You’re the HR Consultant

 You are functioning as a consultant, assisting the HR Director for a large health system. You have just identified the seven “Skill Mix: Determinants” listed on page 576 of the attached article. As the consultant prioritizes the importance of the determinants, then state why you chose the top three. 

Skill mix in the health care workforce

: reviewing the evidence
James Buchan1 & Mario R. Dal Poz2

Abstract This paper discusses the reasons for skill mix among health workers being important for health systems. It examines the
evidence base (identifying its limitations), summarizes the main findings from a literature review, and highlights the evidence on skill mix
that is available to inform health system managers, health professionals, health policy-makers and other stakeholders. Many published
studies are merely descriptive accounts or have methodological weaknesses. With few exceptions, the published analytical studies were
undertaken in the USA, and the findings may not be relevant to other health systems. The results from even the most rigorous of studies
cannot necessarily be applied to a different setting. This reflects the basis on which skill mix should be examined — identifying the care
needs of a specific patient population and using these to determine the required skills of staff. It is therefore not possible to prescribe in
detail a ‘‘universal’’ ideal mix of health personnel. With these limitations in mind, the paper examines two main areas in which
investigating current evidence can make a significant contribution to a better understanding of skill mix.

For the mix of nursing staff, the evidence suggests that increased use of less qualified staff will not be effective in all situations,
although in some cases increased use of care assistants has led to greater organizational effectiveness. Evidence on the doctor–nurse
overlap indicates that there is unrealized scope in many systems for extending the use of nursing staff. The effectiveness of different skill
mixes across other groups of health workers and professions, and the associated issue of developing new roles remain relatively unexplored.

Keywords Health personnel; Clinical competence; Personnel staffing and scheduling; Patient care team; Nursing staff; Physicians;
Allied health personnel/utilization; Professional role; Review literature; Meta-analysis (source: MeSH, NLM ).

Mots clés Personnel sanitaire; Compétence clinique; Affectation personnel et organisation temps travail; Equipe soignante; Personnel
infirmier; Médecin; Personnel paramédical/utilisation; Rôle professionnel; Revue de la littérature; Méta-analyse (source: MeSH, INSERM ).

Palabras clave Personal de salud; Competencia clı́nica; Admisión y programación de personal; Grupo de atención al paciente; Personal
de enfermerı́a; Médicos; Técnicos medios en salud/utilización; Rol profesional; Literatura de revisión; Meta-análisis (fuente: DeCS, BIREME).

Bulletin of the World Health Organization 2002;80:575-580.

Voir page 579 le résumé en français. En la página 579 figura un resumen en español.

Introduction
The World Health Report 2000 noted that determining and
achieving the ‘‘right’’ mix of health personnel are major
challenges for most health care organizations and health
systems (1). Health care is labour-intensive and managers of
health care provider units strive to identify the most effective
mix of staff that can be achieved with the available resources,
taking into consideration local priorities.

The term ‘‘skill mix’’ is usually used to describe themix of
posts, grades or occupations in an organization (strictly
speaking, this is more accurately referred to as ‘‘grade mix’’).
It may also refer to the combinations of activities or skills
needed for each job within the organization. This paper gives a
brief overview of the determining factors that should be taken
into consideration when assessing and adjusting skill mix. It
then summarizes the main findings from a literature review,
highlighting the evidence on skill mix that is available to inform
health system managers, health professionals, health policy-
makers and other stakeholders.

There is no common starting point for examining skill
mix in different countries, sectors and health systems.
Resource availability, regulatory environments, culture, cus-
tom and practice will all have played a role in determining the
typical or normal mix of staff in a particular health system. To

the extent that these factors vary, so will the typical mix. Indeed
there are marked variations between countries and regions in
terms of the mix of health care occupations (2). Table 1
highlights some of the key considerations that explain why skill
mix is important in many health systems (3).

The factors that generate pressure for change in the skill
mix are notmutually exclusive, and changing the skill mix is not
the only option for responding to them. Employing organiza-
tions should also review other possibilities, such as improving
the use of hospital beds, capital equipment and other
resources; improving staffing patterns in relation to day-to-
day fluctuations in workload and patient dependency; and
adjusting the distribution of resources (e.g. between tertiary,
secondary and primary care).

Reviewing skill mix
Our review of publications examining skill mix in health care
was based on two literature searches. The first was undertaken
for the World Health Organization (WHO), and focused on
English-language material published between 1986 and 1996
found through CINAHL, Medline, RCNNurse ROM, ASSIA
Plus, and FirstSearch (4). The second comprised a follow-up
search of English-language material published in the period
1996–2000 through CINAHL, Medline, ASSIA and Nurse

1 Faculty of Social Sciences and Health Care, Queen Margaret University College, Clerwood Terrace, Edinburgh, Scotland, EH12 8TS (email: jbuchan@qmuc.ac.uk).
2 Scientist, Department of Heath Service Provision, World Health Organization, Geneva, Switzerland.

Ref. No. 01-1262

575Bulletin of the World Health Organization 2002, 80 (7)

Online. The search terms used were: ‘‘skill mix’’, ‘‘skill
substitution’’, ‘‘personnel mix’’, ‘‘reprofiling’’, ‘‘staffing levels’’,
and ‘‘staffing mix’’. The term ‘‘changing roles’’ was also
included for the second search.

The review indicated a growing interest in skill mix, with
more than twice as many publications recorded for the period
1996–2000 as for the previous 10 years (1986–96). The main
findings are grouped as follows: reviews and meta-analyses;
large-scale (‘‘macro’’) data surveys; single-site (‘‘micro’’)
examinations of roles and mix in nursing and other non-
medical health professions; single-site (‘‘micro’’) examinations
of role overlap between doctors and other health professionals;
and studies on introductions of new types of worker.

There are several limitations to the review. First, there
may be publication bias, because unsuccessful attempts at
changing skill mix may be less likely to be recorded and
published. Second, searches rely on the use of key words; skill
mix is covered by a broad range of possible key words, and
some relevant publicationsmay have beenmissed. Third, most
of the publications reviewed are in English; this will lead to bias
in terms of the countries and health systems being examined.
In particular, the majority of the publications are from the
USA, where the health system is predominantly in the private
sector and there is a free-market approach to employment
legislation and job stability.

Reviews and meta-analyses
The small number of meta-analyses includes two North
American papers that focus on doctor–nurse roles and overlap
(5, 6). Two international reviews (drawing heavily on United
States sources) have recently been undertaken in the United
Kingdom (4, 7), alongwith a review focusing specifically on the
doctor–nurse mix in primary care (8).

While meta-analyses support a more conclusive over-
view than can be drawn from individual studies, they have
limitations when applied to a context-bound issue such as the
assessment of skill mix. The meta-analyses reviewed reveal

evidence (mainly but not exclusively from the United States)
that, in settings where there is actual or potential role overlap
between registered nurses and doctors, there is scope for a
cost-effective increase in the role and deployment of the
former. In particular, the use of clinical nurse specialists, nurse
practitioners and clinical nurse midwives can improve care
outcomes (often measured by patient satisfaction), while
maintaining or reducing costs.

Large-scale (‘‘macro’’) data surveys
These studies assess large datasets, often frommultiple sites, to
determine the extent to which variations in measures of
outcome can be attributed to differences in staffing level or
staffing mix. As with meta-analyses, the majority of these
studies have been conducted in the USA. Recent reports are
summarized in Table 2 (9–11).

These large-scale analyses of secondary data can give
some insight into the relation between staffing level or mix
and indicators of cost or quality. They can also provide
potential benchmarks for employing organizations, see, for
example, the discussion of the early stages of a multicountry
comparative study (12, 13), a multicountry study examining
the extent of use of ‘‘trained’’ nurses and overall resource use
in long-term care in England, Japan, Sweden, Spain and the
USA (14), and a multicountry analysis of variations in doctor–
nurse ratios (15).

While large-scale surveys have the potential to increase
our understanding of the complex relationships between
staffing, cost and outcome variables, they have two main
weaknesses. First, by definition, they are retrospective, and it
may be some time before the lessons of the analysis are known.
(For example, one study (11) was published in 1998, but uses
datasets from 1993.) So while they may inform policy, they are
less likely to have an immediate impact on practice at the
operational level. Secondly, they rely on secondary data from
available datasets, whichmeans that the findings are predicated
on the accuracy and completeness of the data.

Table 1. Skill mix: determinants, requirements and possible interventionsa

Determinant Requirement Possible interventions

Skill shortages Response to shortages of staff in particular
occupations or professions

Undertake skill substitution; improve use
of available skills

Cost containment Improved management of organizational costs,
specifically labour costs

Reduce unit labour costs or improve productivity
by altering staff mix or level

Quality improvement Improved quality of care Improve use and deployment of staff skills
to achieve best mix

Technological innovation;
new medical interventions

Cost-effective use of new medical
technology and interventions

Re-train staff in new skills; introduce different mix
or new types of worker

New health sector programmes
or initiatives (e.g. Roll Back Malaria)

Maximum health benefits of programme
implementation, by having appropriately
skilled workers in place

Determine the cost-effective mix of staff
required; enhance skills of current staff; introduce
new types of worker

Health sector reform Cost containment, improvements in quality
of care and performance, and responsiveness
of health sector organizations

Adjust staff roles; introduce new roles and new
types of worker

Changes in the legislative/regulatory
environment (note: this is also
a possible intervention)

Scope for changes in (or constraints on)
role for different occupations, professions

Adjust staff roles; introduce new skills and new
types of worker

a For further discussion of these issues see Buchan et al. (3 ).

576 Bulletin of the World Health Organization 2002, 80 (7)

Policy and Practice

Single-site (‘‘micro’’) examinations of roles and mix
in nursing and other non-medical health professions
The literature on the effect of different mixes of health
professionals and unqualified nurse aides, assistants and/or
support workers primarily comprises individual descriptive
studies. The vast majority of these focus on mixes of different
grades of qualified nurse, or of qualified nurses and nursing
auxiliaries/care assistants. Relatively few published analytical
studies cover other, non-medical health professionals or health
care workers. The two most common topics examined in this
field are the effectiveness of an all-qualified nursing workforce
in comparison with a qualified/unqualified mix, and the impact
on organizational costs and effectiveness of increasing the
proportion of care assistants/support workers in the nursing
workforce. A third topic, which is relatively under-explored, is
the implication for cost and quality of care of the involvement
of traditional practitioners (e.g. traditional birth attendants)
(16), relatives (17) and volunteers (18, 19) as part of the care
team.

The first topic, care provided entirely by qualified nurses,
was mainly examined in North America in the period up to the
mid–late 1980s; since then it has become less apparent in the
literature. The second topic, a qualified/unqualified, mix became
particularly apparent in the 1990s, as cost-containment led to a
re-examination of nursing skill mix in many countries, organiza-
tions and sectors. There are also some non-nursing examples,
including the use of care assistants in physiotherapy (20).

Substitution of cheaper care assistants for more
expensive nurses for cost-containment purposes has become
increasingly apparent in recent years in many countries. Many
of the publications in this area are written by and for qualified
nurses, and set out their concerns about being replaced or
having their skills undervalued (21, 22). These papers argue
that a cheaper skill mix may be no more cost-effective
because of the various hidden costs associated with skill
dilution. This argument cites factors such as higher absence
and turnover rates of less qualified staff; higher levels of
unproductive time because care assistants have less auton-
omy and capacity to act independently, and reported
concerns about possible harm to patients if care assistants
are required to work beyond their technical or legislated
capacity. Most of these studies tend to be unit-level before-
and-after examinations of the effects of introducing or
increasing the use of care assistants. There is no unanimity in
results or conclusions, even setting aside issues of metho-
dology and comparability.

The work of Gardner (23) and Krapohl and Larson (24)
indicates a number of models of qualified/unqualified mix in
nursing:
– Traditional aides/assistants/auxiliaries, mainly trained on the

job, performing simple nursing tasks in support of
registered nurses.

– Non-clinical assistants/extender clerks/aides, mainly involved in
non-clinical clerical/housekeeping work (can be multi-
skilled support workers).

– Technical assistants/operating department assistants with a
specified remit in relation to complex technological
processes, assisting nurses.

– Primary practice partner nursing assistants, paired with primary
nurses to maintain delivery of care by primary nursing.

– Vocationally trained/qualified carers, traditional nurse aides
undergoing an additional training programme of several
weeks or months, in some countries leading to a vocational
qualification, to take on nursing care responsibilities under the
direction of registered nurses or other health professionals.

The model in use can be determined on the basis of whether
the support staff are being used to supplement, complement or
replace (substitute for) qualified nurses.

Studies of the impact of the introduction of unlicensed
assistants in the USA have shownmixed results (25). Some have
suggested a positive impact: cost savings using patient care
assistants (26), and using nurse aides with no adverse effect on
patient satisfaction (27). Other studies have been less clear cut,
or have found the opposite, highlighting problem areas such as
decreased quality and increased on-call work, sick leave and
overtime working (28), reported higher workload for registered
nurses and, initially, a higher turnover of patient care technicians
(29), and a larger proportion of more highly qualified nurses
being related to higher reported quality of care (30).

While the qualified/unqualified mix in nursing has
received a comparatively high level of attention in the literature,
there are major limitations to the findings. Many of the studies
are methodologically weak; they often report on short-term
implementation, and are often written by those who champion
the use of unqualified support staff. As in other areas of
research, there may also be a bias towards publishing studies
with clear and positive findings.

Occupations other than nurses have received relatively
little attention. In some countries, especially in Latin America
and the Caribbean, there has been some examination of
different mixes of technicians (31). Although the number of

Table 2. Examples of large data surveys on skill mix

Focus Key findings

Registered nurse staffing in relation to total staffing and
outcomes in 494 United States nursing homes (9 )

Although registered nurse staffing is more expensive, it is the key
to improving outcomes in residents

Hospital characteristics, staffing level and mortality rates
in 3763 United States hospitals. Multiple regression analysis,
controlling for severity of illness (10 )

Mortality rates decreased as staffing per occupied bed increased for
medical residents, registered nurses, registered pharmacists and
medical technologists. Mortality rates increased as staffing levels per
occupied bed increased for licensed practical nurses and for administrators

Relationship between registered-nurse-adjusted patient days
(a measure of nurse staffing levels) and various adverse events
(e.g. urinary tract infections after major surgery, pneumonia
after surgery; thrombosis after surgery) (11 )

Inverse relationship between registered nurse staffing and adverse
events; the higher the proportion of registered nurses, the lower the
incidence of adverse events

577Bulletin of the World Health Organization 2002, 80 (7)

Skill mix in the health care workforce

these technicians is large and growing in some cases, no
analytical study was found. Studies on pharmacists tend to
focus on an analysis of activity related to the control of
prescriptions and expenditures or even on the interaction with
patients and their families (32, 33). Few studies attempt to
evaluate the pharmacists’ work in relation to that of other
health workers (34).

Another fundamental limitation is that very few studies

and reports really examine role or skill. In practice, most of

those that attempt to assess costs and quality implications

focus on grade, qualification or job title rather than skill or role.
Grade or job title is used as a proxy for level of skills or as a

definition of a role.

Single-site (‘‘micro’’) examinations of role overlap
between doctors and other health professionals
Skill substitution and the development of alternativemodels of

care delivery using nursing/midwifery staff rather than doctors

have been examined in a number of studies. There have been

some randomized controlled trials to assess quality/outcome,

and some meta-analyses of research studies (see above). The

evidence on overlap and scope for substitution between nurses

and doctors has been reviewed by several teams of researchers

(for example, 5–7, 35, 36). There are also a number of studies

of skill mix in dentistry, but these are not covered by this

review.

Contributions to a recent issue of the BMJ argue that the

time is ripe for a major reconstruction of the working

relationship between doctors and nurses (37–39). The editorial

in the same issue highlighted a growing concern that the

relatively expensive (and often scarce) skills of medical

practitioners should be better deployed, with less role overlap,

and with nurses working in advanced roles. The first of three

randomized controlled trials examining general practitioner

(GP)/nurse practitioner overlap looked at nurse-led manage-

ment of patients with minor illnesses in general practice. It

found that the nurses were effective and that patients reported

higher levels of satisfaction than with GPs (37). The second,

which examined the care given by nurse practitioners andGPs,

found that patients were more satisfied with the care given by

the nurse practitioners, that drug prescription rateswere similar

between the two groups, and that the nurses provided more

relevant information to patients than the doctors (38). The

third report examined the cost-effectiveness of GPs and nurse

practitioners (39). It found similar patterns of drug prescription

between the two groups, and no significant cost differences,

because the nurses spent more time, on average, with each

patient than did the doctors. Reported patient satisfaction was

higher for the nurses.

A review of research in this area supports the view that,

in defined situations, there is scope for maintaining or

improving quality of care, while maintaining or reducing

organizational costs, by increasing the role and deployment of

clinical nurse specialists, nurse practitioners and clinical nurse

midwives. The available research does not, however, fully map

out the parameters of role overlap/substitution, and many

possible models remain untested. The definition of an ideal

balance between doctors and nurses also has to take into

account potential constraints on change relating to legislation,

professional regulation and associated organizational and

contextual factors.

Studies on introductions of new types of worker
Many health systems have considered or implemented the

introduction of new cadres or groups of health worker to fill a

skills gap or improve the cost-effectiveness of the skill mix in

the health workforce. In practice, these are often persons in

existing occupations or grades with additional skills or an

extended role. In some countries, such cadres have been most

evident in rural and remote areas, where it may be difficult to

recruit conventional health professionals. They include:
– conventional support workers (in catering, patient trans-

port, cleaning, catering and food distribution, and clerical

areas) who are multiskilled or have an extended role;
– care assistants and auxiliaries who are multiskilled, have

undergone ‘‘cross-training’’ or have an extended role (e.g.

health community agents in the family health programme in

Brazil (40));
– current health care professionals (e.g. nurse practitioners)

with an extended role;
– technicians with new roles (e.g. in surgery or anaesthesiol-

ogy, as in Mozambique (Pellis G., unpublished WHO

consultant report, 1998)).

The extent to which truly ‘‘new’’ cadres of worker have been

introduced to health systems is difficult to determine as there is

much blurring of roles, with conventional workers being given

extended roles, perhaps with a new job title. So are there new

types ofworkers or simply new types ofwork being undertaken

by existing staff? Moreover, cultural, professional and

organizational differences mean that the role of a specified

worker or professional in one country or health systemmay be

different from that in another. Some country health systems

have developed roles that are country-specific or system-

specific, such as nurse anaesthetists, respiratory therapists and

medical assistants/clinical officers in Africa; and physician

assistants in theUSA.Many of these roles have been developed

as a solution for the shortage of doctors.

Conclusions
There are significant limitations to the current evidence on skill

mix in the health workforce. Many published studies in this

area are merely descriptive accounts, which add little in terms

of use of methods or interpretation of results. Where studies

do move beyond description, their usefulness is often

constrained bymethodological weaknesses, lack of appropriate

evaluations of quality/outcome and cost, and/or use of small

sample sizes. Moreover, many of the studies were undertaken

in theUSA, and the findingsmay not be relevant to other health

systems and countries. The results may therefore be suspect,

and of little use for comparative purposes or in drawing general

conclusions.

The results from even the most rigorous studies cannot

necessarily be applied to a different setting, organization or

health system. They remain true only for the time and place

fromwhich they are derived. This is the basis onwhich skill mix

is examined— the need to identify the care needs of a specific

patient population and match these to the skills of staff

available. It is thus impossible to prescribe in detail a universal

idealmix of health personnel. Skill mix is both a determinant of,

and determined by, organizational and system context.

Reviewing, and perhaps adjusting skill mix therefore requires

578 Bulletin of the World Health Organization 2002, 80 (7)

Policy and Practice

the capacity to analyse the context, identify appropriate
solutions, andmanage sustained changewithin the system (41).

Despite these limitations, examination of the current
evidence can make a significant contribution to a better
understanding of skill mix among nursing staff and in the
doctor/nurse balance. The evidence suggests that increased
use of less qualified (cheaper) nursing staff will not be effective
in all situations, although in some greater use of care assistants
has improved organizational efficiency. Evidence on the
doctor/nurse overlap indicates that there is unrealized scope,
within the constraints of country- and system-specific
regulations, for extending the use of nursing staff and for
further development of care delivery led by nurses/midwives,
for example, in maternity units.

The effectiveness of different skill mixes across other
groups of health workers and the associated question of the
development of new roles remain comparatively under-

explored. It is evident from this brief overview that
determining the skill mix and defining roles in the health care
workforce will continue to present a major challenge to health
professionals, managers and policy-makers. More robust
guidelines, based on sound evaluation of existing skill mix
patterns, and better dissemination of good practice are needed
to expand the evidence base and support informed decision-
making in this area. n

Acknowledgements
This paper is based on a background report prepared for the
Global Health Workforce Strategy workshop, organized by
WHO, and held in Annecy, France, in December 2000. The
support of Health Services Organization and Delivery, World
Health Organization, Geneva, Switzerland, is acknowledged.

Conflicts of interest: none declared.

Résumé

Dosage des compétences parmi les personnels de santé : examen des données
Le présent article examine les raisons pour lesquelles le dosage des
compétences parmi les personnels de santé est important pour les
systèmes de santé. Il passe en revue les données existantes (et en
identifie les limites), résume les principaux résultats publiés et
relève les données disponibles qui peuvent intéresser les
responsables des systèmes de santé, les professionnels de santé,
les responsables des politiques de santé et autres acteurs des
systèmes de santé. La plupart des articles publiés sont uniquement
descriptifs ou présentent des faiblesses méthodologiques. A
quelques exceptions près, les analyses publiées ont été réalisées
aux Etats-Unis d’Amérique, et leurs résultats peuvent ne pas être
applicables à d’autres systèmes de santé. Les résultats des études
même les plus rigoureuses ne sont d’ailleurs pas nécessairement
applicables dans d’autres contextes. Ces remarques montrent sur
quelles bases doit se faire l’examen du dosage des compétences –
identifier les besoins en soins dans une population de patients et
partir de ces besoins pour déterminer les compétences requises du

personnel de santé. Il n’est donc pas possible de prescrire en détail
un dosage théorique « universel » de compétences parmi le
personnel de santé. Compte tenu de ces limites, l’article examine
deux grands domaines dans lesquels l’étude des données actuelles
peut apporter une contribution importante à la question de la
définition du dosage optimal des compétences.

En ce qui concerne le personnel infirmier, les données
montrent que le recours accru à un personnel moins qualifié ne sera
pas efficace dans toutes les situations, même si dans certains cas on
a pu améliorer l’efficacité organisationnelle en faisant davantage
appel à des aides-soignants. Les données sur le recoupement des
compétences entre médecins et infirmières montrent que bien des
systèmes pourraient recourir beaucoup plus largement au
personnel infirmier. La question de l’efficacité de différents dosages
de compétences dans d’autres groupes d’agents et de professions
de santé ainsi que la question connexe de l’élaboration de
nouveaux rôles sont encore assez peu explorées.

Resumen

Combinación de aptitudes entre el personal sanitario: examen de la evidencia
En el presente artı́culo se analizan las razones que aconsejan una
buena combinación de aptitudes entre el personal sanitario. Se
examina la evidencia disponible (identificando sus limitaciones),
se resumen los principales hallazgos de una revisión de la
literatura y se ponen de relieve los datos sobre combinación de
aptitudes de que se dispone para informar a los administradores
de los sistemas de salud, los profesionales sanitarios, los
formuladores de polı́ticas de salud y otros interesados directos.
Muchos de los estudios publicados son meramente descriptivos o
presentan fallos metodológicos. Con pocas excepciones, los
estudios analı́ticos publicados se llevaron a cabo en los Estados
Unidos, por lo que los resultados quizá no sean pertinentes para
otros sistemas de salud. Incluso los resultados del más riguroso de
los estudios pueden perder toda validez en un entorno distinto.
De aquı́ se desprende la manera de proceder para examinar la
combinación de aptitudes: hay que identificar las necesidades de
atención de una población especı́fica de pacientes, y utilizarlas
para determinar las aptitudes que se requerirán del personal. Por

consiguiente, no es posible prescribir detalladamente una
combinación ideal «universal» de personal sanitario. Teniendo
en cuenta estas limitaciones, el documento examina dos áreas
básicas en las que la investigación de la evidencia disponible
puede contribuir sensiblemente a arrojar luz sobre la combinación
de aptitudes necesaria.

En cuanto a la combinación de personal de enfermerı́a, los
datos al alcance indican que una mayor utilización del personal
menos calificado no será una opción eficaz en todas las situaciones,
aunque en algunos casos el aumento del recurso a auxiliares ha
redundado en una mayor eficacia organizacional. La evidencia
disponible sobre la superposición de funciones entre los médicos y
las enfermeras indica que en muchos sistemas hay un margen
desaprovechado para recurrir más al personal de enfermerı́a. La
eficacia de diferentes combinaciones de aptitudes en otros grupos
de agentes de salud y profesiones y la cuestión asociada del
desarrollo de nuevas funciones constituyen un campo que
permanece relativamente inexplorado.

579Bulletin of the World Health Organization 2002, 80 (7)

Skill mix in the health care workforce

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Policy and Practice