30 Countries Most in Need of Professional Nurses

One of the greatest dangers facing worldwide public health is the global nursing shortage that faces not only the Third World, but many major world powers as well. Nurses are the first line of defense against widespread epidemics, and as the people who treat patients directly and daily, they are the most key components of any health care system. Throughout the world, the World Health Organization is monitoring nations where there are not enough nurses, and sponsoring programs to recruit and educate nurses who can work to improve quality of life through basic healthcare.

Solving the Global Nursing Shortage

Professional nurses are taught to pay attention to details, but at the same time not lose sight of the big picture. Nursing shortages are often only part of social and cultural struggle worldwide, related to poverty, political instability, repressive regimes, religious intolerance, and racism. As technology, science, social media, and world travel transform our world into an ever smaller global village, a conscious awareness of the day-to-day reality in unstable nations is crucial for global understanding at both a human and professional level.

In the US, we tend to think of nursing education as an opportunity for personal betterment, professionally and financially, but nursing education has much wider impact. The choice of a specialization, for instance, is not just a matter of personal preference; it can be part of meeting a worldwide need. Some of the most crucial areas of speciality needed in the rest of the world are:

Even if you are not planning to dedicate your life to preserving health in some distant nation, there is much that you can do as a working nurse or nursing student. Every BSN program requires clinicals and nursing internships, and many programs include the opportunity to study abroad to meet those requirements. There are also numerous nursing scholarships that include global service.

Ranking Methodology

Countries are ordered from the highest shortage to the least. Finding statistics for a common year is a challenge, as is the reporting for nurses independently of other health workers, so sources for statistics may vary in their numbers. Because less developed countries have less recent data available, in order for commonality in reporting time to be relevant, the most recent WHO data is used regardless of year.

Although those statistics in numbers may not reflect current reality, the trends are still valid. Countries reporting more than 23 health workers (doctors, midwives, and nurses) per 10,000 population are not listed. World Health Organization (WHO) considers that ratio is the minimal number required to provide 80% coverage of basic health needs. The absence of any country on the list does not imply that they have obtained a minimal coverage. As a point of comparison, even with nearly 100 nurses per 10,000 population, the United States continues to report a nursing shortage.

Statistics for Nurse/Population ratio come from the WHO Global Health Observatory Data Repository.

1. Haiti

Image by Marcello Casal Jr/ABr , CC 3.0

As one of the poorest countries in the world, Haiti is also one of the most in need of professional nurses. Statistically Haiti has barely one percent of the nurses per population that the United States does. With a long history of internal political instability, as well as outside intervention, a prime location for natural disasters, especially hurricanes and earthquakes, a high population density lacking public health provision, and a lack of local industry, Haiti has not been able to provide advanced education for most of its citizens. Particularly since the devastating 2010 earthquake – which killed more than 200,000 people, including a full quarter of the nation’s civil servants – Haiti has struggled to regain even its previous level of quality of life.

Hurricane Matthew, in 2016, seemed set to finish what the 2010 earthquake started, including setting off a crippling cholera epidemic. Infrastructure for basic utilities, including electricity, potable water, and sanitary waste disposal is not available to most of the population. Communicable diseases from both food and water contamination are common. Numerous international aid organizations are options for short term nurses. French language facility and openness to learning Creole, the trade language, provides options for teaching and education in both formal and informal settings, but poverty often blocks the door to improved health even with awareness of better options.

Nurses Per 1000: 0.011

2. Chile

Located on the western side of the southern cone of South America, Chile has more economic and political potential than nearly any other nation on the continent. Chile has deep natural harbors which facilitate international trade, and because it is six months ahead, or behind, of the northern hemisphere, Chile can provide “in season” produce when it is least available and most expensive in the north. The northern desert region is one of the driest places in the world, and because of its altitude is a marvelous place for space exploration via land based instruments.The varied geography, flora and fauna, topography, including long coastlines and incredible mountains, make Chile a marvelous place for tourists. The region is also rich in mineral wealth. Political unrest lasted about 30 years from about 1960 until 1990, but since then Chile has been stable and prosperous.

With its economic prosperity in the last 30 years, Chile has benefits internally by making infrastructure a priority for its citizens.Public health is a priority and is funded via payroll deduction of 7%. Education is valued and is an option for all ages. There are both private and public universities available for students who seek a higher education. However, as recently as a decade and a half ago, the nurse/population ratio was a mere one-fourth of the WHO recommendation. Ironically, the disparity is caused in part because Chile’s strong educational opportunities mean that health care professionals have been lured away to careers with even higher incomes. Therefore, even though nearly half of Chileans consider health care the nation’s top priority, there are important disparities in access.

Nurses Per 1000: 0.145

3. Madagascar

Image by Saveoursmile (Hery Zo Rakotondramanana) – Flickr

Madagascar, once known as the Malagasy Republic, is an island nation off the east coast of Africa. Beginning with settlers from Borneo some 500 years BCE, Madagascar has a rich cultural heritage. It was not united as one kingdom until the early 1800s. Nearly a century later, French colonialism reigned for well over half a century. Madagascar did not become independent until 1960. Since then both constitutional elected leaders and interim military appointees have led the country; at least one experienced a military coup. Early in 2014 a reportedly fair election returned a constitutional government to power.

The limited infrastructure is a challenge to expansion and development and limits advancement of health care and education.Nearly all of Madagascar’s 22,000,000 people live on less than $2.00 (US) per day. Health care is very limited, but has improved with the use of childhood immunizations; still, access to care is still inadequate. While Christianity is identified as the religion of choice for about half of the population, traditional beliefs and practices still very common. In the vast majority, the people of Madagascar continue to trust in folk medicine over modern science. In response, organizations like the WHO are working with traditional healers to expand healthcare in rural regions. The ratio of nurses/population is similar to that of Costa Rica, but with a diverse population, and no central focus on health, many persons do not have basic healthcare provision.

Nurses Per 1000: 0.218

4. Ethiopia

Located in the so called horn of northeast Africa, Ethiopia has the highest population of any landlocked country in the world. It has the second highest population of all the countries in Africa. Both human history, with evidence of the earliest known presence of Homo sapiens, and a monarchical government dating back about 4000 years, make Ethiopia a treasure chest for history lovers. Unlike other African countries, Ethiopia was never conquered by any European powers and has maintained its status as an independent nation. Dozens of ethnic groups make it a multilingual nation with an equally rich variety of cultural and religious realities. Historically minority religions held to practices that raised concerns about human rights such as marriage by abduction.

The reported ratio of doctors per total population is extremely low even if one uses the highest reported number (2.6/100,000 population). Improper sanitation and contaminated water supplies make for a very high infant mortality rate, and high incidence of communicable disease. The nurse/population ratio is reportedly more critical than that of doctors, with about 2.5/10,000 population reported in 2007. Geographical variations make for a varied climate which can be a small measure of comfort for international nurses looking to contribute to the well-being of others. Because English is the language of instruction in secondary schools, English is widely spoken and understood, and that fact also makes it easier for foreign nurses to provide both nursing care and education for a better tomorrow for the persons and organizations they may serve.

Nurses Per 1000: 0.25

5. Central African Republic

The Central African Republic is located in the heart of Africa, far from any oceans. With a population of about 4,500,000, it is less densely populated than some of the other surrounding countries. Although inhabited for thousands of years, it was ruled as a French colony from the mid-1800s until 1960. In spite of abundant mineral wealth, including diamonds, gold, and uranium, as well as renewable resources in tillable land and hydroelectric power, the Central African Republic is among the 10 poorest countries in the world. Although now independent for over 50 years, the Central African Republic continues to be very unstable politically. Numerous governments have been overthrown violently; war and hostilities between parties and ethnic groups have been frequent. Geographically the land is either flat or rolling and parts are covered with forest. Both a dry and a rainy season provide seasonal variation, but generally the climate is tropical.

Health provision is very limited; and the ratio of nurses/population has actually decreased in the past ten years. However, because over 80% of the population identifies as Christian, there are numerous missions working in Central African Republic which may provide opportunities for nurses who have a working knowledge of French. As in other poor countries, the infrastructure does not readily permit communication or access throughout the country. Although education is officially required for elementary school age children, the illiteracy rate is about 50%. The most recent figures report about 2 nurses/10,000 population, but only 1 doctor/20,000 population. If one is able to confront the reality of conflict and also face the dire need in any one country, Central African Republic is one such place to make a difference.

Nurses Per 1000: 0.252

6. Bangladesh

Image byLucy Milmo/DFID, Wikimedia Commons

Just decades ago, Bangladesh as a country with incredible human suffering. Bordering India on its west, Bangladesh was formed as a separate country from India in 1947. Political unrest and a series of military coups led to the breakdown of basic services; and famine and poverty become wide spread. George Harrison’s 1971 Concert for Bangladesh, the first benefit concert, brought global awareness to Bangladesh’s problems. Since becoming a democracy in the early 1990’s, Bangladesh has stabilized significantly, although as one of the most densely populated countries in the world it still faces major challenges. With a growing economy based on exports of clothing and textiles, as well as sea food, agricultural products, and science and technology, Bangladesh has greater hope for the future than just a few years ago.

Despite Bangladesh’s encouraging rebound, health care provision is a low priority, and reportedly large numbers of persons trained as medical providers actually know very little about health care. Education is funded largely by the government, which lacks the funding and support for proper education; nearly 40 of the population is illiterate. The state of health of many Bengals is precarious, in large part due to the minimal attention paid to the provision of health care generally. The nurse/population ratio continues very low and is far from the minimal requirement as per WHO. Supportive care, as provided by community health workers, see photo above, and nurses are very much in short supply.

Nurses Per 1000: 0.267

7. Sierra Leone

Sierra Leone reached popular prominence in the US around the turn of the century, when its brutal civil war became international news. Because of its extensive natural resources – especially diamonds – Britain made Sierra Leone one of its colonies in mid 1700s, and the nation did not grant independence until about 1961. Political unrest and an 11-year long civil war against dictator Joseph Momoh further impeded development. The mercenary government of Charles Taylor, who overthrew Momoh, continued with atrocities and crimes against humanity. Mining is an important part of the economy, but the wealth generated by diamonds and other minerals is not distributed throughout the population; consequently about 70% of the population of 6,000,000 lives in poverty.

Along with several other West African countries with a coast line on the Atlantic Ocean, Sierra Leone suffers from significant health disparities. The nurse/population ratio has decreased in recent years and is currently less than one eighth of the minimal suggested by the World Health Organization. Although education is obligatory at the primary level, the lack of infrastructure makes enforcement very difficult. During the civil war large numbers of schools were destroyed, but there are three universities in Sierra Leone. As English is the official language, and the language of instruction, nurses are being recruited for jobs in the western English speaking countries. While possibly boosting the local economy by sending home dollars earned abroad, those absentee recruited nurses lead to the decimation of local health care provision. As might be expected from the severe nursing shortage, infant mortality is among the highest in the world. Communicable diseases abound, including HIV/AIDS and the Ebola virus. Potable water is limited. Sierra Leone is without a doubt a place where professional nurses can make a difference.

Nurses Per 1000: 0.319

8. Tanzania

image by Paul Shaffner

Tanzania in eastern Africa faces the Indian Ocean. Together with the island of Zanzibar, off the east coast of Africa, they form the United Republic of Tanzania, their official name. Mount Kilimanjaro, Africa’s highest mountain, is located in Tanzania, and although geographically in the tropics, Kilimanjaro is always snow-covered. European countries, including Portugal, Germany, and Britain, ruled the region since the early 1600s; Tanzania finally gained its independence from Britain in 1960. The first multiple party elections were held in 1995. Economically, Tanzania is a poor country on par with its neighbors, and bases its economy on agriculture. To a lesser degree industry, tourism, and mining also contribute. Over half of Tanzanians profess to be Christians, and about one third say they are Islamic in their faith. Linguistically Tanzania is very diverse with over 100 languages represented, but communication is facilitated as both English and Swahili are official languages.

Health care faces some serious barriers, both politically and economically. Infrastructure is still very limited; only one of five Tanzanians had access to electricity as recently as 2008. Although the population is about 45,000,000, nearly one half of those persons are under 15 years of age, contributing to a significant shortage of healthcare for children.The availability of potable water is limited to about half of the population, and even less have sanitary waste disposal. Communicable diseases, including HIV/AIDS are still too common. Fortunately, primary education is obligatory, and about three fourths of Tanzanians are literate, giving international observers hope for future developments. Health care workers, including nurses, are very much in short supply, but opportunities for international nurses are readily available.

Nurses Per 1000: 0.416

9. Ivory Coast

Although relatively small compared to the larger nations in Africa, Ivory Coast has a population of over 20 million inhabitants. It is located on the southern coast of the “hump” extending toward the west. Sometimes known by its French name of Côte d’Ivoire, for its last colonial power, Ivory Coast has been exploited for its natural resources for centuries, from the trading of precious metals and slaves by the Roman Empire, to Islamic influence and domination through the Middle Ages, to French conquest ending in 1960. Political instability followed independence, and unified leadership was not clearly defined until early this century. Politically power continues to reside primarily in the executive branch with French as a language that unifies the multiple language groups represented.

Health care varies widely in the Ivory Coast due to large disparities in wealth. Ivory Coast is populated by several ethnic groups, the largest of which comprises nearly half of the population. Income is based largely on agricultural production, especially cocoa beans and rubber, but Ivory Coast has a higher per capita income than most of its neighbors. Illiteracy is high, and even more so among women, as boys are much more apt to be schooled. With a multimillion population, there are only two universities in Ivory Coast. A decade ago life expectancy for both men and women was less than 50 years; the Infant mortality is also very high. Physicians number about one tenths of the number of nurses. The ratio of 6/10,000 has increased slightly in the past years, although the actual number has decreased, again probably due to migration for improved financial benefits in more developed countries.

Nurses Per 1000: 0.479

10. Uganda

Uganda borders on several of the countries noted earlier in this ranking. Like some of its neighbors, Uganda was also ruled as a British colony from the middle 1800s until the early 1960s. One legacy of colonial rule is the official use of English, although Swahili is also an official language. Severe political unrest was followed with military coups to place persons in power and attempts were made to maintain power through massive genocide; the most infamous was Idi Amin. Political discord continues, and there is wide-spread corruption. In an effort to maintain power both internal and external investment is very controlled. Natural beauty abounds, but severe human rights violations and rigid controls limit tourism and interest from abroad. Although the economy, based on agriculture and other exports, seems to be improving, poverty has not decreased for the population at large, and is a grim reality for millions.

Uganda’s health care system has severe inequalities, mirroring the inequalities in the society at large. Life expectancy is just over 50 years; infant mortality is high. Only one of three Ugandans are literate even though, in theory, education is obligatory and attempts to follow a British standard. However, costs that must be absorbed by parents make education a luxury for many. Unfortunately, the only public health concern showing significant improvement is the HIV/AIDS infection rate which has dropped significantly in the past three decades. Health care is still not an option for many rural Ugandans, and the nurse/population ration is less than a third of the WHO minimal suggestion.

Nurses Per 1000: 0.648

11. Costa Rica

Costa Rica is one of the most stable countries in Central America, or possibly even beyond there. A civil war about the time of World War II interrupted the stability, but since then it has been a firmly based democracy. Environmental issues are important for Costa Ricans. With coast lines on both the Caribbean as well as the Pacific Ocean, volcanic peaks that stretch over 12,000 ft. above sea level, and lakes and islands, it has justifiably become a tourist attraction with its beautiful flora and fauna in those settings. Infrastructure is lacking, considering Costa Rica’s robust tourist economy, but ecotourism has become a strong part of the economic sector, as is coffee production.

Statistically is it not clear why the ratio of nurses/population is still only a third of the minimal expectation. Most of the usual hallmarks of healthcare disparity – poverty, lack of education, repressive government, and political instability – are not significant issues. Employed persons have guaranteed health care provision and the population is generally very healthy; in fact, “medical tourism” is common because of the care provided, lower costs, and proximity to more developed countries. Education is free and obligatory at the primary and secondary level. Both private and public universities provide higher education. Life expectancy is higher than that of the United States, and one region is known for its centenarians. However, Costa Rica shares a significant shortage in health care professionals considering its economic strength.

Nurses Per 1000: 0.796

12. Rwanda

Image by Sarel Kromer, Wikimedia Commons

In most of the world, Rwanda is unfortunately known because of the horrors of its civil war, from 1990 to 1994. The Rawandan Civil War was marked by the Rawandan Genocide, in which the majority Hutu ethnic group murdered as many as 1 million minority Tutsi and Pygmy Batwa people. In addition, more than 2 million Rwandans fled as refugees. Naturally, the massive genocide affected all aspects of life in Rwanda, including the economy, which is largely based on agriculture. Surrounded by several much larger and established countries, Rwanda’s population is mainly rural and also young, numbering about 11,500,000. Childhood diseases and infant deaths are common.

There are positive developments in the decades since the Civil War, which bode well for healthcare. Tourism is on the rise, with mountain gorillas being a prime attraction, and though the economy remains unsteady, the elected government has made potable water a priority. The provision of safe water contributes incredibly to the well-being of persons, and especially to infants and children. Education is also a priority, and school attendance until the 9th grade is compulsory. However, as in other poorer countries, the lack of means with which to purchase supplies or school uniforms limits participation. There is provision for higher education, and English is the language of instruction. With a national health insurance covering 90% of the population, and increased spending for health, there is a marked decrease in the infant mortality. Nurse/population ratios have improved in the past ten years, but continue at only about one fourth of the minimal number suggested by the World Health Organization.

Nurses Per 1000: 0.832

13. Guatemala

Image by Chensiyuan, Wikimedia Commons

Guatemala, a name based in one of the original indigenous languages, is the closest Central American country to the United States. It is also the most populous country with about 14,000,000 inhabitants, and has about one nurse for every 1200 persons, i.e., less than a third of the minimum considered adequate. Civil wars, intervention from the United States, dictatorships, and other conflicts made Guatemala unstable for many years. More recently it has successfully elected democratic governments and is more politically stable. However, the economic growth is still limited, especially because of the rugged terrain throughout much of the country. Even though large scale farming is not possible, sustainable farming is and does contribute to the economy. Wealth is very unequally divided. Earthquakes and hurricanes have also devastated the country several times. But the ecological diversity also leads to tourism, as does the ethnic and cultural richness present in Guatemala.

For a number of reasons, basic health provision is very challenged, and the infant mortality rate is among the highest throughout Latin America. Non-western, traditional medicine continues to be in conflict at times with more modern practices. Nearly half of the population is of Mayan descent, and although Spanish is the official languages there are numerous other languages spoken throughout the country. In fact, there are areas where Spanish is not spoken at all; there are 21 languages used which have their roots in the Mayan language, creating barriers for healthcare and relief workers. Education is free, but supplies are not, so that although students may go to school they may not necessarily have the basic paper and writing materials they need. Persons who can be cultural brokers, and sensitive to alternate health provision, could help improve access to health care, particularly among the very young.

Nurses Per 1000: 0.864

14. Zambia

Located in central Africa, Zambia is one of the more stable countries in the region, and several years ago was named as one of the fastest-growing economies in the world. Although inhabited and settled for centuries, from the mid-1800s it was under British control until its independence in 1964. Zambia has struggled economically during its history, but recently has improved and exports (including hydroelectric power, mining, mineral, and especially agricultural products) are a major source of income. Nearly half of Zambia’s 14 million plus inhabitants live in urban areas. Although English is the official language, there are over 70 different ethnic groups, as well as Europeans, and Asians. However, employment opportunities are limited and create their own challenges; refugees from unstable and strife-ridden neighbors also add to the multicultural mix and create linguistic challenges for communication and economic growth.

Unfortunately, health provision has not been a priority and life expectancy is just over 50 years. There are numerous hospitals, including at least one teaching hospital. Based on the British system, educational efforts (with free education through primary school) have achieved an 80% literacy rate. Higher education, via universities and technical schools, are an option for those who can afford it. The combination of British education and diminished employment opportunities in Zambia have led to widespread brain drain in the healthcare system. At one point the nurse/population ratio came closer to the minimal suggestion of any countries considered in this ranking, but tragically, for Zambians, the most recent number reported by WHO (2010) was less than half of what it was only five years before: about 7/10,000. Undoubtedly that decrease is due to recruitment from more developed English speaking countries.

Nurses Per 1000: 0.886

15. Democratic Republic of the Congo

Perhaps none of the countries with a marked shortage of professional nurses better exemplifies the paradox of wealth and resources on the one hand, with ongoing need and failure to provide even fundamental needs of its population on the other, than the Democratic Republic of the Congo. Located in the heart of the African continent, and one of the most wealthy countries in the world in regard to natural resources, the DRC’s history of being exploited by external powers, and then in turn exploiting its own people, seems somehow closely related to its going tragedies. It has been administered by external powers, including Belgium; forced exploitation of natural resources by locals decimated the population, killing millions early in the 20th century. Local government politics and policies, along with greed and lack of leadership led to numerous name changes of both the country itself and major cities. The economy has not boomed despite incredible natural resources, including mineral and natural navigable waterways, probably due to corruption and greed of those in power.

Health provision is extremely deficient; the DRC has the second highest worldwide infant mortality rate. Wars within the country, displaced persons, lack of infrastructure and extreme poverty have taken the lives of nearly 5.5 million persons in the past 15 years. One index, ranking countries on human development, places it next to last out of 187 countries.Education is neither free nor obligatory. Disparity between the literacy rates of men and women is also demonstrated in the claim by a United Nations committee that women are exploited and do not have basic rights. With a lack of education, the DRC is unable to meet its need for healthcare professionals internally. Nurse/population ration was reported to be about 5/10,000 at the turn of the century; more recent figures show a significant decrease, probably less than one fifth of the minimal WHO suggestion.

Nurses Per 1000: 0.961

16. Bolivia

For years Bolivia, right in the heart of South America, has sought to regain its former connection to the Pacific Coast as a way of ending its landlocked status. Despite the fact that it has a rich cultural and economic history, as the heart of the Inca Empire, its mineral wealth not has not changed the status of ordinary persons, especially after economic restructuring in the 1990s privatized industries, mostly into the hands of foreign investors. Even more so than Paraguay, it has a rich indigenous population which continues to produce beautiful artisan works in a variety of media.

Political instability and a history of contested, illegitimate power have prevented Bolivia from progressing in the provision of health care, and although the country has been declared free of illiteracy, health care does not match education. Life expectancy is limited as is health care. An internet search for information regarding nurses and nursing care in Bolivia results in half a dozen or more “volunteer openings” for nurses ready to travel to Bolivia. Statistically the number of nurses in Bolivia has actually decreased in the past decade. Perhaps this is why international aid organizations are seeking to find volunteer nurses to provide care that otherwise would not be provided.

Nurses Per 1000: 1

17. Colombia

Image by Joao Carlos Medau, Wikimedia Commons

Located on the northwest “corner” of South America, adjacent to Panama in Central America, Colombia has a rich and also tragic history. For nearly 40 years a low-intensity internal conflict between the army and guerrilla forces, often considered to be related to illicit drug production, hampered growth and the well-being of Colombia’s population. Colombia is marvelously diverse in many ways, which contributes to a growing economy as internal conflict lessens, and political stability improves. Goods and services, agriculture and mining do their part in stability as well. Although nearly 100% of Colombians speak Spanish, there are over 101 languages recognized within the country including 65 Amerindian languages.

As Colombia’s economy has improved, health provision has been treated as a priority, and life expectancy reached 79 in 2012. This is amazing given that in 2000 the nurse/population ration was a meager 5.5/10,000. The most recent figures show a slight increase to 6.6/10,000.Education is a high priority at all levels; literacy rate is over 98%. Preschool through university is also included, and total spending is over 15% of the gross national product. Because of the quality of health care and proximity to higher priced countries, health tourism also attracts business.

Nurses Per 1000: 1.08

18. Indonesia

image by Yohanes Budiyanto, Wikimedia Commons

Unlike the many landlocked countries we have explored, Indonesia is a long chain of islands, about fifteen thousand, in fact. The Dutch influence and control began about 1600, until World War II ended the Dutch rule when Indonesia was occupied by Japan. During that time millions of persons died; within days of the end of the war, Indonesian survivors proclaimed the islands independent. Currently it is governed by a presidential system with power concentrated in the president, although there is a representative body as well. Because it lies in an area with numerous volcanoes there are advantages in the form of rich and fertile soil for agricultural purposes; moderate and stable temperatures provide an added benefit. Biodiversity abounds, providing ready tourist trade, while rapid population growth has led to a rapid growth in industry, capitalizing on cheap labor.

With a population of hundreds of millions, spread across thousands of islands, providing education and health services is a challenge. Twelve years of schooling are required of all citizens. Both public and private schools and universities are options; thankfully the concern about literacy has increased the rate to 90% in the past two decades. Health care provision is available at all levels, but the ratio of health workers/population is still far below the minimal suggested. However, as Indonesia’s infrastructure and economy improves, there are encouraging signs; since the mid-1990s, the ratio has almost doubled.

Nurses Per 1000: 1.3

19. Dominican Republic

Populated some eight centuries before Columbus landed there in 1492, the Dominican Republic is one of two island nations, sharing the island of Hispaniola with Haiti. With about 10,000,000 inhabitants, ten percent of whom live in the capital city, the Dominican Republic is hard pressed to provide a very high standard of living. Services are the economy’s largest provider. Income varies greatly, ranging from extreme wealth to extreme poverty. Since the same 2010 earthquake that decimated Haiti, and Hurricane Matthew, which caused widespread destruction to both Haiti and the DR, refugees from Haiti have contributed to overpopulation.

Healthcare has been slow to progress in the Dominican Republic due to decades of political instability, much of it the result of American interentionist policies. The influx of Haitian refugees has corresponded with a rise in Antihaitianismo, brutally racist policies and behaviors that have left Haitians and their descendants as a permanent underclass. Healthcare is also restricted by policies based on a fundamentalist Christian worldview, including strict anti-abortion laws and a growing HIV/AIDS epidemic. One national university offers degrees in allied health professions, including nursing. Statistically the number of nurses has increased in the past decade, but even the most recent statistics from World Health Organization report only a fraction of the minimal considered valid for basic health provision.

Nurses Per 1000: 1.33

20. Nicaragua

U.S. Navy photo by Mass Communication Specialist Seaman Apprentice Joshua Adam Nuzzo

Bordering the much more prosperous Costa Rica on the south, Nicaragua is without a doubt the poorest country in Central America. Although geographically a tropical country, Nicaragua’s exposure to both the Caribbean and Pacific Ocean leads to a biodiversity that makes Nicaragua a welcome spot for tourists. Ethnically it is also diverse; even the name reflects the name of an early indigenous leader. Although the population of nearly 6,000,000 persons is racially mixed (it includes nearly 10% of African descent, and even more of European descent), Nicaragua does not have a history of racial conflict. Politically it has been more stable recently, but historically dictatorships supported by the United States left it struggling for many years. A major earthquake in 1972 destroyed most of the capital city, but funds intended for reconstruction were appropriated by the dictator, so development was further delayed.

Health care, or more accurately, the lack of health care, continues to be a concern. Communicable diseases are on the rise, although immunization for childhood diseases is adequate. Maternal and perinatal deaths are too high, and the disparity of health care provision is a major concern for those responding. As recently as the year 2000 the number of nurses was less than one seventh of the minimal WHO requirement. However, after the establishment of democratic government, there are encouraging signs. Higher education is focused in the capital city, Managua, but literacy campaigns throughout the country following the overthrow of the dictatorship (when Nicaragua’s educational system was among the worst in Latin America) have been highly successful. With further education, improved health care generally follows. Aid organizations are present in Nicaragua and provide opportunities for nurses who want to respond to these needs.

Nurses Per 1000: 1.38

21. Peru

Image by Martin St-Amant, Wikimedia Commons

Bordering Chile to the south, Peru shares some of the vast desert as well as the powerful Andes Mountains. But even more than Chile, Peru was home to a marvelously preserved pre-Colombian culture and people. Although some of the most visited sites, like Machu Picchu, were only discovered about a century ago, most of the sites were known and pillaged by early Spanish explorers. Following independence from Spain, Peru enjoyed moments of prosperity and growth, but for many years, especially in the late 20th century, internal conflict and authoritarian governments stifled growth and prosperity. Unlike Chile, Peru has large land areas with tropical climate on the eastern side of the Andes in addition to mineral wealth, and sea food products, so exports are an important part of the economy.

Figures on health are hard to come by; the most recent figures show an improvement from Peru’s unstable years, but the ratio of nurses/population is still only a fraction of the WHO recommendation. Although recently Peru has had one of the fastest growing economies on a world wide scale, poverty continues to be a harsh reality, particularly in the mountain regions and among the indigenous people. There are large numbers of indigenous people in Peru with many different ethnic groups represented; Quechua speakers make up not quite 15% of the population of 3 million. Though significant disparities remain, universal care and outreach to rural regions has been increasing, according to the WHO.

Nurses Per 1000: 1.49

22. Paraguay

Although land-locked, Paraguay has the advantage of two major river systems that provide abundant water for energy, industry, and agriculture. For 35 years one of the most brutally oppressive military dictatorships in South America, under Alfredo Stroessner, severely limited education and human rights, with far-reaching effects that continued even after a democratic government began in 1993. Twelve years ago, Paraguay was only slightly less lacking in professional nurses than Haiti, but has the advantage of a growing economy and a very young population eager to become take advantage of educational opportunities. Although the most recent statistics are several years out of date, that number has now risen significantly.

Health care provision has improved as more and more professional health care workers are required to do internships in areas that are lacking medical care. Paraguay has two official languages: Spanish and Guarani. The latter is spoken much more frequently than Spanish in rural areas, but basic health care and education can be provided in Spanish, although less effectively. Other ethnic groups, including German, Korean, Japanese, and indigenous groups local to Paraguay provide opportunity for international nurses who want to be able to speak at one language when they arrive. The flora and fauna of Paraguay make it a beautiful country for both short term and longer engagement. Populated with warm and friendly people, it is a good place to make a difference professionally.

Nurses Per 1000: 1.5

23. Bhutan

Image by Arian Zwegers, Wikimedia Commons

Tucked between China and India, Bhutan has less than 750,000 inhabitants. According to some indicators it is the happiest nation in Asia. Although not a part of the British empire, it was influenced by India, and just a decade ago Bhutan became a constitutional monarchy. Bordering on the Himalayas, it has peaks that are well over 20,000 feet in attitude, but also has subtropical climate. Much of the country is mountainous with steep inclines, but there are large areas that are forested and filled with wildlife. Other areas are flatter and provide soil that is appropriate for agricultural production. Agricultural produce is a major source of income for the economy, as is hydroelectric power.

Health care provision in Bhutan is significantly limited, as evidenced by the limited life expectancy of only about 60 years. Bhutan has only one international airport, limiting foreign aid, and has very limited infrastructure, with no rails and few developed highways, due in part to the very rugged terrain. Educationally only about 60% of the population is literate, and there is only one national university, limiting the potential for health care professionals to be formally trained. In the 1990s, major ethnic strife forced more than 100,000 refugees (belonging to the minority Lhotshampa people) into camps; many refugees were later settled in western countries, but ethnic minorities are still persecuted by the Buddhist government. Over the past decade the nurse/population ratio has almost doubled, but even so is less than half of the recommended minimum suggested by the World Health Organization.

Nurses Per 1000: 1.51

24. Jamaica

Image by Ramey Logan, Wikimedia Commons

Generally this ranking has provided information on countries found among those most lacking professional nurses. However, there are several countries where the realities may be less harsh; Jamaica is one such country. Located in the Caribbean Sea southeast of Florida, and south of Cuba, Jamaica was once a British colony. Britain maintained it as a colony for over three hundred years until granting independence in 1962. Jamaica did not experience the political upheavals that other former British Colony nations experienced. Nearly three million people populate this island nation slightly smaller than the state of Connecticut. Although Jamaica has not experienced political unrest, the crime and violence rate is very high, especially in the capital city, Kingston.

That stability has contributed to Jamaica’s well-being and a nurse/population ratio that is more than double that of other countries with a history of British rule. The economy has both private and government sectors and exports provide most of the power to the economy by way of agriculture, mining, and industry. Education is free through secondary (high school) level, and there are numerous universities for those who can afford them. However, because of the legacy of the English language, Jamaica too has lost a significant number of nurses (nearly one third from 2003-2008) to more developed and higher paying countries, who recruit Jamaica’s English-speaking nurses.

Nurses Per 1000: 1.66

25. Nepal

Image by Kogo – market day at Namche Bazar (Khumbu, Nepal)

Home of Mount Everest, the highest peak in the world, Nepal has enjoyed a history of stable governments, but healthcare needs in Nepal are enormous. It has been a kingdom for over two hundred years, but only been a republic in the past ten years. Geographically Nepal has roughly three areas described as mountains, hills, and plains, and due to elevation variations has tropical to temperate climate. Economically Nepal has resources in agriculture, services, and industry with the first two occupying about 85% of the economy. Industry suffers from the lack of skilled laborers, so poverty among those unskilled continues to be reality, although less so than ten years ago. The awesome landscape and rich cultural diversity in way largely unknown to westerners make it an inviting tourist location.

Healthcare in Nepal has historically been limited due to its lack of infrastructure. While infrastructure is growing, especially with technological advances in communication, education is not readily an option, so that the overall literacy rate is still just over 60 percent. That number is not equally represented across genders as men are much more apt to be literate than women. Secondary, or high school, education has limited participation. Health provision has resulted in a decreased the mortality rate in children less than five years of age, although by international standards it is still very high. Indoor plumbing and potable water is not an option for over half of the population. Diseases due to lack of potable water are common, and often devastating for small children. Other diseases of poverty such as tuberculosis and leprosy are also common. The nurse/population ratio is one of the lowest considered here unless one includes midwives and other health care providers, but even so the ratio is barely 2 per 1000 people.

Nurses Per 1000: 2.04

26. Ecuador

Located precisely on the equator, Ecuador, literally “equator”, is the most western country in South America. As a democratic republic it has an unusually complex political history, with numerous other countries claiming portions of what was once Ecuador until well into the 20th century. Ecuador also includes the famous Galapagos Islands, which are noteworthy because of the unique species found there. In 2008 Ecuador became the first nation in the world to recognize the ecological rights, in part to protect the rich biodiversity found on the Galapagos Islands. Ecuador’s history is also rich and diverse; although the Incan culture and history is marvelously preserved, people who migrated from other regions in the Americas lived there prior to the Incas. Indigenous persons make up about 25% of the population.

A rising economy has lessened extreme poverty; currently oil is one of Ecuador’s main resources, along with agricultural products. Because of improvements, provision of adequate preventative and curative health care has been a successful priority in the past decade and a half, and is available for all persons, though indigenous people in the remote areas of the Andes suffer from limited access. The nurse/population ration has improved dramatically during this time, from less than 5/10,000 in about 1998 to 18/10,000 in 2008. Education has not kept up with health, and although it is formally required up to about the ninth grade level, supplies and transportation costs still limit access for the majority of the population. Very few students continue through high school, and even less attend at the university level. With a lack of educational resources, education for health care professionals remains limited, creating the potential for a reversal of improvements.

Nurses Per 1000: 2.08

27. India

Image by Kaustabh, Wikimedia Commons

Although a long way from being the largest country in the world, India has the second-largest population. Easily identified as a triangular-shaped area of land east of Africa, India has a population of over 1.2 billion persons. With its huge population, India currently has a rapidly-growing economy, industry, and major armed forces, including nuclear weapons, but it also has crime, corruption, poverty, and challenges in providing health and education. Even though English is not the official language (Hindi is), since independence from the British Empire in 1947 English continues to be widely used at many levels. However, large numbers of ethnic groups, languages, and cultures provide a challenge for mutual understanding, from politics to education and healthcare.

Despite its economic progress, healthcare remains a challenge in India. Like other English-speaking nations (including Jamaica and Ethiopia, above), education and health are based on the British system, but there are severe shortages in both areas. As in other countries which use English professionally, Indian nurses are recruited to work in more developed countries for a better wage, creating a gap in trained nurses. Though the population has been growing steadily, between 2001 and 2004, the number of professional nurses dropped by more than a third. Since then the ratio has improved and most recently was about 17/10,000–not the desired number but much closer than most of the countries in this ranking.

Nurses Per 1000: 2.09

28. Argentina

Argentina, which forms half of the southern “cone” of South America, is easily “discovered” geographically. With a rich and diverse population, on a larger than first appears land mass, (the eight largest country in the world), Argentina has more roots in Europe than many Latin American countries. A turbulent history of colonial exploitation, internal conflicts, and military coups, with resultant human rights violations and strict controls, have kept the nation economically unstable. Only in the past two decades has Argentina once again become strong economically and been able to respond to internal needs for infrastructure, health, and education. With an incredible variety of geographic features, not to mention multiple climate zones, Argentina has options that few smaller countries enjoy. About three-fourths of the population self-identifies as Catholic; current Pope, the first from Latin America, is from Argentina, a fact not lost to his followers there.

Health care in Argentina has improved dramatically in the last two decades, alongside Argentina’s economy. Agricultural and mineral resources, plus growing industrial strength provide the means for education and a highly literate population with science and technology thriving as well. Education is available at all levels, including the university level which has a large number of public options. Both private and public health care systems have reduced infant mortality rates very significantly in the past half century. However, the most recent figures, from a decade ago, report a nurse/population ratio of about half of what it was when growth was not happening. Migration to more developed countries offering higher salaries is often cited as one of the principle causes of the nursing shortage, and Argentina is not exempt from that reality.

Nurses Per 1000: 4.21

29. Liberia

In mid-2014 Liberia became one of the better known countries in western Africa, a fact that may be good news for truly conscientious and altruistic nurses. As one of the countries experiencing outbreaks of the Ebola virus, with English as the official language, it provides a unique opportunity to use the very best of universal precautions for the spread of disease, and theoretically be safe while caring for persons for whom death seems inevitable. Liberia has the unique history among African nations of being colonized by freed North American slaves who returned to their ancestral continent. However, political instability began as recently as thirty years ago as successive civil wars killed hundreds of thousands of persons.

Health care is limited in Liberia, due especially to the destruction of nearly all health care facilities during civil wars. Agriculture is the foundation of Liberia’s economy, but this was limited until recently; consequently Liberia is one of the poorest countries in the world. Just over 60% of the population is literate; education is not always free and is poorly regulated, though there are several private and public universities. Life expectancy is limited; communicable diseases, including HIV/AIDS, are common. Food shortages contribute to malnutrition and decreased resistance to disease. Figures vary but some reports cite less than a tenth of the minimal required health workers. The challenges to health and a longer life are numerous. Fortunately, there are international aid organizations who are eager to recruit persons willing to provide long and short term engagement in the health and well-being of Liberians.

Nurses Per 1000: 4.56

30. Brazil

Image by Chensiyuan, Wikimedia Commons

As the largest country in Latin America, and the fifth largest in the world, with a population of over 200,000,000 Brazil is perhaps best known for its amazing soccer (football) players. But long before soccer players ruled, large and autonomous indigenous tribes also populated what is now Brazil. Portugal laid claim to Brazil for over 300 years, before independence was granted in the mid-1800s. Portuguese is the official language for all purposes of government, education, and trade, but there are believed to be over 65 tribal groups still not contacted, and nearly half of the population self-identifies as being of mixed race. Because of its enormous size, Brazil is incredibly diverse as well in climate, geography, economy, tourism, and the provision of infrastructure. Some regions of the country are very modern, and huge cities sprawl over large areas of land; others have barely changed in the past century. Well over two-thirds of the population lives in urban areas.

Science and technology seem in many ways to have made Brazil a highly developed nation, but a number of factors, including political instability and corruption, have limited Brazil’s advancement in health care. There is a government directed public health system, but infant and maternal mortality continues to be an issue. The nurse/population ratio has not improved significantly in the past decade and still hovers at approximately one fourth of the minimal WHO suggested ratio. Efforts to make nursing a higher priority and more professional have met numerous challenges, including governmental resistance. Because of the high concentration of urban dwellers, rural areas are often not a priority either in education or health provision. By law, individual states are responsible for education, and so highly developed urban areas report a literacy rate of about 90%, while rural and impoverished areas indicate less than 20% are literate.

Nurses Per 1000: 7.44