“One of the main policy levers that OECD countries can use to adjust the supply of health workers is to change their numerus clausus policies (the annual quotas) regarding the number of students admitted to medical, nursing and other health-related education programmes.
“Most OECD countries have increased considerably student intakes in medical and nursing education programmes over the past decade, in response to concerns about current or future shortages and in some cases to become less reliant on the immigration of foreign-trained doctors and nurses. In Finland, France, Netherlands and United Kingdom, most of the increase in medical student intakes occurred in the early 2000s with the number stabilising afterwards, whereas in Australia, Canada, New Zealand, Portugal and Sweden, the increase continued steadily throughout the period.
“Student admissions in nursing education have also expanded substantially in most OECD countries since 2000. In Australia, Ireland and the United States, admissions growth has been fairly rapid and steady throughout the period, also reflecting previous concerns about projected shortages. In the United States, student admissions in registered nurses (RN) education programmes doubled between 2001 and 2013 (rising from about 100,000 to 200,000 per year). This expansion in admissions in RN education programmes has increased so much that there are now concerns of an over-supply of new graduates. The most recent projections from the US Department of Health and Human Services in 2014 estimated that if student admission rates remain at their 2013 level, there might be an over-supply of more than 300,000 RNs by 2025.
“The number of students admitted in medical education programmes in the United States has also increased, but at a slower rate than in nursing. Between 2001 and 2013, student intakes in US medical schools grew by over 33%. However, the number of residency posts has not increased at the same pace, creating a bottleneck.
“In the United Kingdom, the rapid expansion of medical student intakes starting in the early 2000s was accompanied by a sharp reduction in the annual inflow of foreign-trained doctors from the peak reached in 2003 when health spending and the recruitment of doctors and other categories of health workers were growing very rapidly. The number of new graduates from nursing schools in the United Kingdom has also gone up over the past decade. This was accompanied by a sharp reduction in the inflow of foreign-trained nurses between 2004 and 2009. However, since then, the number of foreign-trained nurses has gone back up, driven mainly by the migration of nurses trained in other EU countries (e.g., Spain and Portugal) to meet unexpected demands for nurses. There are also large outflows of nurses trained in the United Kingdom towards Australia, Canada, New Zealand and the United States.”
Source: OECD (2016), Health Workforce Policies in OECD Countries: Right Jobs, Right Skills, Right Places, OECD Health Policy Studies, OECD Publishing, Paris. dx.doi.org/10.1787/9789264239517-en
“Out of 31 OECD countries for which information is available, 21 increased the number of students admitted in medical education programmes between 2007 and 2012. For the remaining ten, the number remained relatively stable. With regards to nursing education, a vast majority of countries (21 out of 32) have also increased the number of students admitted between 2007 and 2012, while nine countries have maintained the number more or less constant during that same period. Only Portugal and the Slovak Republic have reduced the number of students admitted in nursing programmes. While the United Kingdom reported that the number of students admitted in nursing had been fairly constant in the United Kingdom as a whole, the number decreased in England.
“Most countries reported to have increased student admissions for both medical and nursing programmes from 2007 and 2012, but there are some exceptions. In Italy and Poland, the intake of medical students increased, whereas the intake of nursing students remained constant. In Finland, Korea and Mexico, the opposite was reported, with an increase in nursing education intake, whereas admissions to medical education remained more or less stable.”
Source: OECD (2016), Health Workforce Policies in OECD Countries: Right Jobs, Right Skills, Right Places, OECD Health Policy Studies, OECD Publishing, Paris. dx.doi.org/10.1787/9789264239517-en
“In some countries, such as the United States, medical education is offered mainly as a graduate degree, following completion of a first bachelor degree in biology or other fields. In other countries, such as France, medical education comes in the form of an undergraduate degree, with students accessing medicine directly from secondary education. Some other countries offer a hybrid model of medical education, with possibilities to enter both at the undergraduate and/or graduate levels for eligible students. For instance, in the United Kingdom, while the majority of students still access medicine right from secondary school (undergraduate degree), since 2000, some universities accept students with background in life sciences, dentistry or biomedicine, into the third year (the start of a graduate degree). These additional entries into medical education programmes were designed to enlarge access to students who hold a bachelor in a relevant field.
“Once a student completes basic medical education, he/she typically has to take a final exam which might serve to validate his/her degree, rank them for their post-graduate training and, in some cases, also grant them with a medical license (often accompanied with some conditions regarding their scope of practice). The following step is usually some specialty training through some forms of internship or residency period. Each country offers various medical specialties of different lengths. Generally, training to become a Family Doctor/General Practitioner (GP) is one of the shortest specialties, averaging three years in many countries. Other specialisations, notably surgery, take longer. In the United States, residency programmes usually last on average three to eight years, but if a student decides to pursue a more advanced sub-specialty, the training can prolong up to eleven years. In some countries, an initial training of one to two years (normally in hospital) precedes any specialty training. For instance, in the United Kingdom, a two-year post-graduate training (called “foundation training”) was introduced right after medical school in 2005 (Medical Careers, 2014). During this training period, new graduates rotate, every 3 to 4 months, between different specialities. The first year leads to registration with the General Medical Council. The completion of the second year allows the trainee to apply for specialty training programmes (General Medical Council, 2014).”
Source: OECD (2016), Health Workforce Policies in OECD Countries: Right Jobs, Right Skills, Right Places, OECD Health Policy Studies, OECD Publishing, Paris. dx.doi.org/10.1787/9789264239517-en
“Across OECD countries, there are also several models for initial, specialised and advanced nursing education (Figure 3.A1.2). During the 1980s, with the developments in health services and increased complexity of care, in many OECD countries, nurse education shifted from hospital based training programmes to university based degrees. This led to a new era of nurse education, allowing nurses to not only access undergraduate, but also post-graduate level education. In Europe, over the last three decades, there have been two main phases of reform to harmonise nurse education. Firstly, by creating a unified European platform of nursing programmes and licencing, to improve the level of graduates, and allow mutual recognition across EU countries. Secondly, to integrate nursing programmes within higher education systems and have university based degrees (Spitzer and Perrenoud, 2006).
“Following their first university degree, nurses have numerous options for more advanced studies or specialisation. For example, in certain countries, nurses can opt for more advanced studies (e.g., a master’s degree) to become an Advanced Practice Nurse (APN) such as a Nurse Practitioner. In the United States, a range of master’s degrees are available to prepare students for an array of different positions as APNs such as NPs, Clinical Nurse Specialists, Clinical Nurse Leaders, among others. PhD programmes can be also pursued after a master’s degree and are usually more research oriented (Institute of Medicine, 2011).
“Registered nurses can also further enhance their professional knowledge and scope of practice by choosing a specialty programme. A wide variety of programmes may be available in each country. In the United Kingdom, four main tracks are predominant: clinical, management, education and research. For each one of these options, several career options exist depending on the level of education the student reaches. Whereas a postgraduate degree might allow for a career as a nurse consultant, a PhD would open the option to become a professor at University.”
Source: OECD (2016), Health Workforce Policies in OECD Countries: Right Jobs, Right Skills, Right Places, OECD Health Policy Studies, OECD Publishing, Paris. dx.doi.org/10.1787/9789264239517-en
“Entry into tertiary education often means costs for students and their families, both in terms of tuition fees and living expenses, although they may also receive financial support to help them afford it. Most national students entering tertiary programmes enrol at bachelor’s or equivalent level in OECD countries (see Indicator B4). Public institutions charge no tuition fees to national students in nearly one-third of countries, including Denmark, Finland, Greece, Norway, the Slovak Republic, Slovenia and Sweden (Figure C5.1). In a similar number of countries, tuition fees are moderate, with the average cost for students below USD 2,000. In the remaining countries, tuition fees range from about USD 2,600 to over USD 8,000 per year. They exceed USD 10,000 in England (United Kingdom), where the majority of students enrol in government-dependent private institutions (Figure C5.1).”
Source: OECD (2020), Education at a Glance 2020: OECD Indicators, OECD Publishing, Paris, https://doi.org/10.1787/69096873-en.
“Higher tertiary education after a bachelor’s degree leads to better labour-market outcomes. Graduates with a master’s or doctoral or equivalent degree have better employment opportunities and earnings prospects (see Indicator A4). However, despite the earnings advantage from completing a master’s programme or a doctorate, tuition fees in public institutions for full-time national students in these programmes are similar to those for bachelor’s programmes in the majority of OECD countries (Table C5.1). The additional expenses that master’s and doctoral students face are limited to the additional years of education and the foregone earnings due to the delayed entry into the labour market. In most countries where tuition is free of charge at bachelor’s level, there are also no fees at master’s and doctoral levels. In other countries, similar tuition fees are charged on average across the different levels of tertiary education, as in Austria, Canada, the Flemish Community of Belgium, Italy, Japan, the Netherlands, Portugal and Switzerland (Table C5.1).
“In contrast, tuition fees for master’s programmes in public institutions are about 30% higher than for bachelor’s programmes in Chile, France, Korea and the United States, while in Australia, the French Community of Belgium and Spain they are over 50% higher (Table C5.1). These higher fees may limit participation at this level, if they are not paired with financial support to students. In a few countries (e.g. Australia, Italy and Switzerland), public institutions charge lower fees for doctoral programmes than for bachelor’s and master’s programmes to promote enrolment in doctoral programmes and attract talent for research and innovation. In Australia, for example, the annual average tuition fees in public institutions for doctoral programmes are about 15 times lower than for bachelor’s programmes (less than USD 300 compared to about USD 5,000). In fact, very few national doctoral students are charged any fees in Australia (less than 5% of doctoral students in public institutions). However, public institutions in Chile, France, Korea, New Zealand and the United States charge higher tuition fees for doctoral programmes than for bachelor’s programmes (data for the United States refer to master’s and doctoral programmes combined) (Table C5.1).”
Source: OECD (2020), Education at a Glance 2020: OECD Indicators, OECD Publishing, Paris, https://doi.org/10.1787/69096873-en.
“As a somewhat arbitrary rule of thumb, countries with percentages of more than 10% of supply should be considered significant surpluses or shortages. For the countries with a projected doctor supply of over 200,000 in 2030, we project shortages for France (-55,458, -22.8%), Italy (-83,527, -31.7%), Japan (-48,861, -15.0%) and the United States (-219,677, -21.6%) and we project surpluses for Germany (56,372, 12.7%), Mexico (53,914, 11.6%), Spain (29,856, 13.1%) and the United Kingdom (16,309, 7%). These eight countries account for 71% of the total projected supply of the 32 OECD countries included in Table 3. Across all 32 countries, we project a shortage of 386,358 doctors (-8.5%) in 2030.”
Source: Scheffler, Richard M, and Daniel R Arnold. “Projecting shortages and surpluses of doctors and nurses in the OECD: what looms ahead.” Health economics, policy, and law vol. 14,2 (2019): 274-290. doi:10.1017/S174413311700055X
“There are two paths to gaining acceptance into a medical school in the United States. The more common and traditional method entails gaining acceptance into a 4-year university and completing a Bachelor’s degree while completing 2 years of pre-medical requirements. These requirements vary by school but most commonly include one year of biology with lab, one year of general chemistry, one year of organic chemistry with lab, and one year of physics. Some schools also require coursework in behavioral and social sciences, one year of writing/English, and up to one year of mathematics. Students must also take the MCAT as a standardized test with the purpose to assess one’s capacity for the rigors of medical school.
“Alternatively, high school students may enter a combined B.S./M.D. or B.A./M.D. program. These programs allow students to earn a Bachelor’s degree and then proceed directly into a medical program for a Doctor of Medicine (M.D.). One benefit to these programs is that students may forego the typical medical school admissions process that most pre-medical students undergo at the end of their undergraduate careers. Additionally, these programs are often in the form of accelerated 6- or 7-year programs (as opposed to the traditional 8) and most, but not all, relinquish the student from MCAT requirement.
“Application numbers to medical schools in the United States are at an all-time high and increasing every year. Most recently, 53,029 applicants applied in 2016 and 21,025 matriculated, yielding an acceptance rate of 39.6% [47]. The rate of growth in medical school positions has not matched the rate of demand, and therefore the last several years have demonstrated an average downward trend in acceptance rate with few exceptions. Studies have shown that scores on the MCAT have limited predictive validity for medical school performance and licensing exam measures [48]. With the understanding that objective measurements including test scores and grades are not sufficient to identify candidates who will go on to become competent and successful physicians, the medical school admissions process has moved toward a more holistic approach including increasing the weight of nonacademic data [44].”
Source: Zavlin D, Jubbal KT, Noé JG, Gansbacher B. A comparison of medical education in Germany and the United States: from applying to medical school to the beginnings of residency. GMS Ger Med Sci. 2017;15:Doc15. DOI: 10.3205/000256, URN: urn:nbn:de:0183-0002568
“The cost of medical school tuition in the United States has developed a reputation worldwide for being exceedingly expensive. Tuition, fees, and health insurance at public medical schools averages at $34,592 per year for residents and $58,668 for nonresidents, meaning those who are not from the same state as the school. Private medical schools cost an average of $55,534 per year for residents and $56,862 for nonresidents [59]. These figures do not include living expenses, which vary in each locale. A total of 76% of medical students graduate with educational debt [60]. Of these students with debt, the average for students graduating from public medical schools is $180,610 (median $180,000) and the average for students graduating from private schools is $203,201 (median $200,000) [60]. Additional premedical education debt, referring to undergraduate university studies, has most recently been estimated with average figures of $25,550 to $39,950 depending on college type [61]. The majority of tuition and living expenses are paid by family contribution or loans. Part-time employment is uncommon among medical students in the United States, and in many schools strictly forbidden. Few students are fortunate to receive significant scholarships to alleviate the financial burden of medical school. The significant debt of graduating medical students is considered the major burden of becoming a US physician. These costs translate to the fact that the United States operates the most expensive healthcare system in the world [7].”
Source: Zavlin D, Jubbal KT, Noé JG, Gansbacher B. A comparison of medical education in Germany and the United States: from applying to medical school to the beginnings of residency. GMS Ger Med Sci. 2017;15:Doc15. DOI: 10.3205/000256, URN: urn:nbn:de:0183-0002568
“A society that aims to create brilliant physicians requires a brilliant educational system. Even though Germany and the United States are both wealthy and highly industrialized countries providing outstanding healthcare of the most recent standards, engage in medical and scientific knowledge exchange, conduct research together [62], and develop modern guidelines for patient care, their approaches to training medical students are significantly different (Table 1).
“The first major discrepancy is the structure of the academic process between high school and graduating as medical doctor. If successful in the highly competitive application process to medical schools, German students enjoy the simplicity of an integrated 6-year program that allows them to focus completely on their studies, clinical rotations, or any research activities knowing that a medical degree is guaranteed if all credentials are successfully completed. On the other hand, the United States rather employs a two-stage process. American undergraduate students initially require a Bachelor’s degree that may or may not involve participation in classes unrelated to the medical field. Although certain pre-medical prerequisite courses are required to apply to medical school, these only account for 2 years of the typical 4 required for a Bachelor’s degree. Next, it is necessary to take the MCAT exam and once again go through the stress and financial burdens of the application and interview process to medical school. The second significant distinction in medical education is of monetary manner. Despite recurring public debates about the high levels of tuition costs in the United States, these fees have been steadily increasing in a manner that is exceeding inflation. Interestingly, this financial obstacle does not seem to impact the popularity of medical school programs since student applications remain high. Large tuition loans are typically paid back after residency when six-digit physician salaries are norm and taxes lower than in Germany [63].”
Source: Zavlin D, Jubbal KT, Noé JG, Gansbacher B. A comparison of medical education in Germany and the United States: from applying to medical school to the beginnings of residency. GMS Ger Med Sci. 2017;15:Doc15. DOI: 10.3205/000256, URN: urn:nbn:de:0183-0002568
“Another decision for policymakers is whether government support for graduate medical education and for hospitals that treat a high proportion of low-income patients would continue under a single-payer system, and if so, how those payments would be structured. For example, teaching hospitals could have higher payment rates or receive compensation for their teaching costs through direct payments outside the single-payer system. Similarly, hospitals that treat a large portion of low-income patients could receive additional government support.”
Source: Congressional Budget Office, Key Design Components and Considerations for Establishing a Single-Payer Health Care System. May 2019.
“In addition to the short-term effects discussed above, changes in provider payment rates under the single-payer system could have longer-term effects on the supply of providers. If the average provider payment rate under a single-payer system was significantly lower than it currently is, fewer people might decide to enter the medical profession in the future. The number of hospitals and other health care facilities might also decline as a result of closures, and there might be less investment in new and existing facilities. That decline could lead to a shortage of providers, longer wait times, and changes in the quality of care, especially if patient demand increased substantially because many previously uninsured people received coverage and if previously insured people received more generous benefits. How providers would respond to such changes in demand for their services is uncertain. To encourage the supply of providers in the longer term, the government could more heavily subsidize the cost of graduate medical education to encourage people to continue to enter medical professions.”
Source: Congressional Budget Office, Key Design Components and Considerations for Establishing a Single-Payer Health Care System. May 2019.
“Globally, investment in the health workforce is lower than is often assumed, (12) reducing the sustainability of the workforce and health systems. The chronic under-investment in education and training of health workers in some countries and the mismatch between education strategies in relation to health systems and population needs are resulting in continuous shortages. These are compounded by difficulties in deploying health workers to rural, remote and under served areas. Shortages and distribution challenges contribute to global labour mobility and the international recruitment of health workers from low resource settings. In some countries, in addition to major under-investment in education, particularly in underserved areas, imbalances between supply capacity and the market-based demand determined by fiscal space, and between demand and population needs, result in challenges in universal access to health workers within strengthened health systems, and even the paradox of health worker unemployment co-existing with major unmet health needs.”
Source: World Health Organization. (2016). Global strategy on human resources for health: workforce 2030.
“The global shortages projected for 2030 may not occur if labor productivity could be increased, for example, through better use of technology, improved skills development, and institutional reforms. A major challenge to the international community is to determine what kind of additional investments will be needed not only to increase the number of health workers in those countries facing health workforce shortages, but also to achieve greater productivity and efficiency with the limited number of available health workers and a more effective distribution and deployment of health workers both within and across countries.
“Opportunities exist to bend the trajectory of the number and types of health workers that are available to meet public health goals and the growing demand for health workers. Improvements in health worker productivity supported by technology-driven efficiency gains, changing the skills mix and other cost-savings approaches could potentially lead to fewer health workers needed to provide equivalent levels of health care services. On the other hand, advances in technology could also increase the scope and complexity of healthcare interventions, and may lead to even greater demand for more and higher skilled health workers.”
Source: Liu JX, Goryakin Y, Maeda A, Bruckner T, Scheffler R. Global Health Workforce Labor Market Projections for 2030 [published correction appears in Hum Resour Health. 2017 Feb 20;15(1):18]. Hum Resour Health. 2017;15(1):11. Published 2017 Feb 3. doi:10.1186/s12960-017-0187-2
“Traditional approaches to addressing human resource constraints in the health sector have focused on “needs-based” workforce planning, which estimates health workforce requirements based on a country’s disease burden profile and commensurate scale-up of education and training capacities to increase the supply of health workers to provide those services [9, 10]. In this approach, health workforce density has been found to be associated with decreases in maternal and infant mortality rates [2, 11], as well as in the total burden of disease as measured in disability-adjusted life years (DALYs) [12]. Using this approach, the World Health Organization (WHO) estimates that a health workforce density of around 4.45 health workers per 1000 population corresponds to the median level of health workforce density among countries that have achieved, or have come close to achieving, UHC [13]. Policy makers could then identify the production capacity and associated financing necessary to increase the stock of health workers to meet these health service requirements [4, 13].”
Source: Liu JX, Goryakin Y, Maeda A, Bruckner T, Scheffler R. Global Health Workforce Labor Market Projections for 2030 [published correction appears in Hum Resour Health. 2017 Feb 20;15(1):18]. Hum Resour Health. 2017;15(1):11. Published 2017 Feb 3. doi:10.1186/s12960-017-0187-2
“Our projections assume current trends continue into the future. Changes in the migration patterns of doctors and nurses could have a significant impact on future doctor and nurse surpluses and shortages (see e.g. Kopetsch, 2009; Aiken et al., 2004; Forcier et al., 2004; OECD, 2010; Gouda et al., 2015). In 2013–2014, 460,000 foreign-trained doctors and 570,000 foreign-trained nurses (accounting for 17% of all doctors and 6% of all nurses) were estimated to have been working in OECD countries (OECD, 2016). A recent report showed that the share of a country’s doctors that are foreign-trained varied widely across OECD countries in 2015 – from over 30% in Israel, New Zealand, Norway, Ireland and Australia to under 3% in the Czech Republic, Netherlands, Estonia, Poland and Turkey (OECD, 2015). For the five countries with a share of foreign-trained doctors above 30%, we project an average shortage of -3.6% of supply. For the five countries with shares below 3%, we project an average shortage of -18.4% of supply. Thus, our projections are consistent with the notion that countries can lessen or resolve future doctor shortages if they are willing and able to import foreign-trained doctors.
“However, relatively high current rates of doctor importation may not make countries immune to future doctor shortages. The United States, with 25.0% of its doctors being foreign-trained is well above the OECD average 17.3%, but we still project the United States to have considerable doctor shortages in 2030. In contrast, Germany is well below the OECD average with only 8.8% of its doctors being foreign-trained, but we project Germany to have a surplus of doctors in 2030. Germany is producing enough doctors domestically that it can retain its low rate of doctor importation while avoiding future doctor shortages.
“The share of foreign-trained nurses also varied considerably across OECD countries in 2015 – from over 10% in New Zealand, Switzerland, Australia, the United Kingdom and Israel to under 3% for 12 OECD countries, including France and Spain. The four countries above 10% foreign-trained that appear in Table 4 – Australia, Israel, Switzerland and the United Kingdom – are all projected to have sizable nursing shortages in 2030, so it appears that their relatively high importation of nurses is not going to be enough to keep them from future nursing shortages.”
Source: Scheffler, R., & Arnold, D. (2019). Projecting shortages and surpluses of doctors and nurses in the OECD: What looms ahead. Health Economics, Policy and Law,14(2), 274-290. doi:10.1017/S174413311700055X
Suggested Resources
World Health Organization: State of the World’s Nursing Report (2020)
Organization for Economic Cooperation and Development: Education at a Glance 2020: OECD Indicators
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