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FUTURE FINANCIAL
ECONOMICS OF
HEALTH PROFESSIONAL
EDUCATION
PROCEEDINGS OF A WORKSHOP
Patricia A. Cuff and Megan M. Perez, Rapporteurs
Global Forum on Innovation in Health Professional Education
Board on Global Health
Health and Medicine Division

THE NATIONAL ACADEMIES PRESS
Washington, DC
www.nap.edu
THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC
20001
This activity was supported by contracts between the National Academy of

Sciences and the Academic Collaborative for Integrative Health, Academy of
Nutrition and Dietetics, Accreditation Council for Graduate Medical Education,
Aetna Foundation, Alliance for Continuing Education in the Health Professions,
American Academy of Nursing, American Association of Colleges of Nursing,
American Association of Colleges of Osteopathic Medicine, American Association of
Colleges of Pharmacy, American Board of Family Medicine, American Board of
Obstetrics and Gynecology/American College of Obstetricians and Gynecologists,
American College of Nurse-Midwives, American Council of Academic Physical
Therapy, American Dental Education Association, American Medical Association,
American Occupational Therapy Association, American Osteopathic Association,
American Psychological Association, American Society for Nutrition, American
Speech-Language-Hearing Association, Association of American Medical Colleges,
Association of American Veterinary Medical Colleges, Association of Schools and
Colleges of Optometry, Association of Schools and Programs of Public Health,
Association of Schools of the Allied Health Professions, Athletic Training Strategic
Alliance, Council on Social Work Education, Ghent University, Health Resources and
Services Administration, Jonas Center for Nursing and Veterans Healthcare, Josiah
Macy Jr. Foundation, Kaiser Permanente, National Academies of Practice, National
Association of Social Workers, National Board for Certified Counselors, Inc. and
Affiliates, National Board of Medical Examiners, National Council of State Boards of
Nursing, National League for Nursing, Office of Academic Affiliations—Veterans
Health Administration, Organization for Associate Degree Nursing, Physician
Assistant Education Association, Society for Simulation in Healthcare, THEnet—
Training for Health Equity Network, Uniformed Services University of the Health
Sciences, and University of Toronto. Any opinions, findings, conclusions, or
recommendations expressed in this publication do not necessarily reflect the views
of any organization or agency that provided support for the project.
International Standard Book Number-13: 978-0-309-45755-2

International Standard Book Number-10: 0-309-45755-6
Digital Object Identifier: https://doi.org/10.17226/24736
Epub ISBN: 978-0-309-45758-3
Additional copies of this publication are available for sale from the National
Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800)
624-6242 or (202) 334-3313; http://www.nap.edu.
Copyright 2017 by the National Academy of Sciences. All rights reserved.

Printed in the United States of America
Suggested citation: National Academies of Sciences, Engineering, and Medicine.

2017. Future financial economics of health professional education: Proceedings of
a workshop. Washington, DC: The National Academies Press. doi: https://doi.org/1
0.17226/24736.
The National Academy of Sciences was established in 1863 by
an Act of Congress, signed by President Lincoln, as a private,
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science and technology. Members are elected by their peers for
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president.
The National Academy of Engineering was established in 1964

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by their peers for extraordinary contributions to engineering. Dr. C.
D. Mote, Jr., is president.
The National Academy of Medicine (formerly the Institute of

Medicine) was established in 1970 under the charter of the National
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contributions to medicine and health. Dr. Victor J. Dzau is president.
The three Academies work together as the National Academies of

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Engineering, and Medicine chronicle the presentations and
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other participants, the planning committee, or the National
Academies.
For information about other products and activities of the National

Academies, please visit www.nationalacademies.org/about/whatwed
o.
PLANNING COMMITTEE FOR FUTURE
FINANCING OF HEALTH
PROFESSIONAL EDUCATION: A
WORKSHOP1
ERIN FRAHER (Co-Chair), University of North Carolina at Chapel Hill

WARREN NEWTON (Co-Chair), American Board of Family Medicine
EDSON ARAUJO, World Bank
MARY BETH BIGLEY, Health Resources and Services Administration
KATHLEEN KLINK, Office of Academic Affiliations, Veterans Health
Administration
ROBERT (ROB) SMITH, Health Education England
JOANNE SPETZ, University of California, San Francisco
ZOHRAY TALIB, The George Washington University
Consultant
SCOTT REEVES, Kingston University and St George’s, University of
London
__________________
1 The National Academies of Sciences, Engineering, and Medicine’s planning
committees are solely responsible for organizing the workshop, identifying topics,
and choosing speakers. The responsibility for the published Proceedings of a
Workshop rests with the workshop rapporteurs and the institution.
GLOBAL FORUM ON INNOVATION IN
HEALTH PROFESSIONAL EDUCATION1
MALCOLM COX (Co-Chair), University of Pennsylvania, formerly U.S.

Department of Veterans Affairs
SUSAN SCRIMSHAW (Co-Chair), The Sage Colleges
ROBERT (BOB) ADDLETON, Alliance for Continuing Education in the
Health Professions
MARY BARGER, American College of Nurse-Midwives
TIMI AGAR BARWICK, Physician Assistant Education Association
DAVID BENTON, National Council of State Boards of Nursing
MARY BETH BIGLEY, Health Resources and Services Administration
JOANNA CAIN, American Board of Obstetrics and
Gynecology/American College of Obstetricians and Gynecologists
MARILYN CHOW, Kaiser Permanente
AMY APARICIO CLARK, Aetna Foundation
THOMAS WARREN CLAWSON, National Board for Certified Counselors,
Inc. and Affiliates
DARLA SPENCE COFFEY, Council on Social Work Education
DARLENE CURLEY, Jonas Center for Nursing and Veterans Healthcare
JAN DE MAESENEER, Ghent University
MARIETJIE DE VILLIERS, Stellenbosch University
KATHRIN (KATIE) ELIOT, Academy of Nutrition and Dietetics
JOHN FINNEGAN, JR., Association of Schools and Programs of Public
Health
ELIZABETH (LIZA) GOLDBLATT, Academic Collaborative for Integrative
Health
CATHERINE GRUS, American Psychological Association
NEIL HARVISON, American Occupational Therapy Association, Inc.
PATRICIA HINTON WALKER, Uniformed Services University of the
Health Sciences
ERIC HOLMBOE, Accreditation Council for Graduate Medical Education
ELIZABETH HOPPE, Association of Schools and Colleges of Optometry
EMILIA IWU, Jonas Center for Nursing and Veterans Healthcare
PAMELA JEFFRIES, The George Washington University
DARRELL KIRCH, Association of American Medical Colleges
SANDEEP (SUNNY) KISHORE, Young Professionals Chronic Disease
Network
ANDREW MACCABE, Association of American Veterinary Medical
Colleges
LUCINDA MAINE, American Association of Colleges of Pharmacy
BEVERLY MALONE, National League for Nursing
MARY E. (BETH) MANCINI, Society for Simulation in Healthcare
ANGELO MCCLAIN, National Association of Social Workers
LEMMIETTA G. MCNEILLY, American Speech-Language-Hearing
Association
MARK MERRICK, Commission on Accreditation of Athletic Training
Education
DONNA MEYER, Organization of Associate Degree Nursing
WARREN NEWTON, American Board of Family Medicine
BJORG PALSDOTTIR, Training for Health Equity Network (THEnet)
MIGUEL PANIAGUA, National Board of Medical Examiners
RAJATA RAJATANAVIN, Mahidol University
London
EDWARD SALTZMAN, American Society for Nutrition
KAREN SANDERS, Veterans Health Administration
NELSON SEWANKAMBO, Makerere University College of Health
Sciences
STEPHEN SHANNON, American Association of Colleges of Osteopathic
Medicine
SUSAN SKOCHELAK, American Medical Association
RICHARD (RICK) TALBOTT, Association of Schools of the Allied Health
Professions
ZOHRAY TALIB, The George Washington University
MARIA TASSONE, University of Toronto
GEORGE THIBAULT, Josiah Macy Jr. Foundation
DEBORAH TRAUTMAN, American Association of Colleges of Nursing
RICHARD (RICK) W. VALACHOVIC, American Dental Education
Association
SATYA VERMA, National Academies of Practice
ADRIENNE WHITE-FAINES, American Osteopathic Association
HOLLY WISE, American Council of Academic Physical Therapy
XUEJUN ZENG, Peking Union Medical College
BRENDA ZIERLER, University of Washington
Global Forum Staff

PATRICIA A. CUFF, Senior Program Officer
MEGAN M. PEREZ, Research Associate (until May 2017)
BRIDGET CALLAGHAN, Research Assistant (until January 2017)
AMBAR SAEED, Research Assistant (from January 2017)
FAYE HILLMAN, Financial Officer
JULIE PAVLIN, Board Director, Board on Global Health
__________________
1 This is the list of Forum members as of October 7, 2017.
Reviewers
This Proceedings of a Workshop was reviewed in draft form by

individuals chosen for their diverse perspectives and technical
expertise. The purpose of this independent review is to provide
candid and critical comments that will assist the National Academies
of Sciences, Engineering, and Medicine in making each published
proceedings as sound as possible and to ensure that it meets the
institutional standards for quality, objectivity, evidence, and
responsiveness to the charge. The review comments and draft
manuscript remain confidential to protect the integrity of the
process.
We thank the following individuals for their review of this
proceedings:
DAVID BENTON, National Council of State Boards of Nursing

ANN H. CARY, University of Missouri–Kansas City School of Nursing
and Health Studies
LORETTA NUNEZ, American Speech-Language-Hearing Association
London
Although the reviewers listed above provided many constructive

comments and suggestions, they were not asked to endorse the
content of the proceedings nor did they see the final draft before its
release. The review of this proceedings was overseen by DEBORAH E.
POWELL, University of Minnesota Medical School. She was
responsible for making certain that an independent examination of
this proceedings was carried out in accordance with standards of the
National Academies and that all review comments were carefully
considered. Responsibility for the final content rests entirely with the
rapporteurs and the National Academies.
Acknowledgments
Enormous thanks goes to the workshop planning committee for

developing and executing a timely agenda for studying the future
financial economics of health professional education. In particular,
the National Academies of Sciences, Engineering, and Medicine
would like to thank the workshop planning committee co-chairs, Erin
Fraher and Warren Newton, who deserve recognition for their
leadership in this endeavor, as well as the planning committee
members, Edson Araujo, Mary Beth Bigley, Kathleen Klink, Robert
Smith, Joanne Spetz, and Zohray Talib, for their support throughout
the workshop. Thanks also goes to workshop consultant Scott
Reeves for his expert advice and assistance. Such an event could not
have happened without the keen dedication of the Global Forum on
Innovation in Health Professional Education staff, including Patricia
Cuff, senior program officer and Forum director; Megan Perez,
research associate; Bridget Callaghan, research assistant; and
Ambar Saeed, research assistant. Special appreciation goes to Julie
Pavlin, director of the Board on Global Health. Most importantly,
thanks goes to the 45 sponsors and 57 members of the Forum who
make it possible to host events like the workshop described in this
proceedings.
Contents
Acronyms and Abbreviations
1 Introduction
2 Matching the Health Workforce to Population Needs
3 Understanding and Applying a Model for Financing Health

Professional Education
4 Reflections and Potential Next Steps for Building a Model
APPENDIXES
A Workshop Agenda
B Future Financing of Health Professional Education Workshop

Background Document
C Speaker Biographical Sketches
D Forum-Sponsored Products
Acronyms and
Abbreviations
ASPPH Association of Schools and Programs of Public Health

ATP ability to pay
CODA Commission on Dental Accreditation
GAO U.S. Government Accountability Office

GME graduate medical education
GMENAC Graduate Medical Education National Advisory
Committee
GP general practitioner
HCW health care workforce

HEE Health Education England
HPE health professional education
HPV human papillomavirus
HRH human resources for health
HW health worker
IMF International Monetary Fund

IPE interprofessional education
IRR individual rate of return
MHF mental health facilitator
NHS UK National Health Service
OECD Organisation for Economic Co-operation and

Development
PHC primary health care
ROI return on investment
THEnet Training for Health Equity Network
UHC universal health coverage

USUHS Uniformed Services University of the Health Sciences
WHO World Health Organization

WSU Walter Sisulu University
WTP willingness to pay
1
Introduction1
The U.S. Government Accountability Office (GAO), the World

Health Organization (WHO), and the World Bank all agree that “an
adequate, well-trained, and diverse health [care] workforce is
essential for providing access to quality health [care] services” (GAO,
2015). However, according to the World Bank, “despite more than a
decade of concerted global action to address the health workforce
crisis, collective efforts are falling short in scaling up the supply of
health workers” (Evans et al., 2016). The resulting health workforce
shortage affects people’s access to quality health care around the
globe. The WHO independent expert group to the High-Level
Commission on Health Employment and Economic Growth led by
Richard Horton predicted that “the resultant negative externalities of
untreated sickness and disability will have direct adverse economic
consequences” (Horton et al., 2016). Such adversities include
personal financial deficits caused by lost days of work, a need to
draw upon already restricted budgets to care for loved ones, and
loss of future income as children are kept from school to support
family members who cannot work. In addition to affecting family
finances, untreated sickness and disability also affect employers’
bottom line as they try to function with a compromised or absent
workforce.
The WHO states that chronic underinvestment in health workforce
education and training creates a mismatch between strategies to
educate the right number and mix of health professionals and
meeting the needs of the population particularly within remote and
underserved communities (WHO, 2016). Even in high-income
countries with well-functioning health systems, such as the United
States and Britain, there can be an oversupply of health workers and
health professionals coexisting with a shortage owing to imbalances
in the distribution of health workers (Evans et al., 2016; WHO,
2016). According to the GAO (2015), a “more coordinated effort
could help to ensure an adequate supply and distribution of the
health care workforce.” Incentives are important levers policy makers
and others have to influence recruitment, motivation, and retention
of health professionals. The International Council of Nurses and
others have noted that “incentives can be positive or negative,
financial or nonfinancial, tangible or intangible” (ICN et al., 2008).
Matching population health needs with the right number, mix,
distribution, and skill set of health workers while considering how
supply and demand drive decisions within education and health was
the topic of a National Academies of Sciences, Engineering, and
Medicine workshop held October 6–7, 2016, in Washington, DC. The
workshop, titled Future Financing of Health Professional Education,2
was hosted by the Global Forum on Innovation in Health Professional
Education (see full list of Forum members). It was open to the public
and was also a webcast.3
As written into the statement of task found in Box 1-1, this
workshop sought to explore resources for financing health
professional education in high-, middle-, and low-income countries,
and to examine innovative methods for financially supporting
investments in health professional education within and across
professions. Through presentations and small-group discussions,
participants of the workshop had an opportunity to apply broad
concepts—set up by economists and health workforce experts—to
personal situations within their own profession. The workshop began
with a welcome from Susan Scrimshaw; she, along with Malcolm
Cox, form the leadership of the Global Forum on Innovation in
Health Professional Education.
BOX 1-1
Statement of Task
An ad hoc committee will plan and conduct a 2-day public
workshop to explore resources for financing health professional
education in high-, middle-, and low-income countries. The
workshop will examine innovative methods for financially
supporting investments in health professional education within
and across professions that might include such topics as:
Nontraditional methods of learning for improving financial

efficiency
Public–private partnerships
Inventive payment strategies, incentives, and social
financing
Modernizing and maximizing government support
Maximizing investment by health care systems themselves
Generating cost savings data reflecting greater returns on
investments with healthier communities
These issues will be considered during the 2-day public

workshop that will be planned and organized by an ad hoc
committee of the National Academies of Sciences, Engineering,
and Medicine. The committee will develop a workshop agenda,
select and invite speakers and discussants, and moderate the
discussions. Following the workshop, an individually authored
summary of the event will be prepared by designated
rapporteurs in accordance with institutional guidelines.
Scrimshaw described how this workshop is a reflection of the
increasingly complex topics Forum members have elected to
undertake for their activities. These topics include the role of health
professionals and educators in addressing the social determinants of
health, interprofessional work and learning, assessment within and
among the health professions, and defining professionalism in and
with society. Previous activities such as the ones listed in Appendix D
frequently set the stage for exploring other important topics, such as
accreditation, which was looked at in an April 2016 workshop, and
this workshop topic on financing health professional education.
With those brief remarks, Scrimshaw handed the microphone to
Erin Fraher, University of North Carolina at Chapel Hill, who
underscored the importance of this workshop, which is taking place
at a time of great change and uncertainty in health care.
ORIENTATION TO THE WORKSHOP

Erin Fraher, University of North Carolina at Chapel Hill
My job this morning is to tell you, why now? What is the sense of
urgency? Why are we here? These were the words of Erin Fraher,
who continued to say incredibly rapid health system changes are
occurring that are putting new demands on the health workforce.
She then described the multiple ways the system is changing.
Factors Influencing Health Professional

Education Financing
Traditional roles for many of the health professions are shifting,4
and the importance of preparing a workforce for population health
has taken hold. Recently, the Josiah Macy Jr. Foundation issued
conference-driven recommendations on preparing registered nurses
for enhanced roles in primary care (Josiah Macy Jr. Foundation,
2016). There are occupational therapists and physical therapists who
are increasingly working in people’s homes in an attempt to prevent
readmissions to the hospital. Social workers are taking on incredible
roles in health care that they perhaps have always done, but maybe
are becoming more in the forefront now that other health
professions are recognizing the importance of addressing the social
determinants of health.
In building on the work of social services, Fraher asked what new
roles might an upstream social focus in health create within the
health workforce? The health workforce is increasingly changing as
more roles look at spanning boundaries that bridge community and
health care settings. These new areas include community health
workers, health coaches, and others who are working with
communities. This transformation has caused role changes and
placed new demands on the health care workforce.
At the same time, new payment models and new care delivery
models, such as accountable care organizations, have created a new
way of interacting as a team that includes new players with a social
or community-engaged focus.
The major issue for Fraher as a workforce researcher is the shift in
care from acute to community settings and what that might mean
for the workforce. For example, how does the nurse who has done
all of his or her clinical placements and work in acute care settings
get retrained in order to work in ambulatory care? While such
change offers tremendous opportunities for nurses in community-
based settings, how do health systems and payers of education
respond to the challenge of retraining or retooling the current
workforce to be relevant for meeting the changing needs of patients
and populations?
The future of education is not just about preparing students who
are in the pipeline. If health care is to be transformed to better align
with health systems, the global health workforce already in practice
will need to be retrained because they are the people who are going
to transform health care, said Fraher.
A difficulty is how health professionals and educators will meet
this challenge at a time of constrained resources. Some are looking
for new sources of money and new ways of financing health and
educational activities, but increasingly, payers of health professional
education are asking, “What am I getting for that money? What is
the return on investment for dollars spent on education?” Fraher
further commented that the discussion goes beyond the roughly $12
billion spent each year on graduate medical education (GME)
(Dower, 2012). The discussion also includes nursing, physical
therapy, occupational therapy, and all the health professions. The
key question, said Fraher, is what is the return? How is education
creating a workforce that is responsive to the needs of the health
care system and the population?
These are the challenges facing health professional education that
framed the workshop and that underscore the absolute timeliness of
this workshop. Fraher stated that education will need to keep pace
with changes in health care, demographics, and technology; training
will have to shift from acute to community; interprofessional practice
models will need to be the focus; and all of these changes will need
to occur with little to no extra money.
Workshop Goal and Objectives

The goal of this workshop is to help Forum members and
workshop participants think about how to face these challenges.
Fraher then outlined the learning outcomes envisioned for the
conference. One is to increase participants’ understanding of the
evidence that is currently available. Another is to test traditionally
held assumptions through structured dialogue realizing that at times,
assumptions can create tensions. Fraher hopes the discussions will
bring those tensions to the forefront so they can be openly
addressed in hopes of better understanding the varied perspectives.
The final outcome and learning objective is to explore financial
levers or incentives that can be used to address the challenges
identified by workshop participants and speakers.
Organization of the Proceedings of a
Workshop
These learning objectives described by Fraher are embedded in an
agenda that is found in Appendix A of this Proceedings of a
Workshop and is reflected in the following chapters. Chapter 2
begins with the framing of health professional education financing
from a global perspective, provided by Edson Araujo. As a Brazilian
and an employee of the World Bank, Araujo offers an economic lens
to describe the needs of the population and what the health
professional education system is producing. Existing in between
these forces is the market, which hopefully sends the right market
signals but has been known to fail, resulting in mismatches. This
chapter lays out a discussion about those mismatches and some of
the challenges they create for health professional education
financing systems. It also contains a discussion about the design of
an ideal health professions education financing system and the
guiding principles that could be the foundation for such a system.
Some of these attributes could include being responsive to society,
flexibility, and a focus on lifelong learning.
Within this chapter is a conversation about the actors involved in
health professional education financing. Answering this involved a
stakeholder analysis where the workshop participants explored the
following questions: Who is involved? What kind of influence do they
have? What kind of levers can they pull? What do they want to do?
How can they be incentivized?
Chapter 3 then compares (1) proposed notions discussed by the
workshop participants with (2) health professional education
financing examples drawn from South Africa, the United Kingdom,
and the United States. It also looks at tensions in health professional
education through the pedagogy of debates. These debate
propositions explore whether public spending on health professional
education should be significantly increased, and whether it is
acceptable to demand a social return on investment from health
professional schools. Embedded in this chapter are ideas drawn from
the four breakout groups that delve more deeply into different
aspects of the mismatches and other relevant issues, such as levers
and drivers for financing health professional education.
Chapter 4 offers an opportunity to reflect on the discussions taking
place throughout the workshop and those specifically related to
building a model for financing health professional education. In this
regard, Charles Ok Pannenborg, formerly with the World Bank,
highlighted numerous windows through which health professional
education could be viewed from a financial perspective. Malcolm Cox
gave his personal reflections on building a model such as the one
described throughout this proceedings. His remarks led into Erin
Fraher’s presentation; she took her original model on financing
health professional education and reworked it based on comments
she heard throughout the workshop. Her additions and edits to the
model (including a new title that uses the term financial economics),
the guiding principles, and the list of actors are found in Chapter 4.
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Dower, C. 2012. Health policy brief: Graduate medical education.
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f.php?brief_id=73 (accessed July 13, 2017).
Evans, T., E. C. Araujo, C. H. Herbst, and O. Pannenborg. 2016.
Addressing the challenges of health professional education:
Opportunities to accelerate progress towards universal health
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GAO (U.S. Government Accountability Office). 2015. Comprehensive
planning by HHS needed to meet national needs: Report to
congressional requesters. Document GAO-16-17. Washington, DC:
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McPake, K. S. Reddy, R. Reinikka, J.-O. Schmidt, L. Song, V.
Tangcharoensathien, S. Trent-Adams, D. Weakliam, and A. E.
Yamin. 2016. Final report of the expert group to the High-Level
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ICN (International Council of Nurses), International Pharmaceutical
Federation, World Dental Federation, World Medical Association,
International Hospital Federation, and World Confederation for
Physical Therapy. 2008. Guidelines: Incentives for health
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Josiah Macy Jr. Foundation. 2016. Registered nurses: Partners in
transforming primary care. Recommendations from the Macy
Foundation Conference on Preparing Registered Nurses for
Enhanced Roles in Primary Care. New York: Josiah Macy Jr.
Foundation.
WHO (World Health Organization). 2016. Global strategy on human
resources for health: Workforce 2030. Geneva, Switzerland: WHO.
__________________
1 The planning committee’s role was limited to planning the workshop, and the
Proceedings of a Workshop has been prepared by the workshop rapporteurs as a
factual summary of what occurred at the workshop. Statements,
recommendations, and opinions expressed are those of individual presenters and
participants, and are not necessarily endorsed or verified by the National
Academies of Sciences, Engineering, and Medicine, and they should not be
construed as reflecting any group consensus.
2 The term financial economics more accurately captures the discussions that
took place at the workshop, which is why the title of this Proceedings of a
Workshop differs from the title of the workshop. Financial economics is defined as
a “branch of economics focused on the elements of time, risk, opportunity cost,
and other variables related to financial decisions. This field of study concentrates
on how financial moves are made under uncertain conditions” (BusinessDictionary,
n.d.).
3 Videos of the workshop can be found on the Global Forum on Innovation in
Health Professional Education workshop website, http://nationalacademies.org/hm
d/Activities/Global/InnovationHealthProfEducation/2016-OCT-6.aspx (accessed
March 9, 2017).
4 Throughout the workshop, speakers referred to health professions and health
professionals. While professions has a broader context than professionals, it was
left to the individual preference of the speaker as to which term he or she used.
2
Matching the Health

Workforce to Population
Needs
Key Messages Identified by Individual

Speakers and Participants
Market failures cause suboptimal allocation of resources in the
health care and health professional education markets (such as
shortages, skill imbalances, and unequal distribution of the
available health workforce). (Araujo)
Recognizing the importance of market forces within health labor
and education markets is an essential step to aligning education
investments to health systems’ goals. (Araujo)
Predicting the direction of the health system to ensure an
adequately sized, trained, and distributed workforce is difficult at
best; therefore, having the ability to quickly adjust education based
on market signals would better synchronize education with health
systems that are responsive to the population needs. (Fraher)
A mismatch between what is being produced through education
and what the population needs can lead students to accrue large
debts. (Fraher)
TENSIONS AND CHALLENGES TO ADEQUATELY

AND EFFICIENTLY FINANCE HEALTH
PROFESSIONAL EDUCATION
Edson Correia Araujo, World Bank
Edson Correia Araujo is a senior economist at the World Bank, and led
the World Bank health workforce global knowledge program. His
presentation focused on the interaction between health professional
education (HPE) and labor markets from a global perspective, with
examples of trends and challenges from low- and middle-income countries
as well as high-income countries.
The Health Labor Market: A Framework for

Analysis
Araujo led a recent World Bank publication, The Economics of Health
Professional Education and Careers: Insights from a Literature Review
(McPake et al., 2015). The aim of the publication was to document what is
known about the influence of market forces on the health professional
formation process. The report explores the interactions between the
markets for health care and for health workers, as well as the health
professionals’ education choices in the context of low- and middle-income
countries.
Araujo described the market forces that exist within the health labor
market, describing the factors influencing the demand for and the supply
of health workers (see Figure 2-1). As shown in Figure 2-1, the demand
for health care influences the production and training of health workers—
or the supply of health workers. In principle, this demand should be
determined by the population’s health care needs. In ideal circumstances,
health care needs would be translated into actual demand, and the
training institutions would produce the necessary supply of health workers
to fulfill the demand. However, this seldom happens owing to the
existence of market failures in both health and labor markets. These
market failures explain, to a great extent, the persistent challenges most
countries face in producing, deploying, and retaining an adequate and
well-performing health workforce. The health worker shortage (described
in Chapter 1) is further exacerbated by the imbalances in the distribution
across and within countries, he said. In most countries, health workers
tend to be concentrated in urban and wealthier areas, leaving rural and
poorer areas with severe shortages. In Togo, for example, 17 percent of
doctors serve 80 percent of the population living outside of the country’s
capital (World Bank, 2011). This pattern is found in low-, middle-, and
high-income countries across the globe.
In addition to its importance to health service delivery, the health
workforce represents a large portion of the labor force in most countries,
and this number is growing despite economic recessions. In the United
States, for example, the health workforce share of total employment is
10.71 percent, with a cumulative growth of 11.2 percent during the latest
recession (Turner et al., 2013). Among Organisation for Economic Co-
operation and Development (OECD) countries, the health and social
sectors share of total employment is just over 10 percent on average,
with large cross-country variation—the highest share of 15 percent in the
Nordic countries and the Netherlands, and the lowest share of about 3
percent in Mexico and Turkey (OECD, 2016). The increase of health sector
jobs raises concerns related to sustainability of health systems and the
effect on the economy as a whole. Globally, health workers salaries
account, on average, for 34 percent of countries’ total health expenditures
—and 57 percent in the United States (Hernandez-Peña et al., 2013;
Turner et al., 2013). These trends emphasize the importance of producing
a health workforce in adequate numbers, with the appropriate skills and
competencies to maximize job creation and to improve population health
outcomes.
FIGURE 2-1 Framework for analysis of health workers labor market
dynamics.
NOTE: ATP = ability to pay; HRH = human resources for health; HW = health
worker; WTP = willingness to pay.
SOURCES: Presented by Araujo, October 6, 2016 (McPake et al., 2013,
adapted from Soucat et al., 2013).
The Interaction Between Labor and Education

Markets
Araujo cited the Lancet Commission report (Frenk et al., 2010) that
states that the challenge lies in transforming the needs, which are
generated by the population, into demand. Such a transformation of
needs into demand does not always occur. Often, this is attributed to an
information gap between the patients and the providers. Health
economists see this lack of transformation as a market failure, said
Araujo, and have been working for years to address it.
Araujo then presented a model (see Figure 2-2) showing the interaction
between education and labor markets within the health sector. He began
to describe the conflicts, tensions, and imbalances between health care
needs and demand, health professional training and supply, and demand
and supply.
FIGURE 2-2 The interaction between education and labor markets for health
workers.
NOTE: This is an adaptation of an original work by the World Bank.
Responsibility for the views and opinions expressed in the adaptation rests
solely with the author of the adaptation and are not endorsed by any member
institution of the World Bank Group.
SOURCES: Presented by Araujo, October 6, 2016 (adapted from McPake et al.,
2015).
An Overview of Need, Demand, Supply, and Training of

Health Professionals
According to the model presented, the market for HPE is skewed by the
same market failures inherent to health care markets (McPake et al.,
2015; Preker et al., 2013). The main market failure is, as mentioned
above, information gaps. Patients, or consumers, know less about their
own health status and the appropriate treatment than the health care
providers. This information asymmetry results in providers supplying more
health care than necessary or demanded (supplier-induced demand).
Additionally, the demand for health workers and for health services are
influenced by perceived need, which is different from actual need. This
can result in a gap between willingness to pay and informed willingness to
pay; in other words, patients may be unwilling to pay for services that
they need, or may be willing to pay for services that are not necessary or
are not cost-effective. Another issue that results from information gaps is
the problem of wage rates not reflecting the value of the health
professional as measured by social return and effect on public health.
Another market failure that affects HPE, as identified by Araujo, is the
challenge of transforming health care needs into actual demand. The
distribution of ability to pay for services is often inversely related to
needs; people with the greatest need, often the poor or those in rural
areas, tend to have weaker demand to buy the services they need
because of barriers to access and inability to pay. In addition, said Araujo,
the governments often have limited fiscal capacity to compensate for
health care services or weak political will to compensate these individuals
or to invest in public services to help fulfill their health needs.
Market failures cause suboptimal allocation of resources in the health
care and HPE markets. First, there is a global shortage of health workers,
and the shortage is growing. A World Bank report estimated that the
global demand for health workers will rise to nearly 80 million by 2030,
which is about double the current stock (Liua et al., 2016). This report
also projects a global demand shortage of 15 million health workers by
2030, maintaining the current patterns of demand and production of
health workers (Liua et al., 2016). When taking into account aging
populations, rise of chronic diseases, and other changes in health care,
this shortage will likely increase. The second imbalance Araujo identified is
skill bias, or overspecialization. Globally, there is a tendency for health
workers to seek specialization, and as a result, there is a persistent supply
of health workers for higher lifetime-earning specialties. This also results
in a persistent excess of demand for lower lifetime-earning positions,
often the public health workforce and generalist practitioners (McPake et
al., 2015). Third, there is an acute maldistribution of health workers. The
majority of health workers worldwide tend to be concentrated in affluent
urban areas rather than in rural and poorer areas (Preker et al., 2013).
Many health workers often migrate from low- and middle-income
countries to high-income countries to seek greater financial and working
opportunities.
The supply of health workers is influenced by numerous factors
including workers’ training capacity, the real or perceived need for health
workers, and the availability of trained staff willing to practice. From the
labor market perspective, wage rate is a key variable influencing the
supply. Economists observe the influence of wage rate based on the
private rate of returns to education; in other words, the individual returns
that one receives for investing time and resources into training (or the
private return). High private rate of returns is a market signal to
prospective students, affecting their career choice, and therefore the
supply of health workers. In addition, as previously discussed, patient
demand and insurance reimbursement often fail to flow resources
according to public health needs, often resulting in higher payments for
highly specialized services. This means that these specialized services
have a higher rate of return to health professionals providing them.
Private return is different from the public and social returns for that
individual’s training, which Araujo believes should guide HPE financing
decisions. If the market is left untouched, the private returns will be more
influential on individual decision making and, likely, the current skill
imbalance will remain.
Another important trend affecting health labor markets is the increased
use of technology in health care. Technology incorporation results in a
higher rate of return to education for higher skilled workers, as these
services are more expensive and demanded by patients. This results in
changes to the elasticity of demand for high-skilled workers relative to
low-skilled workers, and makes it difficult to substitute between higher-
and lower-skilled workers (Schumacher, 2002).
Population Health Needs and Demand for Health Workers

Araujo stated that owing to the market failures discussed, unregulated
health labor markets are unlikely to move to an equilibrium, or a situation
where needs, demands, and supply are matched. If the health labor
market is left alone, the outcomes will likely negatively affect poor,
remote, and disenfranchised populations. The demand for health workers
is influenced by
market signals, sent through rates of returns to education, which

affect individuals’ training and career choices (careers with higher
compensation are more likely to attract individuals; whereas, careers
with low compensation drive individuals away from those positions);
and
patient demand and insurance reimbursement failing to reflect the
social and public value of HPE.
Araujo said that these market forces influence the allocation of labor
inputs and often result in
health care jobs concentrated in urban or hospital settings, focusing

on acute care to treat ill patients;
shortage of primary health care positions and shortage of health
workers in rural and poor areas; and
access to care based on a patient’s ability to pay for care.
To demonstrate the links between compensation and individual career

choice, Araujo presented some evidence to workshop participants. First,
he presented a table from Roth (2011) that showed physician specialties,
the individual rate of return (IRR), the years needed to graduate, and the
median annual earnings. Noninvasive radiologists have a 38.9 percent IRR
with median annual earnings of $304,586.10. On the other end of the
spectrum, family practice doctors have a 16.8 percent IRR with median
annual earnings of $132,479.28. General pediatricians have a 13.9
percent IRR with median annual earnings of $138,240.00 (Roth, 2011).
Another study found that cardiologists made roughly double the amount
of primary care physicians reiterating the fact that “over their lifetimes,
primary care physicians earn lower incomes—and accumulate
considerably less wealth—than their specialist counterparts” (Vaughn et
al., 2010). Araujo also presented evidence showing that in countries of
the OECD, the growth rates of salaries for general practitioners are
historically lower than for specialty positions.
Araujo explained that in Brazil, the growth of private health insurance in
the late 2000s boosted the demand for health workers in the country.
Given the government’s inability to expand the production of health
workers quickly, there was a large expansion of private medical and
nursing schools in the country (Scheffer and Dal Poz, 2015). In China, the
challenge relates to low compensation to health workers in a fast-growing
economy. Health care occupations have lower salaries than other
occupations with similar education requirements (Qin et al., 2013). There
are strong incentives for health workers to produce more services
(supplier-induced demand) and see more patients in order to supplement
their salaries. This creates tensions between the health care professionals
and the patients, in some cases resulting in violent incidents. Araujo said
that as a result, health professions became less attractive to prospective
students, and those who chose a health professional career often choose
not to enter clinical practice, instead choosing to enter the biotechnology
or pharmaceutical industries (which are fast-growing industries in modern
China).
Referencing the Lancet Commission report (Frenk et al., 2010), Araujo
reminded workshop participants that only 2 percent of total health care
expenditure goes toward health professional education (about $100 billion
out of the roughly $5 trillion spent globally). To him, this is a very small
investment for a sector that is mostly based on labor. He also pointed out
that the spending is not focused where it needs to be in order to meet
population health needs, as there are problems with student debt, cost of
application, and faculty salaries.
Health Workforce Supply and Health Workers’ Training

The production of health professionals is influenced by the availability of
resources and the rate of return to education, as well as models of
training, regulation, prestige, and quality of life. However, HPE institutions
do not always respond to the demand for training. These aforementioned
factors cause many effects on the supply of health workers (Evans et al.,
2016):
inadequate scale and narrow scope of education institutions;

curricula focused only on marketable skills, owing to certain
specialties having higher rates of return than others;
accreditation and licensing functioning as barriers to entry and failing
to promote quality; and
a weak and homogenous pool of eligible students, that often lacks
students from economically disadvantaged backgrounds.
These effects then result in a health workforce with a skills imbalance

(more specialists than primary care professionals), a workforce that is
overspecialized (as a result of the technology changes), and a higher cost
of training.
Supply of Health Workers and Health Workers’ Training:

The Health Workforce Shortage
Araujo stated that there is a shortage of health professionals, and the
needs and the demands of the growing global population are not being
met. In most countries, the demand is much higher than the supply of
health workers. This means society is not producing health professionals
at the same rate as the population growth and is not keeping up with
demands for services. The same is true for all health workers and not just
professionals where the supply is not keeping up with the need and the
demand. This is a global issue, and is especially acute in low- and middle-
income countries, as shown in Figure 2-3.
FIGURE 2-3 Global trends in demand, supply, and needs to health workers,
2013–2030.
SOURCES: Presented by Araujo, October 6, 2016 (Liua et al., 2016).
Looking at public and private education, it appears that the public

education sector has not been able to meet the increased demand for
health workers. The private education sector is growing, but it is still
unable to meet the increasing demand, said Araujo. These issues can also
affect quality, given that private HPE institutions are often unregulated in
low- and middle-income countries. Araujo noted that these trends are
observed in Brazil, India, Indonesia, and many other countries. Quality
assurance mechanisms (accreditation of schools and certification of
professionals) need to be in place to ensure that the supply of health
workers meets quality standards, said Araujo. However, it is also
important to avoid entry restrictions into the labor market beyond what is
necessary to assure quality; accreditation and certification are sometimes
seen as instruments to restrict labor market entry and artificially control
supply.
Another issue that Araujo raised is the problem of student debt. HPE, in
general, is very expensive. If students have to bear the cost of education,
there will be incentives to pursue specializations with higher salaries (and
consequently, receive higher rates of return to education). This could
result in health care occupations with relatively lower salaries being
ignored—and often, these are the positions that have a higher impact on
population health care needs. The growing size of student loans results in
students more likely to seek jobs with higher salaries in order to pay back
their loans.
The Health Labor Market Imbalances

Revisiting Figure 2-2, Araujo described the results of health labor
market imbalances; specifically, imbalances between population health
need and population health demand, between population health demand
and health workforce supply, and between health workforce supply and
health worker’s training and careers (see Figure 2-4). The demand and
supply sides are interlinked, and affected by the market signals coming
from the population health care needs, from health service delivery and
payment systems, and from HPE institutions. The imbalances result in
many outcomes identified by Araujo, as noted below and also in Figure 2-
4:
neglect of poor, rural, and remote populations

balance of the workforce in terms of preventive and promotive
interventions, as well as lower performance
labor shortages
unemployment and underemployment
skills imbalances
over specialization
high costs of training
FIGURE 2-4 Health labor market imbalances.
NOTE: This is an adaptation of an original work by the World Bank.
Responsibility for the views and opinions expressed in the adaptation rests
solely with the author of the adaptation and are not endorsed by any member
institution of the World Bank Group.
SOURCES: Presented by Araujo, October 6, 2016 (adapted from McPake et al.,
2015).
He reminded workshop participants that it is important to consider the

link between the cost of care and what one pays for HPE. In addition, he
noted that the growing cost of higher education is not specific to the
health professions but is an issue in many other sectors.
To summarize the various factors that affect the supply and demand of
health professionals, Araujo presented Figure 2-5. The figure shows the
interactions between some of the various supply and demand elements;
the arrows demonstrate how these elements interact. The figure
highlights the diverse interconnections influencing HPE outcomes and how
these are linked to health labor market institutions and dynamics. It also
provides a framework to guide how public investments can be channeled
to target the outcomes of interest, which is a well-balanced workforce
with the appropriate numbers (i.e., supply) and skills.
Another random document with
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Galician troops are sufficiently numerous to be worth calling armies
at all.
The first thing to do is to cut down unnecessary commanders-in-
chief and staffs. The Galician, Castilian, and Estremaduran
commands should be at once amalgamated, and put under
Castaños, with one single staff for all three. Probably the same
should be done with the Andalusian, Murcian, and Valencian
commands. An immense body of superfluous staff-officers must be
sent back to Cadiz at once. As a second step he would have to
revise the organization of the country into captain-generalships and
intendancies. Captain-generals often hampered army-commanders;
intendants must probably be put under military authority. This was no
doubt wrong in principle. But the civil intendant was powerless, in a
country just liberated from the enemy and full of trouble and disorder.
He could not exert authority unless he were lent military assistance:
yet he would probably fall out with the military chief, because their
ends would be divergent[278]. ‘When the enemy is still in the country
that must be done which tends most directly to drive him out—
whatever constitutional principles may be violated in the process[279].’
Finally, Wellington resolved that he must come down to Cadiz in
person to urge his schemes of reorganization on the Regency and
the Cortes—obviously a most invidious task, since no nation likes to
have administrative reforms thrust upon it by a foreigner—more
especially by a foreigner whose tone is dictatorial and whose
phrases seem almost deliberately worded so as to wound national
pride.
On December 12th he started out to deal with the Cadiz
bureaucrats, planning to cover the whole 300 miles from Freneda in
six days. As a matter of fact he took eleven, partly because he was
smitten with lumbago, which made riding painful, partly because he
was delayed one night in the Pass of Perales, and two at
Albuquerque, by floods, which made mountain-streams impassable
for many hours. Immediately on reaching the seat of government,
where he was received with great state if with little real cordiality, he
started on his campaign against the Regency, the Cortes, and the
Minister of War. It is much to the credit of the Spaniards that, though
many of his demands were unpalatable, the greater part of them
were conceded with slight variation of terms. It is curious to note the
points on which the Regency proved recalcitrant and started
argument. Of the four great preliminary conditions which Wellington
exacted, they granted at once that which seemed the most important
of all—the creation of a Spanish chief-of-the-staff to be attached to
Wellington’s head-quarters, and conceded that all military
correspondence should pass through his hands. The person
selected was General Wimpffen, a Spanish-Swiss officer, of whom
we have had to speak occasionally in dealing with Catalonian affairs
—he had been Henry O’Donnell’s adjutant-general in 1810. He was
a non-political soldier of good abilities, and Wellington found him
laborious and obliging: there seems never to have been any friction
between them. Secondly, the Regency granted the great point that
the whole British subsidy should be applied to such military
expenses as Wellington should designate: and they afterwards went
so far as to order that in the recovered provinces nine-tenths of the
taxes raised should be devoted to military purposes. But they
haggled on the two conditions dealing with military patronage.
Instead of giving the generalissimo power to revise all appointments,
they proposed that ‘no officer should be promoted to a chief
command, or the command of a division, or any extraordinary
command, except at the recommendation of the general-in-chief.
With regard to other promotions the rules of the Spanish service
shall be strictly observed.’ This left all patronage from the rank of
brigadier-general downward in the hands of the Minister of War and
the Cortes. And whereas Wellington had proposed, as his second
condition, that he should have power to cashier any officer whom he
considered deserving of such punishment, the Regents offered him
only the right of suspending and sending away from the army in the
field officers guilty of grave misconduct[280].
It is clear that these variations on the original proposals had two
main objects. The Spaniards evidently thought that if Wellington had
every officer down to the lowest under his thumb, liable to be
cashiered without any appeal, he might use this tremendous power
to stock the whole army with men of one political colour, and make it
into a machine quite independent of the Government, and capable of
being turned against it. And similarly there was a great difference
between the right to send an officer away from the front, and the
right to drive him out of the army. To be put on half-pay, or on
administrative duty in some office at Cadiz, was a much less terrible
fate than cashiering.
It must be remembered that many Spaniards thought Wellington
capable of aiming at a military dictatorship, to which he might be
helped by generals who were considered Anglophils, such as
Castaños, his nephew and chief-of-the-staff Giron, or Morillo. And
others believed that British policy secretly desired the seizure of
Cadiz and Minorca and the reduction of Spain to a Protectorate. Now
if there had been any truth in these absurd suspicions, there is no
doubt that the powers which Wellington demanded would have given
him the chance of carrying out such designs. And there were an
infinite number of Spanish officers, from generals like La Peña down
to petty governors and members of provincial staffs, who had come
into direct contact with Wellington, and knew his unflattering opinion
of them. All these men in disgrace, or disgruntled placemen, thought
that the new generalissimo would start his career by a general
cashiering of those against whom he had an old grudge.
Hence pressure was brought to bear upon the Regents and the
Cortes from many and diverse quarters, with the common plea that
there must be no British military dictatorship, and that Spanish
officers must be protected from possible persecution and
oppression. The underlying idea was that if the mass of the middle
and lower grades in the army were out of Wellington’s supervision, it
did not matter so much who held the post of army-commander or
captain-general. For the chiefs, though in influential posts, were few,
and would not be able to carry their subordinates with them in any
unpopular movement dictated to them by the generalissimo.
After much discussion, and with reluctance[281], Wellington
accepted the modifications—thinking that the other things conceded
gave him practically all that he needed. He was to find out his error
in the year that followed. He had not guarded himself against seeing
officers with whom he was satisfied removed from his field-army
under the pretence of promotion, or of transference to other duties,
or of political offences. He had forgotten to demand that he should
have the power of retaining as much as that of dismissing generals.
In this way he was deprived of the services of Castaños and
afterwards of Giron, both of whom he was anxious to keep.
Successors technically unobjectionable, whom he had no wish to
‘blackball,’ were substituted for them, to his deep regret. And another
evasion of his intention was that officers whom he had intended to
disgrace, and had removed from the front, were given posts
elsewhere which could not be called ‘divisional’ or ‘separate’
commands, but were quite desirable; and so while the letter of the
bargain was kept, the purpose of inflicting punishment on such
people was foiled.
Another long controversy was provoked by Wellington’s proposal
that the small armies should be amalgamated, and that unnecessary
captain-generals with their staffs should be got rid of. Much but not
all of what he asked was conceded. The Murcian and Valencian
armies were consolidated, and given the new name of the ‘Second
Army’—the Catalan army being still the ‘First Army’. But they were
not amalgamated with the Andalusian command (now the ‘Third
Army’), as Wellington suggested. And similarly the Estremaduran,
Castilian, and Galician armies, with the outlying Cantabrian division,
ceased to be the 5th, 6th, and 7th Armies, and took the new name of
the Fourth. And a great reduction of staffs and removal of contending
military authorities was procured, by nominating Elio, commander of
the new 2nd Army, to be Captain-General of Murcia and Valencia,
Del Parque of the 3rd Army to be Captain-General of Granada and
Jaen, and Castaños to be Captain-General alike of Estremadura,
Galicia, and Castile. This was all to the good, but the Cortes refused
Wellington’s other proposal, that the civil government in each
province should be placed under the control of the army-
commanders. Declaring that it was constitutionally impossible to
abolish the independence of the civil power, the Cortes yet conceded
that the jefe político (or provincial prefect) and the Intendant should
obey the Captain-General ‘in all matters relating to the Army[282],’
also that nine-tenths of the revenue in each province should be
allocated to the military budget. This would have worked if all parties
concerned had been both willing and competent; but it remained a
melancholy fact throughout the next campaign that the army-
commanders could seldom get either money or food from the civil
authorities, and that most essential operations were delayed by the
absolute impossibility of moving large bodies of men without
adequate magazines or a fair supply of money. The only regular
income of the army was that drawn from the British subsidy.
But the worst of Wellington’s troubles were yet some months
ahead. The Regency with which he had made his bargain[283] was
displaced in March 1813, and succeeded by another. The Cortes
was jealous of the Executive, and had determined to make for itself a
supreme authority which should have neither brains nor energy. The
subject of quarrel chosen was the old Regency’s alleged slackness
in carrying out a recent Act which had abolished that moribund
abuse the Inquisition[284]. After an all-night sitting and a vote of
censure, the Regents were dismissed, and replaced by a group
appointed under an absurd principle borrowed from the old régime,
which was applied because it suited the desires of the assembly for
the moment. It was composed of the three senior members of the
Council of State—senility and weakness being desired. These were
the Cardinal Bourbon—Archbishop of Toledo—an aged scion of the
royal house, and the Councillors Pedro Agar and Gabriel Cisgar,
who had been Regents before, but had been got rid of for
incompetence. Thus all real power went to the Chamber itself—the
Regency having become a negligible quantity. Wellington’s position
was decidedly impaired by the change—largely because a new
minister-of-war had come into office, General Juan O’Donoju, of
whom he had an evil memory as Cuesta’s chief-of-the-staff during
the Talavera campaign. This clever, shifty, and contentious Irish-
Spanish officer broached the theory that the agreement of December
1812 did not bind the new Regents, because they had never
assented to it, and because it was contrary to the spirit of the
Constitution that a foreigner should have the power to appoint or
dismiss Spanish generals.
When Henry Wellesley at Cadiz, instructed by his brother, turned
his heaviest diplomatic batteries[285] upon the Regents, and privately
warned the leading members of the Cortes of the awkward results
that would follow the repudiation of the agreement, O’Donoju was
disavowed but not displaced. He continued to give perpetual trouble
through the following summer by his persistent intrigues. Wellington
was by no means satisfied with the attempts that were made to
propitiate him, by the formal recognition of his status as
generalissimo by the new Regents, and the gift of a great estate in
Granada, the royal domain of Soto de Roma, which had been
usurped by Godoy. He did not want grants but real authority. Of his
future troubles we shall have to speak in their proper place.
The most enduring of them was provincial maladministration,
which rendered so many of his orders futile. For usually when he
directed a division to move, he was informed that it was destitute of
both munitions and transport[286]. And changes of organization were
often made against his protests—e. g. a new army regulation cut
down all regimental formations to a single battalion of very heavy
strength (1,200 bayonets). Wellington would have preferred a two-
battalion formation, in which the second unit should act as a dépôt
and feeder to the first[287]. He complained that if a regiment was badly
cut up in action, there would be no machinery for keeping it up to a
decent average. The experience of the British army with regard to
single-battalion corps had been conclusive against the system for
the last five years of Peninsular service. But his protests were vain—
internal organization of units did not come within the wording of his
powers as generalissimo, and the new organization continued,
dozens of second battalions being scrapped.
The net result was that, when Wellington took the field in May
1813, he only had with him two of Castaños’s divisions and three of
those of the Army of Galicia—less than 25,000 men. The Andalusian
‘Army of Reserve,’ which had been promised to him, started late for
want of organization, moved slowly for want of magazines, and only
reached the front when the battle of Vittoria had been won and the
French had been expelled from Spain[288]. The Cortes had at least
160,000 men under arms; not a sixth part of them were available
during the decisive operations. But of this more in its proper place.
Portugal, as usual, contributed its share to the troubles of the
Commander-in-Chief, though they were but trifling compared to the
Spanish problems. The Prince Regent at Rio de Janeiro was an
expensive person, who actually at the worst of the war drew money
out of Portugal from the Braganza private domains, though he had
all the revenues of Brazil to play with[289]. Moreover, he had a
tiresome habit of sending incompetent hangers-on to Europe, with a
request that berths might be found for them. But he was not actively
noxious—the same could not be said of his wife, the Spanish
princess Carlotta, who was still harping on her natural claim to be
Regent of Spain on behalf of her imprisoned brother Ferdinand, and
still interfered from time to time at Cadiz, by ordering the small knot
of deputies who depended on her to attack the existing regency, or
to vote in incalculable ways on questions of domestic politics.
Fortunately she was so great a clerical and reactionary that the
‘Liberal’ majority in the Cortes had secretly resolved that she should
never get into power. When the old regency was evicted in March
1813, it was suspected that the Cardinal Bourbon was put at the
head of the succeeding body mainly because the presence of a
prince of the blood in the Executive seemed to make it unnecessary
to import another member of the royal house. For this small mercy
Henry Wellesley wrote a letter of thanksgiving to his brother at the
front. It was fortunate that the Prince Regent himself gave no
encouragement to his wife’s ambitions, being as indolent as she was
active, and very jealous of her secret intrigues with foreigners. At
one time during the winter of 1812-13 she showed an intention of
departing for Europe, but with the assistance of the British
ambassador João succeeded in frustrating her scheme for appearing
at Cadiz in person to claim her supposed rights.
Meanwhile the civil government of Portugal continued to be
directed by the existing Council of Regency, of whom the majority
were honest if not always well-advised. It is true that Wellington’s old
enemies[290] the Patriarch of Lisbon and the Principal Sousa still
remained members of it: the determination to evict them which he
had declared in 1810 was never carried out—the one was so
powerful from his position in the Church, the other from the influence
of the widespread Sousa family, that in the end he left them
undisturbed. They were perhaps less dangerous in the Regency
than out of it, with their hysterical appeals to narrow national
sentiment, protests against the doings of their colleagues, and
perpetual intrigues. A frondeur is partly muzzled when he holds
office. And in practical administration they were steadily voted down
by the majority of the Regency, consisting of the Marquis of Olhão,
the Conde de Redondo[291], Dr. Nogueira, and last but not least the
British Minister Sir Charles Stuart, whose presence on the board was
perhaps necessary, but certainly very trying to Portuguese amour-
propre. The three native regents were genuine patriots, and good
friends of the alliance, but a little antiquated in their views as to
administration and finance. The Secretary of State, Miguel Forjaz, to
whom so many of Wellington’s letters are addressed, was a much
more modern personage with a broader intelligence: indeed,
Wellington considered him on the whole the most capable statesman
in the Peninsula.
There were two standing sources of friction between the British
army and the Portuguese Regency—both inevitable, and both
tiresome from the point of view of the necessary entente between
two allied nations. The more irritating but less important was trouble
caused by the daily movement of troops, especially troops in small
bodies, or individual officers. A perusal of the records of many
scores of courts martial, as well as of the correspondence of
Wellington and Beresford, leads to the conclusion that there were
grave faults on both sides. Parties of British soldiers on the march,
when unaccompanied by an officer, were given to the illegal
‘embargoing’ of carts or mules, to the extortion of food by force or
threats, to mishandling of the peasantry when denied what they
asked: occasionally they went so far as acts of murder or arson[292].
And it cannot be denied that individual officers of unsatisfactory type
were occasionally guilty of gross misconduct—drunken orgies,
wanton disregard of legal authority in requisitions, even acts of insult
or assault on local magistrates[293]. On the other hand, the
provocation was often considerable—there were plenty of cases
established of the denial of legal billets, which kept parties waiting in
the rain for hours, of wanton incivility, of attempts at extortion in
prices, of actual highway robbery[294], and false accusations brought
up to cover neglect of duty. One of Wellington’s main complaints was
that he had to waste time in investigating imaginary outrages, which,
on inquiry, turned out to have been invented to serve as
countercharges against accusations of slackness or misfeasance.
He was determined that outrages by the army should cease—
indeed, he hanged, first and last, some fifty soldiers for plunder
accompanied with violence, an offence which he would never
pardon. But the Portuguese magistrates were prone to make
accusations, and then to protest against having to support them by
evidence. By a curious turn of official pride many of them refused to
testify before courts martial, or even to send witnesses to appear
before such bodies, standing to the theory that it was beneath the
dignity of a magistrate to come with evidence before a foreign
military tribunal[295]. The result of this was that offenders brought up
for trial, and often probably guilty, had to be acquitted for lack of
proof. On the other hand, accusations, made and supported, were
sometimes found to be entirely groundless—in one supposed
murder case, the alleged corpse was discovered in perfect health; in
another, a magistrate who accused a British officer of assault was
found to have been dining with him and frequenting his quarters,
long after the supposed offence[296].
The Portuguese Regency was bound to stand up in defence of its
magistrates—Wellington, though always ready to punish proved
crimes, was determined not to take accusation as equivalent to
conviction, merely because it was preferred by a constituted
authority. Hence came perpetual friction and recrimination; that
things were no worse was certainly due to the fact that the
commander-in-chief’s iron discipline, and rigorous dealing with his
own people, could not fail to impress the Portuguese with the fact
that he was always trying to be just.
The other and more fundamentally dangerous source of
wrangling in Portugal was finance. There could be no disputing the
fact that the part of the army which was not directly maintained from
the British subsidy was often six months in arrears of pay, and still
more often on the edge of starvation. Portuguese paper money, in
which many transactions had to take place, and which could be
legally used for a certain percentage of all army payments, was not
only at a habitual discount of at least 25 percent., but also fluctuating
in exchange-value from day to day. Hence came all manner of illicit
speculations by merchants, both British and Portuguese, who were
always trying to buy Government paper at under its quotation for the
day, and to put it off on others at an exaggerated estimate. The
same took place with Commissariat Warrants, which unscrupulous
brokers bought from the ignorant peasantry for a mere song, after
setting rumours about concerning impending bankruptcy of the state,
and then cashed at full face-value in Lisbon or London.
The Regency maintained that all the trouble came from the
simple fact that the war had placed upon the back of Portugal, a
small country, half of whose territory had been wasted by Soult and
Masséna in 1809 and 1810, a much greater burden than could be
borne. The armed forces alone—some 50,000 regular troops, and
often as many militia in the garrisons—were so many hands taken
away from agriculture, the only staple industry of the land. Money
was going out of the realm year by year to purchase wheat, because
the people could not produce enough to maintain their existence.
Prices had risen to heights that terrified those who remembered pre-
war days: the pay of the army was enormous compared to the rates
before 1808, and much of it was going, under Marshal Beresford’s
system, to the British officers who were now holding a clear majority
of all the senior ranks and commands. All available money went to
the army, and the civil administration was starved. The Regency
acknowledged the deplorable state of its finances, but could only
suggest remedies which had grave inconveniences. Another British
loan was asked for; but considering the heavy subsidy that Portugal
was receiving already, the British Government gave little
encouragement to such an idea[297]. The Portuguese minister in
London (the Conde de Funchal, one of the Sousas) suggested a
large measure of confiscation of Church and Crown lands—which
could then be sold. But this would involve a quarrel with the Church
party in Portugal, who had been loyal supporters of the British
alliance, and probably with the Prince Regent also, since he was
drawing a private income from the Braganza estates. It might also
produce a general shock to national credit, for it would deal a blow to
the general stability of society, and terrify all landholders. Moreover,
it appeared doubtful if purchasers of Church lands would present
themselves: and Crown lands were largely uncultivated and
worthless tracts in the Alemtejo[298]. The measure was carried out,
indeed, many years later, during the civil wars of Miguel and Maria;
but then it came as a consequence of a purely domestic struggle, in
which the Church party had taken the beaten side. The
circumstances of 1813 were entirely different. A third expedient
suggested was the establishment of a National Bank, after the model
of the Bank of England, which should take over the management of
the public debt and currency. But credit and guarantees must be at
the back of any such association, and unless the British Government
were ready to become the guarantor (which was impossible) it was
hard to see what new securities could be found.
Wellington’s panacea for financial distress was not heroic
measures but careful and honest administration of details. He held
that there was great slackness and partiality in the raising and
collection of taxes, and that the amount received could be very
largely increased by the abolition of abuses. In a very long
memorandum, addressed to the Prince Regent João in April 1813,
he launched out into an indictment of the whole financial system of
the realm. ‘The great cities and even some of the smaller places of
the kingdom have gained by the war: the mercantile class generally
has enriched itself by the great disbursements which the army
makes in cash: there are individuals in Lisbon and Oporto who have
amassed immense sums. The fact is not denied that the “tributes”
regularly established at Lisbon and Oporto, and the contribution of
ten per cent. on the profits of the mercantile class are not really paid
to the state.... I have recommended the adoption of methods by
which the taxes might be really and actually collected, and
merchants and capitalists really pay the tenth of their annual profits
as an extraordinary contribution for the war.... It remains for the
Government to explain to your Royal Highness the reasons why it
will not put them in practice—or some other expedient which might
render the revenue of the state equal to its expenses.’ He then
proceeds to urge supervision of a Custom House notorious for letting
off powerful importers overlightly, and of the collectors of land-
revenue, who were allowed to keep state balances in their hands for
months without paying them in to the Treasury[299].
In letters to Charles Stuart[300] as a member of the Regency
Wellington let out in much more unguarded terms. The root of
corruption was in the mercantile community, who had squared the
minor bureaucracy. The army and state would have been ruined long
ago, but for his own protests and insistence, by the jobbers of
Lisbon, not only Portuguese, Jews, cosmopolitans of all sorts, but
‘sharks calling themselves British merchants.’ The Government is
‘teased into disapprobation of good measures by the merchants,
who are interested in their being discontinued. But when it is
necessary to carry on an expensive system of war with one-sixth of
the money in specie necessary, we must consider questions and
adopt measures of this description, and we ought to have the
support and confidence of your Government in adopting them.’
Making allowance alike for the difficulties of the Regency, and the
irritation of the much-worried general, it seems fair to say that on the
one hand Wellington was right in denouncing jobbery and urging
administrative reforms, but that on the other hand no such reforms,
however sweeping, would have sufficed to make both ends balance
in the revenue of the exhausted kingdom of Portugal. The task was
too heavy—but the eighteenth-century slackness and corruption,
which still survived in too many corners of the bureaucracy, made it
even heavier than it need have been. It is probable that Wellington’s
palliatives would have failed to make receipts meet expenditure,
however hardly the screw might have been turned. But a levy of 10
per cent. on commercial profits does not look very heavy to the
taxpayer of 1921!
This is a military not an economic or a financial history; it is
unnecessary to go further into Portuguese problems. The main thing
to be remembered is that they bulked large in the correspondence of
the harassed chief, who sat writing minutes on all topics, civil no less
than strategical, in his desolate head-quarters at Freneda.
SECTION XXXV: CHAPTER III
WELLINGTON AND WHITEHALL
The position which Wellington had won himself by five years of

successful campaigning in the Peninsula was such as no British
commander since Marlborough had enjoyed. His reputation was now
European; his views, not merely on the Spanish struggle but on the
general politics of the Continent, had to be taken into consideration
by the Ministry. He was no longer an officer to whom orders could be
sent, to be carried out whether he liked them or not. He had become
a political personage, whose views must be ascertained before any
wide-reaching decision as to the struggle with Napoleon was taken.
In 1813 it is not too much to say that he exercised a determining
influence not only on the military policy of Britain, but on the whole
course of the Great War: as we shall presently see, the triumph of
Vittoria had the most marked and direct effect on the action of
Russia, Prussia, and Austria. But even before Vittoria he had
asserted his will in many ways—he had stopped some projects and
approved others. The factious resignation of his brother Lord
Wellesley from the Perceval Cabinet had not impaired his position,
nor had the coming into office of Lord Liverpool, when Perceval
perished by the bullet of a crazy assassin a month after the fall of
Badajoz. Wellington’s correspondence with the War Minister, Lord
Bathurst, in 1813, is as confidential and amicable on both sides as
had been the case when the domineering Wellesley had been in
power: with the new Prime Minister, Liverpool, there is no trace of
any friction whatever—rather every sign of reciprocal respect.
But the position which Wellington had achieved had its
drawbacks as well as its advantages. Since it had become habitual
for the Cabinet to ask his opinion on high military matters not
connected with the Peninsula, an endless vista of troubles was
opened up before him, for (as always happens in times of
exceptional crisis) the Ministry at home was being plagued with all
manner of solicitations from every quarter of Europe, to which
answers were required.
While Wellington had been trailing back reluctantly from Burgos
to Ciudad Rodrigo, Napoleon had been conducting a retreat of a
very different kind from Moscow to the Berezina, a retreat whose
character and consequences were not known in London or in Spain
for some weeks later. He had left Moscow on October 19th, had
dictated the famous 29th Bulletin, acknowledging the wreck of his
project and the ruin of his army, at Molodetchno on December 3rd,
and had started on his headlong flight to Paris on December 5th,
leaving the small remnant of his host to perish in the snow. He
reached the Tuileries on the night of December 18th, on the heels of
the disastrous bulletin, which his ministers had only received thirty-
six hours before, on the preceding day[301]. In London the fact that
the Russian expedition had failed was well known by the end of
November, but the extent of the failure was only realized when the
29th Bulletin got to Lord Liverpool’s hands, by the usual smugglers’
route, on December 21st, rather less than five days after its arrival in
Paris[302].
The Prime Minister sat down next morning to communicate the
fact to Wellington, and to consult him upon the logical
consequences. ‘There has been,’ he wrote, ‘no example within the
last twenty years, among all the extraordinary events of the French
Revolution, of such a change of fortune as Bonaparte has
experienced during the last five months. The most formidable army
ever collected by Bonaparte has been substantially destroyed. It only
remains to be ascertained whether he will succeed in escaping
himself—and with what remnant of an army.... Under these
circumstances the question naturally occurs whether he will leave
the French army in Spain? We have a report that he has already
ordered 40,000 men from that country to rejoin him—but it is only a
report. I am inclined, however, to be of opinion that he will withdraw
the greater part of his forces from Spain. The only efficient French
Army at the present moment in existence is that under Soult: and
whatever it may cost Bonaparte to abandon Spain, I think he will
prefer that alternative to the loss of Germany. I may be wrong in this
speculation, but give you my reasons, and I am particularly desirous
of calling your attention to this view of the subject, in order that you
may take the necessary means for obtaining early information of the
movements of any French divisions toward the frontier, and that you
may consider what measures may be proper to be adopted if my
conjecture should be realized[303].’
Thus on the first day after the arrival of the epoch-making
bulletin, and before it was known that Napoleon himself had reached
Paris, the great strategical question of the winter of 1812-13 was
formulated, and put before Wellington. Will the French evacuate
Spain? and, if so, what should be done with the British Army in the
Peninsula? There were three possible contingencies—(1) the
Emperor might abandon Spain altogether, in order to have the
nucleus of an army ready for the campaign of 1813 in Germany, or
(2) he might not evacuate Spain altogether, but might cut down his
forces there, and order them to stand on the defensive only, or (3) he
might value his prestige so highly that he would take little or nothing
in the way of troops from the Peninsula, and endeavour to make
head against the Russians with whatever remnant of an army might
be left him in the North, with the conscripts of 1813, and the levies of
the German States—if the latter should remain obedient to him[304].
At first it seemed as if the third and least likely of these three
hypotheses was the correct one. For strange as it might appear,
considering what had happened in Russia, Wellington could detect
no signs of any great body of French troops being moved towards
the Pyrenees. So far was this from being the case, that the
cantonments adopted by the enemy in December were so widely
spread to the South, that the only possible deduction that could be
made was that the whole of the armies of 1812 were being kept in
Spain. We now know that the reason for this was that the
communications between Madrid and Paris were so bad, that
Napoleon’s orders to his brother to draw in towards the North, and
send large drafts and detachments to France, only reached their
destination in February. For many weeks Wellington could report no
such movements as Lord Liverpool had expected.
It was not till March 10th that the much-desired news began to
come to hand[305], time having elapsed sufficient to allow of King
Joseph beginning to carry out the Emperor’s orders. On that day
Wellington was able to send Lord Bathurst intelligence which
seemed to prove that the second hypothesis, not the third, was going
to prove the correct one: i. e. there was about to be a certain
deduction from the French armies in Spain, which would make it
unlikely that they would take the offensive, but nevertheless the main
body of them was still to be left in the Peninsula. Though the enemy
had made no move of importance, it was certain that Soult and
Caffarelli had been recalled to France—the latter taking with him the
troops of the Imperial Guard, which had hitherto formed part of the
Army of the North. To replace the latter Palombini’s division had
been moved from near Madrid to Biscay. A large draft of artillery had
been sent back to France, and twelve (it was really twenty-five)
picked men for the Imperial Guard from each battalion of the Army of
Spain. On the other hand, a body of 4,000 men—probably
convalescents or conscripts—had come down from Bayonne to
Burgos[306]. Seven days later a more important general move could
be detected: not only had Soult gone towards France with a heavy
column of drafts, but the French had evacuated La Mancha, the
troops formerly there having retired north to the province of Avila[307].
Again, a week later, on March 24th, it became known[308] that the
Army of the Centre had moved up towards the Douro, and that King
Joseph and his Court were about to quit Madrid. A little later this
move was found to have taken place: the enemy had evacuated a
broad stretch of territory, and ‘concentrated very much toward the
Douro[309].’ On the same day an intercepted letter, from General
Lucotte at Paris to King Joseph, let Wellington into the main secrets
of the enemy: the General reported to his master that the Emperor’s
affairs were in a bad way, that there would be no men and very little
money for Spain, and that he must make the best of what resources
he had. His Imperial Majesty was in a captious and petulant mood,
blaming everything done by everybody beyond the Pyrenees, but
more especially his brother’s neglect to keep open the
communication with France and to hunt down the northern
insurgents[310].
This useful glimpse into the mentality of the enemy made it
abundantly clear that Lord Liverpool’s original theory, that Napoleon
would withdraw his whole army from Spain in order to hold down
Germany, was perfectly erroneous. At the same time, Lucotte’s
report coincided with all the other indications, in showing that the
enemy had been perceptibly weakened, could count on no further
reinforcements, and must stand on the defensive during the
campaign that was to come.
But while it was still thought in Whitehall that the Emperor might
evacuate Spain altogether, various projects for turning the Russian
débâcle to account began to be laid before Wellington. The first was
a scheme for fostering a possible insurrection in Holland, where
grave discontent was said to be brewing. Would it be wise for the
Prince of Orange, now serving as an aide-de-camp on the head-
quarters staff, to be sent home, so that he might put himself at the
head of a rising? Wellington replied that he no more believed in an
immediate insurrection in Holland than in one in France. ‘Unless I
should hear of an insurrection in France or in Holland, or should
receive an order to send him, I shall say nothing on the subject to the
Prince[311].’ He was undoubtedly right in his decision: the Dutch
required the news of Leipzig, still nine months ahead, to make them
stir: an expedition to Holland in the early spring would have been
hopelessly premature.
A little later came a much more plausible proposition, which met
with an equally strong negative from Wellington. The ever-loyal
Electorate of Hanover was prepared to rise: to start the movement it
would be only necessary to land a nucleus of British-German troops
somewhere on the Frisian coast. Could Wellington spare the three
cavalry regiments, five infantry battalions, and one battery of the
King’s German Legion which were serving with him? After
Tettenborn’s March raid to Hamburg the insurrection actually broke
out, and Bathurst suggested[312] that the time had come to throw a
considerable force ashore in the electorate. He asked whether the
Hanoverian officers in Spain were beginning to chafe at being kept
so far from their homes at the critical moment. Again Wellington put
in a strong negative. He had been to consult General Charles Alten,
‘by far the best of the Hanoverian officers,’ as to the expedience of
sending the Legion to Germany. Alten held that ‘the best thing for
England, for Germany, and the world, is to make the greatest
possible effort here:’ the services of a few thousand veteran troops
would be important in the narrower field in Spain—they would be lost
in the multitudes assembling on the Elbe. If a large body of loyal
levies were collected in Hanover it might ultimately be well to send a
part of the Legion thither: but not at present[313]. This was the policy
which the Ministry followed: in the spring they dispatched to North
Germany only cadres from the dépôts of the Legion at Bexhill—500
men in all, including some experienced cavalry and artillery officers.
In July the 3rd Hussars went across to Stralsund, in August two
batteries of Horse Artillery, all from England[314]. But no deduction of
units was made from Wellington’s Spanish army—only a few officers
were permitted to sail, at their own request. The senior of them,
General Bock of the Heavy Dragoons, unfortunately perished by
shipwreck with his three aides-de-camp off the coast of Brittany in
the winter that followed Vittoria.
Bathurst was so far right that many of the Hanoverian officers
regretted their stay in the Peninsula: on the other hand, Wellington
was not merely trying to keep his own army strong, when he refused
to listen to the suggestions made him. It was perfectly true that 4,000
good soldiers were an appreciable unit in a Spanish battle—while
they would be ‘entirely thrown away,’ as he put it, in Germany. The
margin of strength was so narrow in the Peninsular Army that it was
not safe to decrease it.
The same question that arose about the King’s German Legion
also came up during the spring of 1813 with regard to the
Brunswickers. Many officers of the Brunswick-Oels battalion in the
7th Division were fired with the idea of liberating Germany—they
wrote to their duke, then in England, begging him to have the
battalion ordered home. He replied that he had tried to get the War
Office to let him go to the Elbe, even with a small cadre, a few
hundred men, but had been refused[315]. It is much more surprising
that this corps was not spared from the Peninsula: Wellington had a
bad mark against it, for its terrible propensity to desertion, and a
worse for the behaviour of one of its companies at Tordesillas in the
recent campaign. Probably he thought that, if he surrendered the
Brunswickers, he would have to give up the German Legion also.
It is odd to find that among Wellington’s troubles were not only
the proposed subtraction of troops whom he did not want to lose, but
the proposed addition of troops whom he was not at all anxious to
see in the Peninsula. The story is one which illustrates the casual
methods of Russian officers. In February there came to Freneda a
well-known British secret agent, Mackenzie, the man who had
organized the successful evasion of La Romana’s Spaniards from
Denmark in 1808[316]. He brought letters from Admiral Greig,
commanding the Russian Black Sea fleet, to the effect that there
was a surplus of troops from Tchitchagoff’s Army of the Danube,
which could not be utilized in Germany for want of transport and
supplies. There were 15,000 men who could be collected at Odessa
and shipped to Spain, to be placed in the Allied Army, if Wellington
would accept them. The memory of Russian co-operation in Holland
in 1799 was not a very happy one: but it seemed unwise to offend
the Tsar, on whose goodwill the future of Europe now depended.
Wherefore the answer given was that they might come if the British
Cabinet approved, and if the Spanish and Portuguese governments
saw no objection. ‘One would think that the Emperor had demands
enough for his men,’ wrote Wellington to Charles Stuart, ‘but
Mackenzie says that they have more men than they can support in
the field, which is not improbable. The admission of Russians into
the Peninsula, however, is quite a new feature of the war: and it is
absolutely necessary that the allied Governments should consent to
the measure[317].’ The correspondence with Cadiz and London ended
in the most tiresome and ridiculous fashion—the Spanish Regency
was at the moment in a state of diplomatic tension with Russia, on
some questions of precedence and courtesy. It answered in the most
downright fashion that the presence of Russian troops in Spain
would be neither helpful nor welcome. The British ambassador at
Cadiz was shocked at the language used, which would be most
offensive to the Tsar[318]. But the whole project suddenly collapsed on
news received from London. Count Lieven, the Russian
representative at the Court of St. James’s, declared that he had
never heard of the offer, that he was sure that no such scheme
would be approved by the Tsar, and that there was certainly no
Russian corps now available for service in the Mediterranean.
Admiral Greig had once communicated to him a scheme for a
Russian auxiliary force to be used in Italy—but this was a plan
completely out of date, when the whole Russian army was wanted
for Germany[319]. Wellington had therefore to explain to the Spanish
and Portuguese Governments that his proposals to them had been
made under a complete misapprehension: his amour-propre was
naturally hurt—Greig and Mackenzie had put him in an absurd
position.
Prince Lieven’s mention of Italy takes us to another of
Wellington’s worries. It has been mentioned in the preceding volume
that Lord William Bentinck, commanding the British Army in Sicily,
had already in 1812 been planning descents on Italy, where he
rightly thought the French military strength was low, after the
departure of the whole of the Viceroy’s contingent for the Russian
War, and of many of Murat’s Neapolitans also. So set had he been
on expeditions to Calabria or Tuscany, that he had made great
difficulties when ordered to send out the Alicante expedition to favour
Wellington’s Salamanca campaign[320]. The news of the Russian
disaster had filled Bentinck’s mind with new Italian schemes—the
conditions were even more favourable than in 1812. He was now
dreaming of invading Italy with all the men he could muster, and
proposed on February 24th to the British War Minister that he should
be allowed to withdraw all or some of the Anglo-Sicilian troops from
Alicante. He had also seen Admiral Greig, and put in a claim for the
hypothetical 15,000 Russians who had caused Wellington so much
trouble. Knowing how much importance the latter attached to the
Alicante Army, as the real nucleus of resistance to Suchet in Eastern
Spain, he had the grace to send copies of his February dispatch to
Freneda.
This was a most irritating interruption to Wellington’s
arrangements for the next campaign: the Alicante force was a
valuable piece in the great game which he was working out. To see it
taken off the board would disarrange all his plan. Accordingly he
made the strongest protest to Lord Bathurst against the Italian
expedition being permitted. To make any head in Italy, he said, at

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ERIN FRAHER (Co-Chair), University of North Carolina at Chapel Hill

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Global Forum Staff

This Proceedings of a Workshop was reviewed in draft form by

DAVID BENTON, National Council of State Boards of Nursing

Although the reviewers listed above provided many constructive

Enormous thanks goes to the workshop planning committee for

Acronyms and Abbreviations

2 Matching the Health Workforce to Population Needs

3 Understanding and Applying a Model for Financing Health

4 Reflections and Potential Next Steps for Building a Model

B Future Financing of Health Professional Education Workshop

C Speaker Biographical Sketches

ASPPH Association of Schools and Programs of Public Health

CODA Commission on Dental Accreditation

GAO U.S. Government Accountability Office

HCW health care workforce

IMF International Monetary Fund

NHS UK National Health Service

OECD Organisation for Economic Co-operation and

PHC primary health care

ROI return on investment

THEnet Training for Health Equity Network

UHC universal health coverage

WHO World Health Organization

The U.S. Government Accountability Office (GAO), the World

Nontraditional methods of learning for improving financial

These issues will be considered during the 2-day public

ORIENTATION TO THE WORKSHOP

Factors Influencing Health Professional

Workshop Goal and Objectives

Matching the Health

Key Messages Identified by Individual

TENSIONS AND CHALLENGES TO ADEQUATELY