry of Health of Vietnam launched the Health Professionals Education and Training for Health Systems Reform Project (HPET) for Health Systems Reform Project to execute a more sustainable and effective human resources for health development strategy. In particular, the project has made targeted efforts to improve the quality of workforce education and training to strengthen PHC capacity at the local level.


Since 2009, the Government of Nepal has been working in a public-private partnership (PPP) with the non-governmental organization Possible to expand access to high-quality health care in remote areas throughout the country. The partnership has developed a novel community health worker (CHW) program, to strengthen human resources for health and accelerate progress toward universal health coverage.

PHCPI is a partnership dedicated to transforming the global state of primary health care, beginning with better measurement. While the content on this website represents the position of the partnership as a whole, it does not necessarily reflect the official policy or position of any partner organization.


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