In the tiny Italian enclave of San Marino, there is one nurse for every 100 people. In war-torn Somalia, there is one for every 5,000.

Startling geographical discrepancies have been revealed in a detailed study of global healthcare provision published today by the World Health Organisation.

America, which has 10 per cent the global burden of disease, spends more than 50 per cent of the world's health financing. Africa, afflicted by 24 per cent of world disease, spends less than 1 per cent.

At least 1.3 billion people lack access to the most basic healthcare, with the worst shortages in countries where it is needed most. The result, the study concludes, is a vicious circle with millions of people dying of preventable diseases.

The World Health Report 2006 says that 57 countries - 36 in sub-Saharan Africa - need more than four million additional doctors, nurses, midwives, managers and public health workers to prevent the collapse of their health services.

Chronic shortages are crippling attempts to introduce effective immunisation programmes for children and fight the spread of diseases such as HIV-Aids, malaria and tuberculosis. Efforts to improve maternal and child health care, and to tackle emerging threats such as avian flu, are also being hampered.

"The magnitude of the health workforce crisis in the world’s poorest countries cannot be overstated and requires an urgent, sustained and co-ordinated reponse from the international community," it warns.

The report focuses on the need to address the exodus of workers from the Third World to the West.

Just under a quarter of all doctors trained in sub-Saharan Africa are working among the ageing populations of industrialised countries, where wages are on average 15 times higher.

The report adds, however, that emigres are contributing to their native countries with billions of dollars flowing back home in the form of cash and training.

In some instances, countries with shortages have large numbers of health professionals but they are unemployed because of bureaucratic red tape, political interference and a lack of public money to pay their wages. "This produces a paradox of shortages in the midst of underutilised talent," the report says.

Countries with the biggest shortfalls include India; Indonesia; the Democratic Republic of Congo, Africa’s biggest nation; Kenya; Tanzania and most of West Africa.

Dr Lee Jong-wook, the WHO Director-General, said: "The global population is growing, but the number of health workers is stagnating or even falling in many of the places where they are needed most. Across the developing world, health workers face economic hardship, deteriorating infrastructure and social unrest. In many countries, the HIV/AIDS epidemic has also destroyed the health and lives of health workers."

The World Health Report sets out a ten-year plan to address the crisis. It says that the West has a duty to provide aid to the 57 countries to help to pay for better training and facilities. The cost will be huge: the UN has calculated that training costs for doctors, nurses and midwives were $2 billion dollars a year in India alone.

The report sets a target of these countries spending an extra $10 per person per year - up from $33 to $43 - on healthcare by 2026. "It is an ambitious but reasonable goal," the report concludes.

At a conference marking World Health Day where the report was launched Tim Evans, one of its authors, warned: "We’ll be in much bigger trouble 10, 15 years down the line. We need to anticipate and very little anticipation has been done so far."

Isaac Ziba, a trained nurse who now works at a hospital in Scotland, told reporters at the launch of the report that he left after working in his native Malawi for three years.

"I left because I need a living as a human being first and foremost and the environment I worked in was dissatisfying in many ways," he said. He said that 12 of the 47 students who graduated from his medical school class also left the country.

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