Medical Workforce Training - Health Systems Facts

Graph comparing medical graduates per year, percent share of doctors who are foreign-trained, and the average annual tuition at a public medical school in several nations.

Health Workforce Training - Spreadsheet comparing several national health systems

“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
https://www.egms.de/static/en/journals/gms/2017-15/000256.shtml

“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].”

“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].”

“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.
https://www.cbo.gov/publication/55150

“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.
https://www.cbo.gov/publication/55150

“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.
https://www.who.int/hrh/resources/globstrathrh-2030/en/

“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
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5291995/

“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].”

“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
https://www.cambridge.org/core/journals/health-economics-policy-and-law/article/projecting-shortages-and-surpluses-of-doctors-and-nurses-in-the-oecd-what-looms-ahead/493055A944EF9EC181D8C4C2D3C3247E

Suggested Resources

World Health Organization: State of the World’s Nursing Report (2020)

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Page last updated June 4, 2020 by Doug McVay, Senior Policy Analyst.