who have died. Registries for other health workers are even more loosely kept, or nonexistent, leading to serious questions about the value and comparability of the data over time.

23. What ministries of health typically rep t are tha number of health workers officially known to be employed by the ministry. What the ministries frequently do not know, and s-o do not report, are the number of workers employed by -iultinationals, the armed forces, nongoven ment organizations, industry, and other private providers. Even information on the number of Udotors in full-time private practice is frequently unavailable, despite estimates that private physicians provide as much as 80 percent (Kenya) of health care services (Stuart 1987). Similarly, while it is widely known that the attrition rate for nurses is high before and soon after graduation, it is not as widely recognized that the total number of trained and qualified nurses represents a potential human resources pool that is being neglected.

24. Planning for human personnel development ir seen largely as a national-level resnonsibility, since the process commonly involves projecting future requirements for health workers (Homby et al. 1980). These projections are frequently based on accepted norms, such as one doctor per 5,000 people or one comrmunity health worker per 1,000 people, or on staffing patterms of standard facilities or programs - both existing and planned - sumh as one hoap;ial per district or one health center per 30,000 people. The difference, usually a shortfall, between .sting and required personnel can then be directly translated into training requirements and the implications for training institutes, trainee recruitment, and curriculum development.

25. Several factors are not taken into account in this process, however, such as the financial implication or the ability of the ministry of health to employ the projected number of workers required. Many assumptions go unchallenged, such us the accepted recruitment qualifications and attrition rates among trainees. Rarely is the possibility considered that many tasks carried out by senior professionals might be carried out equally well by auxiliaries or that a different skill mix might implv different norms and facility staffing patterns - and probably lower overall costs.

26. Alternative staffing patterns might receive much greater consideration if more financial in.brmation were available on the costs of training and employing differeni types of health workers. Personnel shortfalls are frequently in-erpreted directly as a need to recruit more trainees, rather than serving as a spur to recruit people who have already been trained, but who are not currently employed in the health sector. The high attrition rates that occur during .raining and soon after graduation, particularly with nurses, also receives inadequate attention. Re-employment and redeployment are other options that need to be considered more widely than they usually are.

27. Several measures are needed to improve planning for health personnel development. One is the development of a simple, standardized system (possibly microcomputer-based) fcr providing basic information on the numbers and distribution of a nation's trained health work force. The system would need to be updated annually for all maior categories of health workers so that it could be used to generate annual updates of planning projections needed to inform decisions on health personnel development. A second measure would be to introduce some reasonable financial estimates of the total costs of training and employing each category of health worker, so that the resource implications of various staffing patterns can be examined. This would enable more realistic cost projections to be estimated and incorporated into all planing activities. A third measure would be to base personnel requirements on the tasks that need to be achieved rather than on the need to train and employ a certain number of people in particular professional categories. Simplified planning guidelines would be needed for allocating various tasks to each cadre. These same guidelines might also be useful to health managers, particularly those in charge of district services and programs.

28. Since implementing these three measures would require a national perspective, the responsibility for doing so should rest largely with the central ministry of health. The ministry is the most appropriate organization to examine the generic issues and practical problems involved in implementing such information systems. The ministry is also in the best position to review guidelines on staffing norms and patterns and to conduct an analysis of the professional and managerial tasks 9