Universal health coverage and nursing and midwifery workforce growth from 2000 to 2023: A longitudinal ecological...

National service coverage and workforce density describe different aspects of health-system development. Comparing their rates of change may reveal patterns overlooked by static workforce counts.

To examine how growth in universal health coverage service coverage relates to growth in nursing and midwifery personnel density across national health systems.

Longitudinal ecological study.

National health systems from 2000 to 2023.

Country-year records: growth profiles included 194 countries; adjusted models included 2290 observations from 169 countries.

We analysed World Health Organization and World Bank indicators. Separately standardised annualised growth rates defined a relative alignment score, with median thresholds distinguishing four profiles. Two-way fixed-effects models estimated associations between service coverage and log workforce density. Sensitivity analyses examined matched endpoint years, alternative growth measures and thresholds, country trends, first differences and country influence.

The reference analysis identified 44 coverage-workforce gap countries, with above-median coverage growth and below-median workforce growth. Matching endpoint years preserved 188 of 194 profiles (96.9%) and retained 41 gap countries. Alternative thresholds identified 30-63 gap countries; the fixed 2010-2023 comparison produced 70.1% agreement among 87 eligible countries. The adjusted coverage coefficient was 0.0294 (95% confidence interval 0.0175-0.0413), equivalent to approximately 3.0% higher workforce density per one-point increase in the index. Coefficients remained positive with country-specific trends (0.0396; 0.0182-0.0611) and first differences (0.0248; 0.0144-0.0351).

Coverage and workforce density were positively associated, but relative growth varied between countries. Matching observation windows preserved most profiles, whereas thresholds and period affected membership. Joint monitoring should consider growth rates, starting levels and reporting quality before investigating workforce constraints. Incomplete reporting, measurement limitations and the ecological design preclude conclusions about staffing adequacy or causal effects.