Inequal distribution of nursing personnel: a subnational analysis of the distribution of nurses across 58 countries

Abstract

Background: Nursing personnel are critical for enabling access to health service in primary health care. However, the State of the World's Nursing 2020 report showed important inequalities in nurse availability between countries.

Methods: The purpose of this study/analysis was to describe the differences in nurse-to-population density in 58 countries from six regional areas and the relationship between differences in access to nurses and other indicators of health equity.

Results: All countries and income groups showed subnational inequalities in the distribution of nursing personnel with Gini coefficients ranging from 1 to 39. The latter indicated situation such as 13% of the population having access to 45% of nurses in a country. The average max-to-min ratio was on average of 11-fold. In our sample, the African region had the highest level of subnational inequalities with the average Gini coefficient of 19.6. The European Region had the lowest level of within-country inequalities with the average Gini coefficient being 5.6. A multivariate analysis showed a clustering of countries in three groups: (1) high Gini coefficients comprised mainly African countries; (2) moderate Gini coefficients comprised mainly South-East Asian, Central and South American countries; (3) low Gini coefficients comprised mainly Western countries, Japan, and Korea. The analysis also showed that inequality in distribution of nurses was correlated with other indices of health and inequality such as the Human Development Index, maternal mortality, and life expectancy.

Conclusions: This study showed that there is a high level of geographic inequality in the distribution of nurses at subnational level. Inequalities in nursing distribution are multifactorial, to improve access to nurses, policies should be bundled, tailored to the local context and tackle the various root causes for inequalities.

Keywords: Demography; Health workforce; Healthcare disparities; Nursing.

Fig. 1

Boxplot of the distribution of Gini index of the subnational distribution of nursing personnel (Gini coefficient close to 0 means equal distribution of nurses across regions) in 58 countries by income group

Fig. 2

Scatter plot of the Gini coefficient (0–100) and density of nursing personnel per 10,000 in 58 countries

Fig. 3

Variation of Gini coefficient (express here as 0–1) of nurse density at subnational level. Country clusters were obtained based on socio-economic indicators only. Note The indicators included in the clustering analysis are available in supplementary material