HCA 542 Journal
This is a 5 week reflective journal, worth a total of 50 points, 10 points per entry.
For five weeks, students are required to document and reflect on human resource issues encountered in his/her workplace. These can be personal experiences, observations or just HR functions that you would like to reflect on. In addition, this journal can be used to elaborate on topics discussed in the course, assignments or material covered in the text for learning purposes. If the student is not currently employed, an article specific to the current week’s chapter topic should be researched and discussed for that week’s entry.
Final grading of your journal will include the following:
Maintain confidentiality in all entries. Do not identify place of employment or employees.
0 – 20 points: Student provides detailed documentation (average of 3/4 to 1 page) of human resources reflections, experiences and learning for all 5 weeks of journal.
0 – 10 points: Entries are typically correct in grammar and format with minimal spelling errors. Information flows in a manner that makes sense and is easy to read and understand.
0 – 20 points: Entries vary each week, exploring new topics and ideas. Student shows learning and reflection of new ideas and application of materials.
Page 1 of 2
HEALTHCARE WORKFORCE PLANNING
Thomas C. Ricketts, III, PhD
Learning Objective
s
CHAPTER
2
27
Learning Objectives
After completing this chapter, the reader should be able to
• trace the history of human resources for health and workforce planning;
• learn why and when workforce planning is undertaken;
• briefly describe the five major methods used in workforce planning;
• understand the key concepts of benchmarking, adjusted needs, and
demand as they apply to workforce planning;
• develop a simple estimate of the future supply of a profession for
a
population; and
• interpret the results of workforce planning reports as they relate to
individual healthcare organizations and delivery systems.
Introduction
Most of this book views human resources management (HRM) from the per-
spective of the healthcare organization. Chapters focus on such topics as job
design, recruitment and retention, and evaluation of individual performance.
However, organizations are also affected by the larger external environment
in which they are situated. In HRM, broad workforce policy and labor mar-
ket factors, which are external aspects, affect an organization’s ability to attract
and retain employees. An organization may have a theoretically sound recruit-
ment program for nurses, but if sufficient numbers of nurses are not being trained
in the national healthcare system, the program will likely prove unsuccessful.
This chapter’s focus is unique among the chapters in this book in
that it addresses workforce planning for communities, regions, states,
countries, and other jurisdictions. It devotes attention to the healthcare
workforce needs throughout society rather than the needs of a particular
organization.
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Human resources for health (HRH) workforce planning deals with
questions, including the following:
• How do we determine the number of surgeons needed in a particular
geographic area?
• What factors help us to best anticipate future supply and need for various
types of healthcare workers?
• What methods are used to project future workforce needs? What are the
strengths and weaknesses of different approaches, and how may they be
most effectively applied?
This chapter, therefore, takes a macro-level perspective on the healthcare
workforce and examines concepts and methodologies that are useful in pro-
jecting workforce requirements for communities and larger regions. Much of
the remainder of this book focuses on internal strategies for managing human
resources, which we can view as micro-level approaches, and addresses work-
force concerns from the perspective of a single organization.
Workforce planning is the assessment of needs for human resources. This
process can be very formal and complex or depend on “back-of-the-envelope”
estimates and can be applied to small organizations or practices as well as to
national and international healthcare delivery systems. Workforce planning fits
in with overall health systems planning and human resources development
and management. One conceptualization sees workforce planning as one of
three steps in workforce development (De Geyndt 2000):
1. Planning is the quantity concern.
2. Training is the quality concern.
3. Managing is the performance and output concern.
The Australian Medical Workforce Advisory Committee (2003) de-
scribes workforce planning succinctly: “ensuring that the right practitioners are
in the right place at the right time with the right skills.” However, the consen-
sus remains that workforce planning is “not an exact science” (Fried 1997).
Workforce planning is used to support decision making and policy de-
velopment for a wide range of concerns. For healthcare organizations to meet
their clinical and operating goals and objectives, they must effectively deploy
and support workers of all kinds. Doing so requires that the numbers and
types of workers match the needs of the patients, regulators, and payers who
make up the functional environment of the healthcare organization. For state,
provincial, and regional or national systems, policymakers also require infor-
mation from planning processes that include workforce projections and assess-
ments. Functionally, workforce planning does several things:
• Interprets tasks and roles
• Establishes education and training needs
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• Explains the dynamics of the workforce
• Describes and disseminates information about workforce and workplace
change
• Defines and identifies shortages and surpluses
The History of Healthcare Workforce Planning
HRH planning dates back to the origins of organized medicine and health-
care. Military planners recognized the need to provide adequate numbers of
caregivers for wounded and ill soldiers, and very rough assessments of the
requirements for qualified medical workers were part of the preparation for
military campaigns. The healthcare system in the Soviet Union, and later in
socialized nations, made use of systemwide planning (which includes an es-
timate of the numbers and types of workers) in structuring healthcare. As
European democracies moved toward national healthcare insurance sys-
tems, they recognized the need to balance their policies for training and
preparing healthcare workers with the anticipated needs of the covered pop-
ulations. Given the importance of human resources to healthcare systems
and the examples of planning that were in existence, it was still possible for
an expert group to observe that “only very recently has there been more of
a substantive debate about this issue internationally” (Dubois, McKee, and
Nolte 2006). While HRH planning has a fairly rich history within individ-
ual nations and among international bodies like the United Nations, it has
received little reflection in most other countries. The United States offers
an exception.
Daniel Fox (1996) describes healthcare workforce policy in the
United States as “contentious and uncertain” and characterizes its history as
a process that moved from “piety, to platitudes, to pork.” His observations
apply mostly to the ongoing debate over whether the government should di-
rectly support the education and preparation of physicians, or indirect
ly
through some levy on social insurance, or not at all. Fox tracked the history
of policies that were discussed and applied over time to support medical ed-
ucation. His analysis pertains to the development of policy that depends on
workforce planning, but he did not speak specifically of that development
process.
Fox’s observations provide a useful context for understanding why we
would or would not plan for a healthcare workforce in the United States.
These reasons have implications for whether planning should be supported.
By calling the initial stage of workforce policymaking the result of “pious”
thinking, Fox implies that policymakers knew exactly the “right thing to do”
and needed no or little specific guidance or planning to assist them. The sub-
sequent dependence on “platitudes” about the reality of need and supply of
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physicians and nurses was made by using “accepted wisdom,” which again
meant that there was little need for either planning or research. The culmi-
nation of the policy stream with “pork” meant that resources were distrib-
uted according to political power with little regard for the “facts”—again, a
situation that does not require the development of information and specif
ic
planning.
Healthcare workforce policy has traditionally been driven by a percep-
tion of a shortage of one or more of the healthcare professions. The history
of concern over shortages may have started with physicians, but nurses were
also considered a special part of the healthcare workforce and were subject to
policy attention. The Nurse Training Act of 1941 attempted to expand nurs-
ing schools during wartime to provide nurses for the military. An apparent
shortage of nurses in the late 1950s generated the first federal legislation to
support training of healthcare professionals for the “market,” not for some
specific federal role. Subsidies for nursing education and public health trainee-
ships were included in the Health Amendments Act of 1956, beginning an in-
cremental expansion of federal government support for healthcare workforce
training.
What followed were a series of healthcare professions laws that en-
couraged the creation of training programs, supported faculty, expanded
schools, or provided special aid for programs to redistribute the workforce.
The Health Professions Educational Assistance Act of 1963 (P.L. 88-129)
provided construction money for healthcare professions schools—funds tied
to increased enrollment requirements to assist with the school’s operating
expenses as well as loans and scholarship programs. The Act authorized sup-
port to medical schools for the first time and firmly established the presence
of the federal government in health-related educational institutions. This
was followed by an almost annual succession of laws that added support for
nurses, created loan-repayment plans, and paid for construction. In 1970,
the National Health Service Corps was created, which put the federal gov-
ernment in a role as a direct provider of healthcare professional service for
the general population.
The precedent had been set for federal involvement in workforce pol-
icy in 1956, but early in the twentieth century many states took on health-
care professions education and regulation as an extension of their responsi-
bility for public education and their implied “police powers” to protect the
health, safety, and welfare of their citizens. Assuming a combination of power
over both education and entry into the healthcare professions seems to sug-
gest that the conditions were ripe for some form of planning on the part of
the states that were investing substantial resources in medical and other
health professions schools and that had ready policy levers to control the sup-
ply of practitioners. However, the politics of the healthcare professions were
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clearly dominated by the professions themselves, and the dominant culture
was to support the market for a highly paid elite physician workforce assisted
by less-well-paid nurses and other caregivers (Starr 1982). According to
Weissert and Silberman (1998), not until the 1990s did the states begin to
“send a message that the medical schools have a responsibility to the state
and its citizens.” For some reason, the states were not overly concerned with
healthcare workforce supply and needs until the beginning of the twenty-first
century.
Workforce planning can be considered a subtopic in the general area of
HRH planning, but the two do not necessarily share a common history, and
important differences exist in the way they are approached. Planning is usu-
ally initiated when a perception exists that limited resources are available to
meet all possible needs and that the market will not adequately distribute the
available benefits.
The Rationale for Healthcare Workforce Planning
History tells us that policy and political pressures are generated when either
the market or the public signals a shortage of some type of basic good or serv-
ice. In the case of healthcare workforce, the shortage is of healing practition-
ers and their supporting trades and professions. The case for formal planning,
however, is often made in a more abstract and value-free context. Advocates
for workforce planning sometimes appeal to a need for “rational policymak-
ing,” but often the stimulus for formal action is when people claim that they
cannot get what they want, need, or deserve.
In the United States today, the perception of a nursing shortage and
the concern over a potential physician shortage are stimulating the de-
mand for workforce planning. In Canada and the United Kingdom, both
of which provide national healthcare coverage, queues for certain types of
care are long, drawing attention to the need for workforce planning. The
World Health Organization (2000, 2006) recognizes that HRH planning
has to be able to respond to changes in technology and global patterns of
migration in both population and profession. The drivers of HRH plan-
ning have expanded to include the workforce’s adaptation to technology
as well as the match of needs to supply. Figure 2.1 describes an analytical
framework for HRH planning that considers the emerging concerns over
global markets; migration; and changes in technology, institutions, and
populations. The figure emphasizes that the healthcare system is embed-
ded in a complex web of very strong external forces that shape the inputs
to the system, including the human resources necessary for the system to
function.
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Overview of Workforce Planning Methodologies
Five basic strategies are used in workforce planning: (1) population-based
estimating, (2) benchmarking, (3) needs-based assessment, (4) demand-based
assessment, and (5) training-output estimating. Each approach has its strengths
and weaknesses, depending on the goal of the planning exercise and the con-
text in which it will be applied. These methods may be used separately or in
combination, depending on the system at which the planning is targeted as
well as the specific policy questions posed during planning.
For national health systems, population-based estimating combined with
training-output estimating may be more applicable than the other methods. The
goal of planning in such systems may be to balance investments in training with
the healthcare needs of the overall population. For individual organizations,
benchmarking with peer institutions may provide useful information on how to
staff a hospital or clinic to achieve productivity. Demand-based assessment can al-
low managers to anticipate the effects of changes in requirements for staff after in-
creased marketing efforts or proactive modifications to product mix (Schnelle et
al. 2004). Needs-based assessment may be appropriate as systems and agencies try
to cope with changes in disease prevalence or the availability of new technologies.
32 H u m a n R e s o u r c e s i n H e a l t h c a r e
Demographic
Transition
Technological
Innovation
Organizational Reform
Institutional
Change
Global
Trade
Human Resources
Work Outcomes
Health System
Work Content Workplace
FIGURE 2.1
The Contexts
for Planning in
HRH
Workforce
Planning
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Population-Based Estimating
This method rests on presumed appropriate or normative ratios of personnel
and professionals to population. These ratios are not always generated from
epidemiological analysis or careful study of productivity and utilization, but
they often come from rules of thumb or from the current state of balance of
practitioners to population. In the United States, several proposals for the
most appropriate ratio of physicians to population have been based on obser-
vations of current and past ratios. For example, in the United States, the
Health Professional Shortage Area criterion views a ratio of 1 full-time equiv-
alent primary care physician for every 3,500 people as an indicator of a severe
level of need. A ratio of 1 physician to 3,000 people accompanied by elevated
population-risk indicators, such as high infant mortality and a high proportion
of people older than 65 years in a “rational service” area, also signals high
need, making the area or population eligible for shortage designation.
In a description of the origins of the Health Professional Shortage Area
(formerly Health Manpower Shortage Area) criterion, a federal report sug-
gested that the 1:3,500 ratio was selected because it was 1.5 times the mean
population-to-primary-care-physician ratio by county in 1974 and because it
qualifies a quarter of all counties with the worst ratios (Bureau of Health Man-
power 1977). That report indicated that the ratio of 1:2,500 was selected as
a measure of relative adequacy, being close to the median ratio for all U.S.
counties in 1974.
Many ratios have been suggested as indicative of adequate supply. Fig-
ure 2.2 summarizes 16 such “ideal” or “adequate” ratios. The ratios are drawn
from work by David Kindig (1994) and the Council on Graduate Medical Ed-
ucation (1996, 1999). The wide variation in ratios points to the weaknesses
inherent in population-based approaches. Variability can be the result of dif-
ferences in assumptions concerning the productivity of practitioners, the
needs for services in the population, and even miscalculations caused by poor
data in surveys and practice lists. Nevertheless, analysts and planners persist in
using ratios as standard indicators of desired staffing or as guides to their stud-
ies of professional supply.
Benchmarking
The benchmarking method takes into consideration existing ratios but adds a
test of efficiency to the analysis. The most prominent example focuses on the
physician workforce in the United States, where regional, population-based ra-
tios have been estimated and compared to organizational ratios (Schroeder
1996; Goodman et al. 1996). In this case, regional ratios for hospital-referral
areas generated for the Dartmouth Atlas of Health Care were compared to the
ratio in a large managed care system and selected market-area ratios where
there was intense or little managed care penetration. This approach to setting
national standards is much more controversial than its use for organizations
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(Malone 1997; Wholey, Burns, and Lavizzo-Mourey 1998). The ratios used in
the Goodman analysis included an adjusted HMO (health maintenance organ-
ization) staffing ratio (1:1,908) and the actual generalist ratio for the Wichita
(1:1,527) and Minneapolis (1:1,316) hospital-referral regions (see Figure 2.2).
Across the United States, using the hospital-referral regions to calculate
denominators, 96 percent of the population lived in areas with more general-
ist physicians than the HMO benchmark, 60 percent lived in areas that ex-
ceeded the Wichita standard, and 27 percent lived in areas that exceeded the
Minneapolis standard.
Advocates of benchmarking view these ratios as achievable, optimal ra-
tios and accept the implication that these ratios describe the most efficient
supply of practitioners. Benchmarking has become a part of the workforce-
analysis process, and the influence of the Dartmouth Atlas of Health Care in
guiding policy debate may make this approach more important. However,
there has been little acceptance of specific standards for setting policy targets
or for setting standards for underservice. The development of a revised stan-
dard for underservice for primary medical care has been under discussion by
the federal government since 1998 when a formal proposal was published but
withdrawn (Ricketts et al. 2007).
Needs-Based Assessment
Perhaps the most obvious method of determining how many healthcare pro-
fessionals should be supported in a system or an organization is to match the
consensus healthcare needs of a population or client base with their biologi-
cal need for care. Unfortunately, healthcare need is difficult to determine and
is subject to much variation. The substantial differences in physician opinions
over the indicators and conditions that signal need for various procedures—
such as carotid endarterectomy and coronary bypass graft operations, among
other costly and specialized interventions—have been well documented (Birk-
meyer et al. 1998; Wennberg et al. 1998). That variation has been persistent,
and even concerted efforts to develop consensus on the need for specialist care
have not been altogether successful (Fink et al. 1984). Those consensus meth-
ods, however, can be applied to more localized situations, and useful guidance
can be developed to determine how many individuals in a population are likely
to require selected services.
The consensus process for needs-based assessment is iterative, where
lists of indicators, signs, and conditions are presented in various combina-
tions and where “expert” clinicians are asked to determine if these combi-
nations are high-, medium-, or low-level reasons for hospitalization, for
conducting a specific procedure, for course of therapy, or for prescribing a
specific medication. The expert panel members rate these combinations, dis-
cuss the results, and re-rate them. These steps usually result in a mix of
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35C h a p t e r 2 : H e a l t h c a r e W o r k f o r c e P l a n n i n g
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combinations—strong agreement on a particular care pathway is achieved,
but agreement on other situations is not as high. However, the area of agree-
ment is usually sufficiently large to allow for estimation of the total burden
of care that certain groups of people are likely to require.
For national or other large populations, analysts can combine sepa-
rate classes of diseases and their associated estimates of care to develop pro-
jections of staffing requirements. This was the approach taken by the Grad-
uate Medical Education National Advisory Committee (1980) when it
developed national projections of need and supply of physicians and primary
care practitioners. That process was called “adjusted needs-based approach”
to workforce planning, and it has been used since its development for spe-
cialty-specific estimates of requirements (Elisha, Levinson, and Grinshpoon
2004). For very specific specialties, the task of determining even supply is
very difficult: “The actual number of FTE [full-time equivalent] neurosur-
geons in practice is more difficult to determine, because the number is con-
stantly changing as a result of death, retirement, modification of practice
habits and mix of clinical practice versus other professional activities” (Popp
and Toselli 1996).
The use of needs-based assessment to plan for staffing is supported in
some sectors of the healthcare system by more carefully structured studies. An
example includes the development of appropriate ratios of dental care practi-
tioners (DeFriese and Barker 1982). Practical applications in healthcare or-
ganizations and bounded delivery systems require a focus on a particular type
of need related to a specific type of organizational form—for example, the
need in relation to staffing for outpatient mental health clinics that are man-
aged centrally and that are located in areas where few alternative sources of
this type of care exist (Elisha, Levinson, and Grinshpoon 2004).
Demand-Based Assessment
This workforce planning method is explicitly economic in nature and is based
largely on past patterns of service utilization. Demand is considered to be
somewhat independent of need for care in that some individuals may seek care
when they are not ill, because they either misread their symptoms or desire to
be treated regardless of medical need. In practice, need and demand are con-
sidered very closely tied. In an economic sense, demand is equal to utiliza-
tion—what is consumed is what is demanded; that is, there is a balance in sup-
ply and demand in the market that is regulated by the price of the goods and
services that are consumed. However, often the case is that demand and sup-
ply are not in balance in a sector such as healthcare because prices are not eas-
ily determined by either the purchaser or the supplier. Still, utilization can be
a strong indicator of demand in a system in which the few barriers to care are
caused by access restrictions. An open argument in the United States is
whether or not the government restricts access by market rationing—a system
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that is opposite the explicit budget-rationing system in countries such as the
United Kingdom and Canada.
A good example of the use of demand-based assessment is provided in
studies commissioned by the American Medical Association (Marder et al.
1988). Any mathematical model that projects the supply or demand for
healthcare professionals must include certain assumptions about the future.
For example, knowing that a substantial growth is likely in the outdated num-
ber and population proportion allows the planner to anticipate much higher
levels of utilization. These elevated levels of demand will be reflected in in-
creased supplies of practitioners who are trained to care for the elderly, pro-
vided the training system is able to respond. In an application of this principle
at a very macro level, a study by Cooper and colleagues (2002) demonstrates
that overall economic activity is what determines the future supply of physi-
cians in the United States. The authors’ assumption is that the supply of med-
ical practitioners is determined by the degree to which demand can be ex-
pressed in a relatively open market for care.
Training-Output Estimating
Training-output estimating is perhaps the most common method for antici-
pating supply of practitioners. Essentially, it draws on data from training pro-
grams, such as the number of enrollees, the number of anticipated graduates,
and the trends in applications. This approach has been used to anticipate
trends in the general supply of physicians (Cooper, Stoflet, and Wartman
2003), general surgeons (Jonasson, Kwakwa, and Sheldon 1995), internists
(Andersen et al. 1990), pediatricians (Bazell and Salsberg 1998), and allied
health professionals (DePoy, Wood, and Miller 1997).
Estimations of the supply of nurse practitioners and physician assistants
rely heavily on trends in enrollment in training programs (Hooker and Caw-
ley 2002; Buerhaus, Staiger, and Auerbach 2000). Anticipating the character-
istics of the future workforce in relation to current training patterns is impor-
tant to understand how well today’s practitioners will meet clinical and social
needs in the future. This issue has become critical in the United States, as the
focus of national policy has shifted toward having a workforce that matches
the racial and ethnic structure of the population (Fiscella et al. 2000).
Challenges and Difficulties of Workforce Planning
The fundamental challenge to HRH planning is that any credible analysis
that points to an impending shortage or surplus of practitioners is likely to
result in a policy or an organizational response that precludes that scenario
from occurring. Retrospective analyses of “how well we did” often empha-
size how poorly the projections performed rather than how much reaction
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these projections generated (Cooper et al. 2002). Disappointingly, such ret-
rospective analyses are applied only to national estimates of the state of the
workforce at some unspecified future time. In planning for physician supply,
rarely are organizational or delivery system analyses discussed and critiqued,
except when making them the basis of national estimates (Weiner 2004,
1994, 1987; Hart et al. 1997).
Planning for nursing staffing includes much more organizational em-
phasis because such planning is considered a “staffing” problem subject to
management, rather than a need to anticipate a market response (Seago et al.
2001). Nursing staffing, however, is also subject to broad-scale analyses to an-
ticipate local conditions (Cooper and Aiken 2001).
International Perspectives
National-level HRH workforce planning is practiced more often in other coun-
tries. This is a function of the political economy of these countries’ healthcare
systems, in which central direction and planning is the norm. In other coun-
tries, most ministries or departments of health include a human resources divi-
sion or section that is responsible for the planning function. The planning that
goes on is applicable to the overall system, where decisions are made concern-
ing the number of practitioners and support staff to be trained or allowed into
the country. Planning for specific staffing needs of institutions often takes place
within the same part of the bureaucracy, but sometimes delineation is made be-
tween strategic planning for national needs and strategic planning for policy
and institutional planning for staffing and management decision making.
Canada, for example, developed the Pan-Canadian Health Human
Resources (HHR) Planning Initiative intended to bring more evidence-
based methods to the work of Health Canada. This consortium effort relies
on external research and analysis groups as well as on internal staff. The task
of the Canadian HHR planning group is focused on assessing the future
staffing and contracting needs of Health Canada and the provincial ministries
and departments, as that nation attempts to reform the Canadian healthcare
system in response to the 2003 First Ministers’ Accord on Health Care Re-
newal. The 2003 Canadian federal budget allocated $90 million over five
years to strengthen healthcare human resources planning and coordination.
The national work and interprovincial planning activities are coordinated
through the Advisory Committee on Health Delivery and Human Re-
sources, which has assigned a planning subcommittee to develop evidence-
based recommendations on education strategies, especially interprofessional
education, and on establishing a workforce that can respond to a patient-centered
healthcare system.
38 H u m a n R e s o u r c e s i n H e a l t h c a r e
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In 1995, Australia developed formal structures in its Department of
Health to oversee planning activities for its healthcare workforce. For politi-
cal and practical reasons, the oversight of planning functions was divided be-
tween two committees—one for medical positions (Australian Medical
Workforce Advisory Committee) and one for all other professions and occu-
pations (Australian Health Workforce Advisory Committee). The central
technical task of these committees is to estimate the “required health work-
force to meet future health service requirements and the development of
strategies to meet that need” (Australian Medical Workforce Advisory Com-
mittee 2003).
The World Health Organization supports the Human Resources for
Health program, which has invested heavily in developing skills of personnel
who can do workforce planning for national and regional healthcare systems
(see www.wpro.who.int/sites/whd for an example of work done in the west-
ern Pacific). Australia, for example, has committed substantial resources
and energy in the development of plans for its rural and remote workforce,
and it has developed a national public health workforce program (see
www.nphp.gov.au/workprog/workforce).
Barriers to healthcare workforce development in all countries in-
clude a failure to specify health goals, limited liaison between the health
and education sectors, and resource constraints. Other factors that have
complicated a strategic approach to healthcare workforce development in-
clude the diversity and rapid evolution of health services, the long train-
ing period for most healthcare professions, and the increasing mobility of
the healthcare workforce. Political ideology can also be a major player. In
New Zealand, the market-oriented health reforms of the 1990s created a
competitive rather than a collaborative environment in which workforce
development was not a priority (Hornblow 2002). That has changed to
some extent in recent years, but the Health Workforce Advisory Commit-
tee that was established to direct policy was disbanded in 2006 (see
www.hwac.govt.nz).
One international development that is beginning to have widespread
effects on workforce planning and planning in a management context is the
European Union’s Working Time Directive (WTD) (Roche-Nagle 2004;
Paice and Reid 2004). This rule applies to a wide range of healthcare profes-
sionals and sets limits on the amount of time an individual is allowed to work
in a day and over a work week. The initial implementation of the WTD began
in August 2007. In August 2009, the directive will restrict the hours that
trainees can work from 58 hours to 48 hours per week. The response to the
restrictions has been to increase the intake of trainees in some systems, such
as the National Health Service in the United Kingdom, and to restructure
some training program schedules.
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Workforce Supply Metrics
Measuring the supply of healthcare professionals is not as straightforward as
it seems. A doctor is what a doctor does, but when considering the overall
professional supply needed for a specific area or organization, the distinction
between what a doctor is and what a doctor does is harder to make. For ex-
ample, in counting primary care physicians, most experts and many explicit
policies consider a family physician as dedicated to providing primary care,
which is defined as healthcare that most people need most of the time. Un-
der that description, a primary care practitioner, then, takes care of the most
common complaints and coordinates the care needs of a patient—be it specialty
or inpatient. However, is a psychiatrist or an OB-GYN a primary care physi-
cian? Each may be the patient’s first contact with the medical system, and each
may coordinate the care for many individuals, but the practice of a psychiatrist
and an OB-GYN is limited to certain aspects of human health and illness.
To add more confusion, in many states and under certain federal regula-
tions, these practitioners are considered primary care physicians. In other sys-
tems, the primary care physician’s work is proscribed by certain rules to include
only ambulatory care. These physicians are most often termed “GPs” or general
practitioners. They may, however, have greater autonomy in the system and be
able to control entry into hospitals. This kind of gatekeeping power may, in turn,
influence the resulting demand or expressed need for surgery and, subsequently,
for surgeons. The dynamics of the system, thus, become important to the esti-
mation of the need for specialists and the staff who support them.
The extent of details involved in creating an inventory of primary care
physicians is indicative of the complexity of any process that tries to ascertain
how well the supply of healthcare professionals meets the needs of a popula-
tion or an organization. This challenge often deters managers as well as plan-
ners from attempting to balance their anticipated needs for healthcare profes-
sionals with likely scenarios for supply. Sufficient models are available on how
to approach HRH workforce planning that can make the effort well worth-
while in reducing overall costs of staffing or training and the costs associated
with mismatches of needs and resources.
Summary
HRH workforce planning is the anticipation of how many practitioners and
support workers an organization or a system will require to achieve its mis-
sion. The development of effective workforce plans depends on the use of ac-
curate and reliable data that describe current supply, pattern of entry and exit
from professions and positions, and the number of incoming workers from
training programs and schools. At the national level, HRH planning requires
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Discussion Questions
41C h a p t e r 2 : H e a l t h c a r e W o r k f o r c e P l a n n i n g
1. What are the major types of healthcare
workforce planning? Provide examples
of situations where each strategy would
be more appropriate than the others.
2. Healthcare workforce planning is often
done after a shortage in a particular
profession is recognized. How could
planning help avert those shortages?
3. Counting healthcare professionals as
part of healthcare workforce planning
is not always straightforward. For a
specific profession—nursing, dentistry,
or medicine—describe how the prac-
tice patterns of the professionals may
change the effective supply of that
profession.
Experiential
Exercise
In 1999, California became
the first state to pass a law
that requires minimum staffing ratios for nurses
in general acute care hospitals (Coffman,
Seago, and Spetz 2002). California Assembly
Bill 394 (AB 394) mandated the Department
of Health Services to create “minimum, spe-
cific, and numerical nurse-to-patient ratios by
licensed nurse classification and by hospital unit
for the inpatient parts of general hospitals in the
state.” In January 2004, those regulations came
into effect, translating into the following: In the
emergency department, one nurse cannot care
for more than four patients, while in postoper-
ative surgical units, nurses cannot care for more
than six patients.
Using the national nursing supply-
and-demand model, the following table on
page 42 shows the projected supply of regis-
tered nurses (RNs) and a trend for inpatient
days in general acute care hospitals in North
Carolina, from 2007 through 2023.
The North Carolina General Assem-
bly is considering implementing a mandatory
staffing ratio that matches the California
rules for emergency departments and post-op
Case
an understanding of major economic and social trends as well as a keen sense
of the politics involved in labor and professions.
Five basic methods are used in workforce planning: (1) population-
based estimating, (2) benchmarking, (3) needs-based assessment, (4) de-
mand-based assessment, and (5) training-output estimating. Each ap-
proach offers strengths and presents weaknesses, depending on the context
in which it is applied. The institutional planner can use all or a combina-
tion of these approaches in developing staffing plans, preparing for
turnover and transitions, and positioning the organization to compete ef-
fectively for resources.
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If North Carolina imple-
ments a staffing law ex-
actly like the one in California, and that law
is put into effect on January 1, 2009, how
would the numbers in the above table
change? Estimate the change in the number
42 H u m a n R e s o u r c e s i n H e a l t h c a r e
surgical units in general acute care hospitals.
The North Carolina Hospital Association
found that in all of the hospitals in the state
with emergency departments and post-op
surgical units, emergency departments ac-
counted for 8 percent of total inpatient days
in 2007, and the post-op units accounted for
11 percent of inpatient days. Overall, hospi-
tal RNs accounted for 38 percent of all RNs
practicing in North Carolina. Three percent
of these hospital RNs worked in emergency
departments, while 2.2 percent worked in
post-op units. The available supply of RNs in
2007 allowed all hospitals in the state to fully
staff their emergency departments and post-
op units.
of RNs required to staff the emergency de-
partments and post-op units of acute care
hospitals in North Carolina. The use of both
units is expected to rise in direct proportion
to the overall use of hospitals as measured by
inpatient days.
Exercise
Year Number of RNs Trend of Inpatient Days
2007 67,712 4,024,336
2008 68,382 4,090,608
2009 69,049 4,156,880
2010 69,718 4,223,151
2011 74,387 4,289,423
2012 75,050 4,355,695
2013 75,536 4,421,967
2014 75,730 4,488,239
2015 75,890 4,554,511
2016 76,020 4,620,782
2017 76,160 4,687,054
2018 76,210 4,753,326
2019 76,208 4,819,598
2020 76,199 4,885,870
2021 76,165 4,952,141
2022 76,065 5,018,413
2023 75,800 5,084,685
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43C h a p t e r 2 : H e a l t h c a r e W o r k f o r c e P l a n n i n g
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Amorim Lopes et al. Human Resources for Health (2015) 13:38
DOI 10.1186/s12960-015-0028-0
REVIEW Open Access
Handling healthcare workforce planning
with care: where do we stand?
Mário Amorim Lopes1*, Álvaro Santos Almeida2 and Bernardo Almada-Lobo1
: Planning the health-care workforce required to meet the health needs of the population, while
providing service levels that maximize the outcome and minimize the financial costs, is a complex task. The problem
can be described as assessing the right number of people with the right skills in the right place at the right time, to
provide the right services to the right people. The literature available on the subject is vast but sparse, with no
consensus established on a definite methodology and technique, making it difficult for the analyst or policy maker to
adopt the recent developments or for the academic researcher to improve such a critical field.
Methods: We revisited more than 60 years of documented research to better understand the chronological and
historical evolution of the area and the methodologies that have stood the test of time. The literature review was
conducted in electronic publication databases and focuses on conceptual methodologies rather than techniques.
Results: Four different and widely used approaches were found within the scope of supply and three within
demand. We elaborated a map systematizing advantages, limitations and assumptions. Moreover, we provide a list of
the data requirements necessary to implement each of the methodologies. We have also identified past and current
trends in the field and elaborated a proposal on how to integrate the different methodologies.
: Methodologies abound, but there is still no definite approach to address HHR planning. Recent
literature suggests that an integrated approach is the way to solve such a complex problem, as it combines elements
both from supply and demand, and more effort should be put in improving that proposal.
Keywords: Review, Health-care workforce planning, Supply, Demand, Needs, Health policy
Health-care human resources (HHR) planning has been
identified as the most critical constraint in achieving the
well-being targets set forth in the United Nations’ Mil-
lennium Development Goals [1]. Moreover, the effective
use and deployment of personnel is paramount to ensure
an efficient service delivery in terms of cost, quality and
quantity [2]. Failure to do so may result in an oversupply
or shortage of clinical staff. While the former may lead to
economic inefficiencies and misallocated resources under
the guise of unemployment [3] or inflated costs through
supplier-induced demand [4], the latter is linked to a more
extensive list of negative effects, including but not limited
to the following: lower quantity and quality of medi-
cal care as few resources exist to provide the necessary
*Correspondence: mario.lopes@fe.up.pt
1INESC TEC, Faculdade de Engenharia, Universidade do Porto, Porto, Portugal
Full list of author information is available at the end of the article
services and the visits are shorter [5]; work overload of
the available physicians and nurses, resulting in sleep-
deprivation, ultimately compromising patient safety [6];
and queues and waiting lists resulting from insufficient
medical staff, causing avoidable patient deaths [7].
Another argument supporting HHR planning is the
recent rise in health-care expenditure, both in per capita
spending on health and as a proportion of per capita
domestic product in real terms [8]. The average annual
growth rate of health-care expenditure in a selection of
18 countries that are part of the Organisation for Eco-
nomic Co-operation and Development (OECD) was 3.0 %
between 1980 and 1990 and 3.3 % in the decade after
[8]. Recent studies confirm the rising trend, with health
spending growing at an average of 3.8 % in 2008 and
3.5 % in 2009 [9], well above the growth rate of the
gross domestic product. Health worker wages account for
© 2015 Amorim Lopes et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution
License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any
medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://
creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
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Amorim Lopes et al. Human Resources for Health (2015) 13:38 Page 2 of 1
9
about 50 % of total public and private health expenditure
across several countries [5], meaning that cost contain-
ment and efficiency improvements will necessarily require
the involvement of the workforce.
In sharp contrast to other scientific areas where a set
of well-defined methodologies and techniques is gener-
ally adopted and refined to solve a given problem, in
HHR planning, methodologies (the conceptual scope of
analysis) and approaches (the techniques applied upon a
particular method) abound, and there is still no commonly
accepted or favoured procedure to accurately forecast
physician requirements [3, 10]. The methodologies fol-
lowed by countries vary significantly, in some cases with
no long-term strategic HHR planning at all, but a wide
array of options does not seem to be a determining factor
in improving the accuracy of forecasting [11]. Despite the
lack of focus, the accuracy of the projections appears to be
making progress in some cases, as a review reporting the
case of The Netherlands shows [12], an encouraging sign
to the ongoing research.
A definite approach to the problem, or at least a sta-
ble starting block, will require a comprehensive overview
of how the problem has been tackled since its inception.
For this purpose, we provide a thorough analysis of the
field, to lay down the foundations for future research, cou-
pled with a historical perspective on the development of
the HHR literature, analysing how the field has evolved
and what methodologies have emerged and continue to be
employed. Secondly, we analyse the strengths and pitfalls
of each of the methodologies and provide a data require-
ment framework containing all the variables and data that
need to be taken into account in order to address the
problem thoroughly. The review is selective as it focuses
primarily on articles that seem to have had a clear impact
on the evolution of the field, although broad in scope
as it attempts to extensively describe all known meth-
ods. Finally, it describes where we stand and the road
ahead, providing a brief overview of new and emerging
approaches to the HHR planning problem.
To the best of our knowledge, the last comprehensive
academic paper on the subject dates back to 1978 [13].
Literature reviews exist but tend to either focus on a par-
ticular period or on a subset of the methodologies or
techniques [11, 14] or to be framed as technical reports
aimed at a wider readership, such as the OECD’s extensive
review of 26 projection models used in 18 countries [9]
or WHO’s policy recommendations to the EU [15]. The
literature reviews can also consist of a technical report tar-
geting a country in particular [16]. In fact, some authors
point out that more systematic reviews, assessments of
potential interventions and further research to aid policy
makers are highly needed [17]. This paper aims to narrow
this gap by being a starting point both for academics and
policy makers.
Literature search method
We carried out an extensive literature review, includ-
ing academic research papers and technical reports from
institutions such as the OECD or WHO. Selected papers
date between 1951 and 2013, and the results were
reported in a chronological and evolutionary way so as
to clearly identify methodologies that are still in use to
this day. The search methodology can be summarized as
follows: after selecting a set of search terms and gener-
ating reliable combinations, we used electronic research
databases to search for related articles. We then selected
a maximum of 20 papers for each combination of search
terms, including the 10 most cited, the 5 most recent and
5 that were randomly chosen. A backward/forward search
was conducted, and the abstract was analysed to ensure
that the papers met the search criteria. Papers that failed
to meet any of the search criteria were excluded.
To identify search terms, we consulted the available
literature reviews and technical reports [5, 10, 11, 13]
so as to a obtain a list of key terms frequently used in
this research field. Table 1 displays the search terms more
frequently employed in the literature. Multiple combi-
nations were selected using these key search terms. For
instance, all possible combinations of health and health-
care with (AND) workforce, manpower, physicians, nurses
and (AND) forecast, projection, planning. Related subor-
dinate queries such as physicians supply forecast, nurses
supply forecast, healthcare supply forecast, healthcare
demand forecast were also employed. These terms were
then used on the online databases PubMed, MEDLINE,
Embase, ProQuest, Healthstar, ABI/Inform, INSPEC,
Google Scholar and Scopus to obtain a base set of the 10
most cited, 5 most recent and 5 randomly chosen papers.
Of this initial selection, an abstract matching and back-
ward/forward search was conducted to assess whether the
topic covered was relevant. Publications that failed to ver-
ify these criteria were excluded. A total of 308 publications
were retrieved, with 75 meeting at least 1 of the inclusion
criteria using the combination of search terms and were
thus included in this review. Table 2 describes our search
methodology.
Scope
HHR planning is a comprehensive field far extending
the number of physicians and nurses. Other health-care
workers such as hygienists, therapists, managers, admin-
istrative assistants and other support staff also play a
critical role, relieving the clinical staff of bureaucratic
and time-consuming tasks. In fact, skill-mix studies show
that proper task delegation is critical to ensure proper
health-care delivery. Furthermore, a complete assessment
may also require the analysis of the impact of other indi-
rect stakeholders, such as workforce educators, regula-
tors, funders and employers. Assessing how the training
Amorim Lopes et al. Human Resources for Health (2015) 13:38 Page 3 of 19
Table 1 Key terms used to conduct the search
Keywords Search queries
Health Workforce planning
Healthcare Healthcare forecasting
Workforce Health human resources
Manpower Health manpower
Physicians Health planning
Nurses Healthcare planning
Forecast Health services
Projection Health supply
Planning Health demand
. . . Healthcare needs
Healthcare providers
Physician forecasting
Nurse forecasting
Nursing staff
Manpower
Manpower planning
Workforce forecasting
Workforce projections
Workforce management
Staff levels
Health staffing levels
Shortage healthcare workers
is conducted (i.e. could the training time be reduced?; do
medical schools have the capacity to train a given num-
ber of trainees?; are more medical schools necessary?),
the impact of regulatory requirements (i.e. is the entry
to medical school limited by government-fixed numerus
clausus?) or financial and service constraints (i.e. can the
Table 2 The search method applied in this review
Step Search method
1 Identify common search terms from reviews, books and
technical papers
2 Generate plausible combinations of terms to be used for
search using the key search terms identified
4 Search for these terms on PubMed, MEDLINE, Embase,
ProQuest, Healthstar, ABI/Inform, INSPEC, Google Scholar and
Scopus
5 Select a base set for the results consisting of the 20 papers (10
most cited, 5 most recent and 5 randomly chosen)
6 Match the abstract and perform a forward and backward
search to verify the relevance of the paper for the selected base
set
7 Exclude papers that address none of the topics covered, that
only make a brief reference to the subject at hand or that are
not written in English
existing hospitals and health-care units absorb a planned
increase in the number of health-care professionals?) is a
critical requirement for a well-guided policy.
Without disregarding the importance of these other
professions, in this paper, we will focus solely on review-
ing the planning of the clinical staff that directly pro-
vide health-care services and, more specifically, on the
physicians and nurses, along with references to related
fields like dentistry. Obtaining reliable projections for the
available and necessary human resources is an obligatory
starting point. Moreover, the prominence will be in the
spectrum of different methodologies that may be used to
obtain forecasts for the number of physicians and nurses,
with short references to the approaches or technical appa-
ratus, commonly used to apply a given methodology a.
Also, our concern is HHR planning only at the national
and regional level. HHR planning at a local level (hospi-
tal or medical centre) is conceptually different, involving
other methodologies and tools, and therefore, it is not
inserted in this paper.
The remainder of this paper is organized as follows:
in the “Background” section, we introduce the general
and governing principles that characterize the health-care
market. The background information provided is critical
to equip the reader with the necessary concepts. In the
“
” section, we proceed with an evolu-
tionary and chronological description of the field, expos-
ing the work and methodologies that have been shaping
the research field. In the “
” section, we discuss
the current trends in this research area and the road ahead
regarding future research directions. We also present a
summary of all the findings, including a table with an
overview of the methodologies and a data-requirement
framework to understand which methodologies can be
used based on the data available, as well as a proposal sug-
gesting a way to develop an integrated approach. Finally,
we finish with a brief summary and conclusion.
Background
HHR planning as a scientific area and topic of theo-
retical and applied research evolved significantly from
non-existence into a remarkable and serious effort of pri-
vate and governmental institutions, which tried to antic-
ipate how many human resources, primarily physicians
and nurses, will be necessary in order to maintain or
even improve the quantity, quality, availability and effec-
tiveness of the medical services provided. Improved life
expectancy and changing demographics, epidemiological
trends, improved socio-economic conditions and an ever-
increasing world population may result in a rise in the
expected demand for health-care services [18] and, there-
fore, further additions to the list of patients of an ageing
medical workforce [19]. It then comes as no surprise that
health workers are recognized as a critical resource for
Amorim Lopes et al. Human Resources for Health (2015) 13:38 Page 4 of 19
achieving population health goals [1], working at the front
gate of the health-care sector.
The health-care sector is an intricate, albeit funda-
mental, part of ancient and modern societies, and it
comprises a long list of agents, from the individual seek-
ing health-care services to the medical staff providing
them, all operating within a legal framework involving
providers, consumers, insurance companies, government,
medical schools and regulatory institutions. Regardless
of the statutory system in place, either a Bismarckian-
based or a Beveridgean-based organization, at its core,
the health-care market is always composed of both sup-
pliers of health services and patients demanding their
services. On the one side is the workforce of physi-
cians, nurses and remaining clinical staff trained and
ready to assist those in need. On the other side stand
the forces that drive the demand for medical services,
strongly related to demographic, socioeconomic and epi-
demiological factors. Analysing these two market forces
is a critical step in assessing whether the available health-
care human resources are enough in quantity and skills
to meet the current and future demand in due time and
may lay solid foundations for further research, considering
perhaps changes to the existing health policy framework.
Despite the similarities, the health-care market diverges
from a traditional market of goods and services for sev-
eral reasons [20]. A high degree and extent of uncertainty
affects both supply and demand; asymmetric information
between physicians and patients, restrictions on competi-
tion, strong government interference and supply-induced
demand are some of the most glaring differences that can
be pinpointed. These may be relevant when assessing the
impact of any policy involving HHR planning.
Supply
Supplying human capital with the appropriate expertise so
as to enable workers to perform and satisfy the demand for
health care is no simple task. The time and effort required
to equip HHR, especially physicians and advanced nurse
practitioners, exceeds that of most other professions. In
some particular health-care professions, the set of nec-
essary skills to qualify for medical practice is acquired
through extensive academic learning which involves the
enrolment in long courses that may take up decades to
complete due to a strict licencing process.
A considerable amount of HHR studies focus solely on
this approach, basing their research on the estimation of
the expected supply of physicians by accounting for the
intakes, exits, migrations and population growth in order
to maintain the present ratio of practitioners, using “stock-
and-flow” models for that purpose [3]. The analysis of the
medical training process is relevant but may be insuffi-
cient, as several other factors may affect the efficiency and
effectiveness of the care services delivered.
Despite the limitations, some measures to overcome
imbalances in the quantity (number) of physicians and
nurses have already been identified in the health policy
literature [17, 21], namely the following: increasing the
number of domestic- and foreign-trained medical grad-
uates or increasing the number of medical schools and
classroom sizes; increasing the enrolment limits (numerus
clausus); reducing the requirements for entry to medical
schools; raising the wages of the medical staff, as well as
the perspectives for their future career path; or reducing
the costs of attending medical school, which may encour-
age potential students to enrol. In Table 3, we provide a
more extensive list of policies to cope with a shortage in
the number of health workers. These proposals are short-
term measures to alleviate the immediate stress put on
the health-care system triggered by an undersupply of per-
sonnel and may not be suitable for tackling long-term
imbalances due to huge shortages or surpluses of medical
staff.
Still within the scope of supply, other approaches for
handling the problem of insufficient human resources
have also been suggested, addressing the problem from
Table 3 Health policy options for targeting health workforce
imbalances and alter health-care outcomes (adapted from [17]
and [86])
Field Policy option
Education Increase numbers of new students
Recruit foreign graduates
Recognize previous learning
Improve curriculum content
Regulatory Recognize overseas qualifications
Introduce temporary employment
regulations
Subsidized education for return of
service
Enhanced scope of practice
Different types of health workers
Financial incentives Increase trainee salaries
Raise wages
Provide non-wage benefits
Introduce incentives for return of
skilled migrants
Establish retirement policies
Employ lay health workers
Professional and personal support Better living conditions
Safe and supportive working
environment
Career development programmes
Public recognition measures
Amorim Lopes et al. Human Resources for Health (2015) 13:38 Page 5 of 19
an angle besides medical training. For instance, the com-
position of the core competences and activities of the
physicians, the skill mix, may be reorganized to enhance
the roles performed by the clinical staff, relieving them
from tasks that could be safely assigned to other health-
care professionals [22]. This strategy does not require a
change in the number of physicians but the restructuring
of the available human resources and medical compe-
tences. Complementarily, supporting policies and reforms
that enhance the productivity, that is, the ratio of out-
put per unit of input given a certain level of technology
and methodology, of the medical staff may result in an
increased outcome that also does not require a change
in the quantity of labour workforce [23]. Assessing the
productivity of the clinical staff is now quite common
[24], and operations research applied to the improvement
of patient flows, queueing, master surgery scheduling,
ambulance fleet management and staff rostering may play
a very important role in increasing current levels of pro-
ductivity. In summary, the initial focus of supply-based
methodologies was on the training process. As of late,
more focus has been given to the productivity and to the
skill mix of the labour workforce as well.
Methodologies for modelling supply
Training (entries and losses) The purpose is to model the
training process so as to predict the number of entrants
in each year. This way, and in combination with migra-
tory flows, mortality, exit and drop out rates, it becomes
possible to estimate the number of physicians and nurses
available for each year, with everything else held constant.
Productivity The productivity of the medical workforce is
not constant, as some professionals work harder or better
than others or simply because there is an excess of bureau-
cracy to comply with. Without touching on the quantity
of professionals, it is possible to reorganize services and
incentives so as to promote increased productivity or
implement lean and operations research recommenda-
tions to significantly improve the output and outcome of
the workforce.
Skill mix Since a degree of interdisciplinarity exists
between medical professionals, it is possible to reassess
the tasks performed by each professional, relieving physi-
cians from day-to-day bureaucratic routines or review-
ing the competences of the nursing profession so as to
broaden their scope of action. Horizontal substitution
(between different medical specialties) and vertical substi-
tution (between different working classes) can be used to
improve the amount of health-care services provided.
Worker-to-population ratios This method establishes a
desired ratio for the number of physicians and nurses per
unit of population and compares it to the actual ratios.
Policies to increase or decrease these ratios may then be
pushed forward. Although simple and easy to apply as
long as data is available, the method lacks the fine detail
of such a complex system, ignoring other factors such as
needs, demand or institutional frameworks that may have
an influence on the productivity of countries or regions
with similar worker-to-population ratios. Moreover, it
abstains from exposing the causes for such asymmetries or
from evaluating the efficiency of the available workforce.
Demand
Demand for health care is a derived demand [25], which
means that people do not seek health care services as a
final good for consumption but as an intermediate service
allowing them to be healthy and to improve their stock
of health capital (well-being). They want to improve their
health, and to do so, they seek health-care services. As
in other markets, the determinants of aggregate demand
for health-care services are population size, income and
preferences. Moreover, for countries where medical care is
mostly an out-of-pocket expenditure, demand is restricted
by the patients’ ability to pay. If a patient requires medical
attention and is unable to finance it, this need for health
care will not translate into effective demand, despite its
existence. Accounting for these cases is especially impor-
tant in countries where health care is not publicly subsi-
dized or where there are obstacles to entry other than the
availability of resources.
The concept of needs in health care is not consensual
in the health literature, with a semantic confusion arising
from its use in health economics [13, 26]. While the eco-
nomic or effective demand translates the actual, observed
demand, usually measured in terms of service utilization
ratios (such as bed occupancy rates, number of inpa-
tients), the needs component tries to fully encompass the
epidemiological conditions that characterize a given pop-
ulation, measured through morbidity and mortality rates
or by the opinion of a panel of experts, and how that
may translate into a given quantity of required health-care
services. Therefore, we see that the classical concept of
economic demand may not reflect the biological needs of
the population, as it may leave out the necessities of the
population regardless of their ability to pay. In the needs
component, the emphasis is on the medical conditions
that may lead to demand for health care, deriving from the
evolution of chronic diseases, prevalence rates and over-
all morbidity patterns. This distinction is better illustrated
in Fig. 1, where we present the case when all demand is
met, at a given price, and equilibrium is attained. The-
oretical demand, projected strictly in terms of biological
needs without a budget constraint (either households’
income or public budget), may not always correspond to
the demand effectively observed. The reason being that
the quantity sought is limited by the disposable income
directed towards out-of-pocket health expenditure or by
limits to the government budget that is allocated to health
Amorim Lopes et al. Human Resources for Health (2015) 13:38 Page 6 of 19
Fig. 1 Law of supply and demand applied to health services. The
health-care market depicted in terms of supply and demand, with a
tentative distinction between potential and effective demand
care. We draw the distinction by plotting both the curve of
needs (potential demand), corresponding to a no gap sce-
nario, and the economic (effective) demand that is actually
observed.
Although needs is a fundamental concept, it should not
be decoupled from economic demand, as it should not
ignore the budget constraints of the economy. In fact, the
country may not have the ability to provide all the health-
care services presumed to fully satisfy needs. If the area
delimited by B (cf. Fig. 1) is larger than the domestic prod-
uct of the economy, it will be impossible to meet all the
perceived health-care needs of the population. Like any
other problem involving scarce resources, a serious anal-
ysis should not abstain from recognizing the existence of
financial impediments. Conversely, it should try to quan-
tify needs, serving as a theoretical benchmark for the
future.
This has not always been the case. Some studies esti-
mate demand solely based on the current level of service
in relation to future projections of demographic profiles
[27, 28], thereby leaving out an important determinant of
demand, the epidemiological needs [29, 30]. When and
how disease trends evolve is critical to properly anticipate
the needs of the population, a proxy to the expected future
demand. For instance, chronic diseases have been increas-
ing globally [31]. China, a country usually not associated
with overweight and obesity problems, has experienced
an upsurge in type two diabetes. According to the data
reported, in 1980, less than 1 % of Chinese adults had
diabetes, but by 2008, the prevalence of the disease had
already reached 10 % of the population [32]. As a result, it
is expected that more endocrinologists will be necessary
to assist with the treatments. The raw definition of needs
is not subject to any boundaries other than those set by
epidemiological constraints and medical advances.
A substantial part of the studies targeting supply hold
current demand constant, thereby leaving out a proper
analysis of what drives demand for health care. In fact,
a change in the factors that influence demand or the
emergence of new health conditions in a population may
require a reorganization in the quantity, composition and
skill mix of the medical workforce to ensure that all sup-
ply meets demand. This suggests that targeting the right
number of people and the right skills depends as much on
the health conditions and epidemiological characteristics
of a given population as on the supply of physicians and
nurses [33].
In summary, three methods are commonly used to anal-
yse HHR planning from a demand-based perspective [13].
Most of the methods build upon the definitions of needs
and effective demand, and some overlap in their scope of
application. Contrarily to the approaches found in supply-
based methodologies, where the object of study remains
the same and alternative analytical methods are employed,
in demand, opting for a different method may change the
scope of the analysis.
Methodologies for modelling demand
Needs (or potential demand) This method determines the
effect of health diseases, epidemiological patterns and
overall mortality and morbidity rates in the demand for
health services and obtains an approximate number of
personnel hours required to cover those needs. Needs are
usually assessed by a panel of experts in epidemiology and
may not match the services that the public wants.
Economic (or effective demand) In this method, we look at
the services actually contracted by the population, subject
to the usual economic constraints that may put an upper
bound on the quantity solicited. In sharp contrast to the
first method, effective demand may not imply a healthy
population, especially for poor countries without a sub-
sidized health-care service since the general citizen lacks
the means to obtain health-care services. The method
ignores needs or wants and assumes that all the remain-
ing variables remain constant, although that requirement
may be relaxed by complementing the results with other
methods.
Service targets Service targets extend a needs-based
approach by incorporating other measures, such as con-
sumer needs, in order to establish service-target ratios
to be accomplished. Service-target approaches decouple
the multiple areas of health-care services and proceed
with an independent analysis of each subsystem, with
the main advantage being a more detailed proposition of
Amorim Lopes et al. Human Resources for Health (2015) 13:38 Page 7 of 19
the changes required, with separate recommendations for
distinct areas.
Evolution of the field
Although the health workforce has long been a concern
to policy makers, including those of ancient Rome [34],
the first academic research articles discussing manpower
planning in general, and health-care workforce planning
in particular, date back to the 1950s. This was a natu-
ral response to both the creation of national health-care
systems and universal insurance schemes.
A universal health-care system with no exclusion based
on preconditions and with no restrictions on access, an
idea put forward by Bismarck in the compulsory social
insurance form, and promoted by Beveridge as a national
health service [35], requires a well-prepared and readily
available team of physicians, nurses and administrative
staff. To ensure that services are in fact provided, public
medical universities were created along with subsidized
access to medical training. These reforms resulted in the
emergence of a national ecosystem of health-care suppli-
ers and a pool of patients, a significant change from the
decentralized network of health-care providers. The ubiq-
uity of access required providers to be distributed evenly
so as to satisfy the needs of the population.
After this period of sustained and prolific economic
growth, a period of crisis followed. Expectably, the eco-
nomic slowdown put the focus on efficiency, towards a
better use of the available resources. During this period,
many developed and developing countries experienced
shortages of health-care providers, mostly nurses [36],
justifying the growing interest in this newborn academic
research field.
This was the period when the first articles on health-
care workforce planning emerged. We separate the analy-
sis of the unfolding of HHR planning into three separate
stages, corresponding to the evolution of how the health-
care worker is perceived as an object of study [37]: (a)
the health worker as a production factor, (b) the health
worker as an economic factor and (c) the health worker as
a necessary resource. This structure is helpful in the sense
that it exposes the role given to the workforce, once stud-
ied as an inorganic fixed-input factor and more presently
viewed as a complex and necessary resource with its own
idiosyncrasies like any other economic agent.
First phase: factor of production
The first articles published on the subject date back to
1950, with HHR planning being perceived as a production
function, where the labour workforce is an input factor.
The research, triggered by general health worker short-
ages in developed countries [38, 39], led a growing and
diversified body of research that diverged into different
approaches. Not surprisingly, some of these articles are
the result of initiatives promoted by governments and
international organizations to address their own domes-
tic shortages of physicians and nurses, while others are ad
hoc contributions of attentive researchers keen on provid-
ing an insightful contribution. The techniques employed
vary from descriptive to predictive or merely comparative
techniques and usually involve econometric regressions,
static tables, linear programming or benchmarking. These
techniques are then applied to the areas of analysis previ-
ously described, either supply, economic demand, needs
and service-target or worker-to-population ratios, which
we will identify next.
A significant part of the research papers produced
at that time are well-documented, with comprehensive
lists and reviews of the models developed still available
[40, 41]. Of these, we highlight those that are still cited in
the literature and available online.
Supply-based methodologies
The very initial concern of those conducting HHR plan-
ning was estimating the necessary number (head count)
of medical professionals to either maintain the current
worker-to-population ratios or reduce/increase it if an
imbalance was found. One of the first insights into the
evolution of the supply of physicians was done by crossing
the observed physician-to-population ratios along with
the posited population growth in the United States of
America, by that time impulsed by the “baby boom” and
by an expected increase in the use of medical services.
The people in charge of HHR planning evaluate the num-
ber of physicians required to maintain the ratios given
those demographic and economic changes [42, 43]. In
the report, the same criterion is used to estimate future
manpower requirements for all the available medical spe-
cialties, nurses and miscellaneous professions necessary
for due operation.
One way of doing so is to look at the current stock of
professionals and factoring in negative and positive flows
that affect the stock. Factors such as mortality, migra-
tion or retirement generate losses to the current work-
force stock. Likewise, entries from medical schools and
immigration increase the current level of professionals.
Models that map this structure are commonly known as
“stock-and-flow”. Despite not using this specific terminol-
ogy, models created at the time already incorporated the
idea of increases and decreases in the current stock due
to exogenous factors and then used that information to
obtain projections [44–46].
Focusing particularly on the supply of nurses in the
United States of America, other papers proceed with an
analysis of the economic factors, namely the hourly wage
and the wage of the nurse’s spouse and the effect on the
supply of nursing professionals [45, 47]. Evidence sug-
gested that hospitals exercise monopsony power, which
Amorim Lopes et al. Human Resources for Health (2015) 13:38 Page 8 of 19
has an impact on how a supply gap may be tackled.
Moreover, results also suggest that the cost of paying
wage incentives to increase working hours is considerably
smaller than the cost of training additional profession-
als, something to take into consideration when evaluating
HHR reforms.
The product of this novel research was tested in the
field. For instance, in the analysis of the health-care work-
force in Taiwan, estimates for the supply were generated
on the basis of retirement, migration and death rates
applied to graduations. They incorporate the training pro-
cess and its effect on the supply of physicians [48].
Methodologies: Training (entries and losses) [42–46, 48],
Productivity [45, 47], and Worker-to-population ratios
[42, 43].
Demand-based methodologies
One of the first publications in the field of HHR planning
starts by differentiating the aforementioned dimensions
of workforce planning [49]. Klarman et al. argue that,
although medical needs could form the basis for determin-
ing workforce requirements, it cannot be decoupled from
economic costs, an active constraint to the extent, scope
and applicability of reformist policies. A forecast of the
necessary supply of physicians is not provided, but it is
suggested that the shortages in the specialty areas may be
a sign of an overall supply shortage.
Another way of predicting the necessary future hospital
beds is by extrapolating from a set of factors assumed to
drive the demand for health care, namely socio-economic
factors and biologic needs, measured through morbidity
rates [50]. This approach was also used to estimate hospi-
tal bed requirements, providing both empirical works on
real data for the United States [51] and theoretical frame-
works with hypothetical parameters [52]. In some cases,
the approach of forecasting bed requirements would be
extended to other health-care units such as primary med-
ical care, nursing home care, consultant medical care
(medical care provided by a physician with specialized
training), hospital care or domiciliary care [52].
Methods for estimating the number of professionals
required (head counts) from a demand perspective also
started emerging at around this time. For instance, in one
case, estimating the number of necessary physicians for
the future was done by calculating the number of profes-
sionals necessary to close the gap between observed and
unattended demand, where demand is measured in terms
of utilization. In this case, using service-level indicators
again for the United States [53].
In other studies targeting the U.S.’s health system, the
influence of exogenous variables such as age, income and
urbanization is used to extrapolate the effect of dependent
variables on health policy and HHR planning, includ-
ing the number of persons with health insurance, the
number of general practitioners, medical specialists, avail-
able short-term general hospital beds, admissions and
mean duration of stay per case [54]. This approach is
also similar to the one used in two other models, the
first using data aggregates to facilitate HHR planning at
national, state and substate levels and the second going
to the level of detail of the individual and his interactions
with professionals and institutions [46].
More comprehensive approaches to estimate economic
(effective) demand were also addressed. Some papers sug-
gested incorporating indicators such as an increase in
population, economic development, improved education,
a change of supply, age distribution and other unpre-
dictable factors. Simple calculations, such as the ones used
in the former Soviet Union, could be performed by extrap-
olating based on observed norms of practice regarding the
number of patients attended and then complemented with
basic biological needs by incorporating data about mor-
bidity and mortality rates [44]. Methods like this were then
applied to countries such as Taiwan, characterizing cur-
rent public and private sector demands for health services
[48].
Another option for measuring demand also elaborated
during this time consisted of using other indirect indica-
tors, namely short-stay services, services of nervous and
mental hospitals, physicians’ services outside hospitals,
dental services and other health services. The data is then
fed into a model that tries to minimize the gap between
the number of individuals employed in medical services
that attend to the demand for personnel in that occupation
[53]. Estimates were generated for the United States.
Finally, it should be noted that attention was constantly
being drawn to the importance of prevailing morbidity, a
basic indicator for assessing medical manpower based on
a needs-based approach. Some authors stress that it is the
hospitals and their internal need for residencies that actu-
ally determine the number of specialties [55]. This may
not reflect with accuracy the actual needs of the popula-
tion since patients could potentially remain unattended or
in long waiting lists, but it is an insightful indicator if wait-
ing lists are also factored in. Finally, they also consider the
specialty of the physicians’ role, warning that general prac-
titioners fulfil key medical functions and should not be
relegated to second place. The concept of skill mix, despite
not formally and explicitly defined, is here put in evidence.
Methodologies: Needs (potential demand) [44, 46, 48–
50, 55], Economic (effective demand) [44, 46, 49–54], and
Service targets [46, 53].
Second phase: economic agent
The first phase of HHR planning was characterized mainly
by an aggregate analysis of the health-care market, with
independent and/or cross-analysis of supply and demand.
Reviews produced at that time refer essentially to needs-
Amorim Lopes et al. Human Resources for Health (2015) 13:38 Page 9 of 19
and demand-based approaches, as well as simple worker-
to-population ratio benchmarks [56]. The phase that
starts in the late 1970s and goes onward through the 1980s
and 1990s redefines the role of the HHR, previously seen
as an homogeneous input factor, into a complex economic
agent [37]. The adoption of such perspective broadens the
scope of analysis, namely by assuming that health-care
workers react to economic incentives.
The deepening of the analysis is done through the appli-
cation of microeconomic theory to the study of health
labour workforce, thereby exposing dimensions that had
gone unnoticed when looking only at the aggregates,
although a macroeconomic analysis continued to take
place [57]. It was triggered by two macroeconomic obser-
vations occurring at this time [37]: a perceived oversup-
ply of physicians and nurses [58–60] and an upsurge in
health-care expenditures [8]. During this phase, atten-
tion was given to topics such as health worker licen-
sure [37, 61], information asymmetry distortions [62] and
its potential repercussion as an unnecessary increment
in demand induced by health suppliers [63] and health
worker performance and productivity [64]. Furthermore,
HHR planning became a major concern in related fields,
such as dentistry [65].
Supply-based methodologies
Although the previously mentioned topics are of notable
relevance, some have no direct utility in the elaboration
of projections and forecasts of future health-care needs,
serving only for policy guidance. For that reason, we
will concentrate our efforts on the performance and pro-
ductivity of health workers, a method fully within the
umbrella of supply. In terms of policy, it is less demanding
to put in practice as it does not require structural changes
to the training process or to medical schools. In theory,
more people can be served with the exact same amount
of human resources if only their productivity increases.
Improving the efficiency of the available pool of resources
is therefore an attractive methodology.
This is the line of research followed in a paper where
a microanalysis of the factors that may influence the out-
put (and therefore productivity) of the health workers is
conducted, in particular nurses in the United States [47].
Sloan et al. found that there is a strong supply response
to the hourly wage. Raising the hourly wage is, in fact,
their proposal to respond to a short-run supply shortage,
arguably a quicker response than changing the number of
intakes to nursing schools. Taking another route to reach
the same goal, one study tries to undercover job satisfac-
tion indicators and perceived productivity in 24 hospitals
for a staff nurse population [66]. The purpose is to under-
stand the factors that may raise productivity but also to
find a connection between job satisfaction and the quality
of care provided. Similarly, waiting and distance times can
also be used to assess the physicians’ productivity, a study
conducted using data from the United States [67].
In the same line of research, some authors conducted an
observational study of 56 physicians in order to uncover
the factors that may influence productivity, measured as
the ratio between the number of patients seen per physi-
cian and the time spent with the patient [24]. The main
research question was understanding which factor con-
tributed the most to the variance in productivity: the
patient or the physician. Results suggest, according to the
study conducted in a Veteran Affairs’ medical centre in
the United States, that the individual physician explains
the variations in productivity observed, with the actual
patient playing a minor role. Similarly, in another study
also conducted in the United States, the productivity of
physician assistants and nurse practitioners and their role
in the health-care workforce is analysed [68]. Scheffler
et al. find that these two categories of health workers
could have a significant influence on the future health-
care workforce if some vertical and horizontal substitu-
tion occurs and tasks are delegated. Note that the change
of setup hereby suggested tackles productivity from a dif-
ferent angle: instead of raising the output, the inputs are
altered.
Methodologies: Productivity [14, 24, 47, 64, 66–68] and
Skill mix [68].
Demand-based methodologies
Studies focusing solely on the demand side produced dur-
ing this phase are considerably less common than in the
first phase. The ones that do so are more concerned with
the lack of attention given to the importance of biologi-
cal needs. It is interesting to note that, at the turn of the
decade and in subsequent years, a lot of emphasis is again
put on the needs of the population. Some authors sug-
gest a needs-based evaluation as a requirement to produce
accurate forecasts [29, 56]. This option contrasts with that
of other authors, which propose using benchmark as a
viable alternative to potential or effective demand projec-
tions [69]. The work developed consisted of comparing
the number of active physicians per capita in the United
States, adjusted for population differences between simi-
lar locations, without uncovering the causes for the given
asymmetries.
Assessing the needs of the population was also the
method of choice in the dentistry field to calculate oral
health workforce requirements. In particular, needs were
projected by the amount of oral care, including preven-
tive, special group care, surgical, orthodontic, periodon-
tal, restorative and prosthetic, that different age cohorts
would require [70]. Then, the time necessary to treat each
of these conditions is estimated, and the number of den-
tists to perform those tasks is derived. Also applied to
dentistry but with a focus on the skill-mix distribution,
Amorim Lopes et al. Human Resources for Health (2015) 13:38 Page 10 of 19
productivity changes are estimated by examining role sub-
stitution in dentistry [71], helping to conduct evidence-
based scenario analyses in The Netherlands.
Methodologies: Needs [29, 70], Skill mix [71] and
Worker-to-population benchmarking [69].
Integrated methodologies
A new strand of the literature also emerged during this
phase covering supply while at the same time consider-
ing projected changes to demand. In a review of supply
projections conducted both in Canada and in the United
States [14], the authors argue that the traditional supply
projection methodology that characterizes the licensure
cycle and productivity metrics is incomplete if unmet
needs of the population are not defined and included as
a clear research goal, as well as economic, financial or
infrastructure resource constraints.
The integrated approach is also present, for instance,
in the implementation of the “System for Health Area
Resource Planning” (SHARP) [72]. This analytical frame-
work combines all the major methodologies: it includes
the socio-economic factors that drive economic demand,
morbidity and the remaining epidemiological factors that
drive needs, the formation process of the health-care
supply of workforce and utilization rates in order to incor-
porate the current use of health-care services. The frame-
work was successfully used to support HHR planning in
Canada, especially in the province of Ontario, reinforcing
the idea that an integrated or systems approach, combin-
ing the multiple facets of the problem, is the way to go in
the future.
Methodologies: Integrated [14, 72].
Third phase: fundamental resource
In this phase, the notion of health labour workforce is
reformulated, this time viewing it as a necessary resource.
From the 1990s onto the 2000s, the emphasis is on the
regional asymmetries in the placement of the workforce
and in the migration flows from developing to developed
countries [37]. All models proposed include both supply-
and demand-based methodologies to tackle the problem.
Integrated methodologies
Methodology-wise, the trend observed is a continuation
of the second phase, with the call for a holistic approach
to the problem. HHR planning must be addressed from
an integrated perspective, including when analysing all
the blocks of the functioning system so as to calcu-
late the current and future gap between supply and
demand [73]. The authors’ proposal is in line with the
SHARP framework: modelling key demand (economic
and epidemiological) and supply inputs. Furthermore, it is
continuously stressed that the epidemiological drivers of
the need for health-care services should always be part of
HHR planning [30, 74].
When looking at the research literature produced at the
turn of the century, this trend becomes clear. Summing
up the results achieved so far, we can see that health-
care workforce planning is a complex endeavour, and it
becomes necessary to identify all the relevant variables to
accurately forecast the necessary resources for the future
[75]. Again, these variables relate to supply and needs
methodologies. A practical work conducted in Lithua-
nia to forecast family physicians for a 10-year timespan
employs this approach [76]. Firstly, this approach calcu-
lates the supply of physicians through the usual process of
modelling the training of physicians. Moreover, it crosses
the supply forecasts with three different projections for
demand: firstly, the requirements established by a panel of
experts using a Delphi technique; secondly, the resources
necessary to increase the number of visits; and thirdly,
an upper bound placed on the worker-to-population ratio
so that one family physician serves no more than 3 000
inhabitants. The conclusions reached suggest that the
well-informed panel of experts elaborated the most accu-
rate projection of demand for family practitioners and that
none of the supply projections was right on target. Simi-
larly, in a forecast analogous to the nursing profession in
Germany, the analysis is extended from the usual supply
and demand to include the effects of occupational flexibil-
ity and employment structure. Adding these two elements
to the analysis has a relevant influence on the projections
[77]. Notably, this pensiveness with the organizational
role, where the HHR is more than an aggregate number
but rather a dynamic and complex sum of individuals, is
clearly gaining traction.
In the same line, some researchers suggest a needs-
based analytical framework that incorporates input from
four separate elements: demography, epidemiology, stan-
dards of care and provider productivity [30], again falling
in the realm of integrated approaches. Alternatively, needs
can be decoupled in a functional form so that service
targets can be defined and deployed [1]. Dreesch et al.
claim that methods focusing strictly on the supply, on the
demand or on both fail to address or recognize the effects
of the skill mix (the potential of substitution) between
health professions. The importance of a more integrated
approach to HHR planning is also restated. With more or
less variables, the trend is clear: recent models use infor-
mation from both demand- and supply-based method-
ologies, including inputs as varied as demography, the
training process, workers’ productivity or biological needs
in order to generate their forecasts [18, 78, 79].
Although the emphasis is fundamentally put on address-
ing the problem from an integrated perspective, new
Amorim Lopes et al. Human Resources for Health (2015) 13:38 Page 11 of 19
strands of literature were also developed during this
phase. For instance, it is suggested that instead of
addressing the problem from a quantitative perspective,
either by adding to or subtracting from the stock of health
workers, it should rather be addressed with internal reor-
ganizations, redefining which tasks can be performed by
whom [80]. Such internal substitution and activity dele-
gation could be executed by transferring skills from the
medical specialist and the general medical practitioner
to other health professional roles, namely nurses with
higher education (midwives) or by creating new roles.
This methodology involves, therefore, playing with the
skill mix of the health-care professionals. This was put in
practice in Ireland by employing a model that targets both
supply and demand, reflecting the concerns for including
all parts of the system [28, 81]. Moreover, it tests four pol-
icy interventions, three of which related to supply and the
last related to the skill mix: increasing vocational training
places, recruiting professionals from abroad, incentivizing
later retirement and increasing nurse substitution so that
nurses can deliver more services. Similar studies, encom-
passing the workforce supply, demand and the skill mix,
were also conducted in the dentistry field during this
phase [82]. In this case, workforce supply and demand for
oral health needs are projected to study the impact of skill-
mix reorganizations. To forecast future dentist numbers,
a simple percentage increase based on previous yearly
increases is considered. To estimate demand, demogra-
phy evolution, rates of edentulousness, patterns of dental
attendance and treatment rates of older people, as well
as general dental service treatment times, are considered.
The effect of the skill mix is then studied considering sev-
eral scenarios of varying skill-mix use. Gallagher et al. find
that widening the skill mix can be extremely helpful to
build capacity for dental care.
Another concern that is raised during this phase is that
of measuring the outcome as an important indicator for
assessing the quality of the health-care services. The out-
come is a fundamental indicator for HHR planning. In
particular, equitable and timely access to health care are a
precondition to a good outcome, which is the variable to
be maximized [83].
In summary, it can be said that this stage was a phase
of settling with methodologies, namely supply-, demand-
and needs-based approaches, and of urging for a more
integrated approach while paying attention to the roles
of each health professional and the degree of substitution
between professions. Furthermore, a concern about the
outcome of health-care services was raised, where effec-
tiveness and quality of the treatment is considered on par
with the number of patients seen (productivity).
Methodologies: Integrated [18, 18, 28, 30, 73–79, 81, 82],
Skill mix [1, 28, 77–82], Needs [30, 77], Service targets [1]
and Productivity [77–79]
Discussion
Five decades of work in HHR planning fuelled by eminent
global shortages of health professionals have contributed
to establishing this research field as an important scien-
tific area, decisive for achieving worldwide health-care
targets [1]. Significant results have been attained. In par-
ticular, new methods and techniques were developed, and
the accuracy of projections improved remarkably [23], and
HHR planning became an area of prominent interest, with
the number of publications in the field increasing over
the years. Moreover, the literature evolved, replacing some
approaches with others, paying more attention to the
health-care workers and their productivity and to the del-
egation and distribution of skills. It prioritized integrated
approaches and the role of epidemiology in addressing the
problem. In fact, when we look through all the methodolo-
gies reviewed (Fig. 2), the emerging trend clearly supports
this claim. Integrated approaches are gaining ground after
decades of partial analyses turning to either a supply- or
a demand-based approach and in its simplest form only
resorting to worker-to-population ratio benchmarks.
In Table 4, we summarize the methodologies and
describe the necessary assumptions for using each of
the approaches, along with their advantages, limitations,
how these limitations are overcome, requirements and the
countries in which their usage was documented (accord-
ing to [9]). In the past, this overview would probably help
in choosing the methodology to adopt. With the call for
more integration, it assists in showing how a methodology
may fill in the gap towards a cohesive framework. Also,
it serves to show that there is no perfect methodology
capable of providing accurate forecasts without consider-
able pitfalls and that there is a trade-off between simplicity
and completeness, where going for a simpler methodology
may implicate leaving out important parts of the problem.
An integrated approach
The importance of a comprehensive, integrated approach
is continuously emphasized throughout the period in
review [3]. Although the need for an integrated approach
had already been stressed in several past publications, it
keeps on reappearing, suggesting that it might not have
been fully addressed as of yet. This approach faces many
challenges. A dynamic, system-level perspective covering
key drivers of supply and demand that includes both man-
power planning and workforce development is critical to
overcome such challenges [81]. The importance of paying
attention to needs is also continuously stressed, as changes
in the health patterns of the populations take place [84].
In summary, integrated approach refers to a method that
incorporates in its process projections of the workforce
supply and the impact of microeconomic and organiza-
tional changes in productivity and in the skill mix, of the
evolution of demand for health-care services and also of
Amorim Lopes et al. Human Resources for Health (2015) 13:38 Page 12 of 19
Fig. 2 Identification of the conceptual methodologies found in some of the literature for the period of 1950–2013
the evolution of health diseases and its potential impact
on the health system.
Notwithstanding, integrating all the pieces may be a
puzzling task. To assist with the task, in Fig. 3, we pro-
vide a high-level functional diagram with a proposal for
how methodologies could be coupled so as to turn it into
a seamlessly integrated system. On the supply side, we
have the current stock of workers along with the training
process so as to obtain an initial snapshot of the cur-
rent workforce. The current stock, which may or may not
be enough to tackle current demand, in which case an
imbalance exists, is subject to positive and negative flows
that may alter its number and composition. This given
quantity of workers may provide more or less health-care
services depending on their productivity and skill mix,
and that influences the conversion from head counts to
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Table 4 The methodological approaches established during the first phase of research
Methodology Description Assumptions Advantages Limitations Overcoming
limitations
Requirements Documented
usagea
Supply
Training Projects the availability of
health-care professionals
based on the current stock
of clinicians, the training
process (entries and
dropouts), migration flows,
attritions and retirement
rates
Demand for medical
services is assumed to
remain constant and
the projections are
used to reduce the
supply gap
Predictions for the
future supply can
be obtained in a
fairly simple and
immediate way
Demand for medical
services is assumed
to remain constant,
which may not
be true No critical
assessment of the
adequacy of current
service levels
Incorporate a model of
demand: economic or
needs-based (or both)
Evaluate current level of
service through waiting
lists, overtime hours,
foreign workers, etc.
Accurate and up-to-
date accounting of
the current stock of
physicians and nurses,
migration rates, entry
and drop out rates
and expected retirees
Service usage levels
from the health-care
sector
Australia, Belgium,
Canada, Chile,
Denmark, Finland,
France, Germany,
Ireland, Israel, Japan,
South Korea,
Norway, Switzerland,
The Netherlands,
United Kingdom,
USA
Productivity Reorganize services and/or
economic incentives to
promote higher
productivity. Work
harder or work smarter
Physicians and nurses
act as rational agents
and react to economic
incentives like wage
increases
Does not require
a change in the
quantity of human
resources. Can be
implemented
immediately
Productivity
improvements may
not be enough to
accommodate large
gaps in the supply of
professionals
Do not preclude from
evaluating the number
of professionals necessary
given different
productivity levels
Operational indicators
like the number of
patients served with a
given number of FTEs
(or head counts)
Australia, Canada,
Japan, Korea,
Netherlands, Norway,
Switzerland, United
Kingdom, USA
Skill mix Delegate certain tasks to
other health professionals.
Substitution can be
horizontal (between
medical professions) or
vertical (between
physicians and nurses)
Professionals can
assume new roles
and perform new
tasks
Does not require
a change in the
quantity of human
resources. Can be
implemented
immediately
Enforcing such
changes can be a
political challange.
Does not solve
large gaps in the
supply
Providing success
stories to involved
stakeholders, health
authorities and
medical associations
Education schools
that can provide
advanced education to
the existing workforce
Netherlands, United
Kingdom
Worker-to-
population
ratios
Specifies desirable worker-
to-population ratios based
on direct comparison with
another region of country
Regions and/or
countries can be
directly compared
Extremely easy to
understand and
apply
Useful for
providing baseline
comparisons
Does not take into
account the intrinsic
differences between
regions and countries,
the productivity and
skill mix of the available
workforce
Does not take into
account the intrinsic
differences between
regions and countries,
the productivity and
skill mix of the available
workforce
Records of the current
workforce to popula-
tion ratios
Chile, France,
Ireland, Israel,
Switzerland,
United Kingdom
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Table 4 The methodological approaches established during the first phase of research (Continued)
Demand
Economic Estimates future
requirements by
projecting the
effect of demographic and
socio-economic factors on
the current level of
service
Current level of
service is adequate.
Skill mix and
distribution of health
service is appropriate
Demographic profile
of the population and
its effect on health-
care demand can be
accurately forecasted
Conceptually easy
to understand and
to apply
Allows
decoupling of the
various components
of demand and their
influence on the overall
aggregate demand
Tends to produce
estimates of HHR
demand that
exceed practical
limits
No critical
assessment of the
adequacy of current
service levels
Ignores the real
demand,
focusing instead on
the effective demand
Take financial constraints
into consideration
Evaluate current level of
service through waiting
lists, overtime hours,
foreign workers, etc.
Include a needs-based
evaluation
Accurate and long-
term demographic
estimates
Service-usage
levels from the
health-care sector
Macroeconomic
indicators and
statistical data crossing
income and usage
Australia, Belgium,
Canada, Denmark,
Finland, Germany,
Japan, Norway,
South Korea,
Switzerland, The
Netherlands, USA
Needs Considers the effect of
epidemiology on the
demand for health-care
services
Projects age- and gender-
specific needs
based on morbidity
epidemiological trends
All health-care
needs can and
should be met
Resources are used in
accordance to needs
Allows for a fine-grained
analysis of the
requirements of
each medical specialty
Is independent of
the current service-
utilization ratios
Easy to understand
Absence of
economic/efficiency
considerations may
render the projections
unattainable
Dependent on
epidemiological
projections which
may not be obvious
Does not consider
the current level
of provision nor
the capacity of the
country to deliver
health care
Consider an upper bound
for a practical result
Consider projections of
the most common health
patterns Incorporate
economic considerations
in the model
Demographic estimates
that are accurate
Service-usage levels
from the
health-care sector
Belgium, Canada,
Germany, United
Kingdom
Service targets Defines normative targets
for the production of
health-care services, which
are then converted to HHR
requirements
Assumes that
established service
targets are
achievable in terms of
financial and
physical capital
resources
Easy to define, interpret
and understand
Facilitates cost
estimation
Requires modest
data and planning
capabilities
May originate unrealistic
assumptions
Ignores financial
and other active
constraints
Incorporate economic
considerations in the
model
Current level of
service
aOECD Report
Source: adapted from Hall and Mejia [13], O’Brien-Pallas [11] and Dreesch [1]
Amorim Lopes et al. Human Resources for Health (2015) 13:38 Page 15 of 19
Fig. 3 An integrated system that incorporates several methodologies to address the many facets of HHR planning
full-time equivalents (FTEs). Such conversion is critical to
properly assess the health-care workforce, as a significant
number of physicians and nurses work part-time only. For
this reason, FTE is a more accurate measure as it nor-
malizes the head counts. On the demand side, economic
(effective) demand can be initially measured by analysing
utilization indicators. How this demand will evolve in the
future will then be subject to typical economic factors
such as demography and the growth of the income/GDP.
In parallel, potential needs can be assessed by incorporat-
ing incidence and prevalence of diseases and then map-
ping a given disease to an estimate of FTE requirements.
Whether future supply forecasts should tackle all of the
estimated needs is a decision left to the consideration of
the policy maker, as this analysis does not incorporate
financial constraints. Such an integrated approach is more
complex, but not necessarily more difficult [12]. In fact,
policy-making cannot abstain from factoring in financial
and service planning considerations in a post hoc analysis,
since there may not be enough resources to accommo-
date for a sudden increase in the number of professionals.
Such analysis is not limited to a money perspective, to
the financial burden inputted on the system for educating
and hiring these medical professionals or to the installed
capacity in terms of medical schools, university hospitals,
hospital beds, primary care facilities and others, in order
to absorb planned increases in the health-care services
labour market.
Data requirements
None of these methodologies can be applied without the
adequate data to feed the model. A bare minimum of
information regarding the available medical workforce is
always required. Table 5 summarizes the most impor-
tant indicators for conducting a proper forecast. It is not
strictly necessary to possess all the information listed, but
the availability of the data increases the probability of a
more comprehensive projection.
Simpler approaches require fewer data. Worker-to-
population ratio benchmarks require a head count of
the number of licensed medical professionals, usually
made available by the government, medical and nurse
associations or by unions. Service targets use the cur-
rent level of service, which can be obtained from the
hospitals’ operational key performance indicators.
Needs
(potential) and economic (effective) demand, on the other
hand, require a more extensive set of indicators. For
needs, it is necessary to assess and validate current and
future incidence and prevalence of diseases and how that
may convert into necessary resources. Both tasks are
not straightforward and usually require acclaimed experts
in epidemiology to step in and provide both the esti-
mates, as well as an accounting of the resources that
will be necessary. Effective demand makes it necessary
not only to obtain metrics similar to those indispens-
able for a service-target analysis (such as the number of
inpatients and outpatients, number of occupied hospital
beds, average length of stay) but also demography and
socio-economic projections and how they affect demand.
Finally, modelling supply is also a challenging task in
terms of data requirements. Unless evidence is found
showing that the worker-to-population ratios will remain
constant for a long period of time, a supply-based anal-
ysis must be factored in. In such a case, it is necessary
to know the current stock of licensed providers, as well
as the number of intakes, exits and annual attritions,
which makes it necessary to model the training of medical
professionals.
Assuming that developing countries are in possession of
fewer data and that developed countries have more infor-
mation available, methodologies that require an extensive
set of data will be difficult to implement in developing
Amorim Lopes et al. Human Resources for Health (2015) 13:38 Page 16 of 19
Table 5 Data requirements for making use of each of the different documented methodologies
Methodology Indicators Data requirements
Supply
Stock of licensed providers
Baseline stock, age/sex distribution, growth projections
High
Annual additions to licensed stocks
Graduates, in-migration (foreign-trained, immigrantes, on temporary work permits),
returned to profession
Education/training programmes
Number of programmes and students enrolled, attrition rates, years to complete
programme, number of graduates, costs
Annual attritions to licensed stocks
Retirements, mortality, career changes, emigration, abroad
Productivity
Labour market
Occupational participation rates, occupational employment rates, employment
projections, vacancy rates, turnover rates, wage rates, productivity growth, cyclical factors,
alternative career options
High
Employment status
Full-time, part-time, casual, full-time equivalent (FTE), average hours worked, direct patient
care hours, no longer practising, not licensed in jurisdiction
Skill mix
Government policy variables
HHR education funding, alternative delivery modes, licencing regulations, professional
roles/deployment, recruitment/retention strategies, immigration policy, remuneration
rates/types, HHR capacity-building
High
Worker-to-population ratios
Health labour workforce
Number of active and employed physicians and nurses Low
Economic
Population demographics
Total population, age/sex distribution, births/deaths, population projections
HighSocio-economic variables
Disposable income, GDP growth projections, ethnic factors
Needs
Population health status
Age/sex mortality, morbidity, acuity
HighEpidemiology
Incidence and prevalence rates, hospital discharges, health patterns of the population
Service targets
Utilization patterns
Number of occupied beds, number of inpatients and outpatients, number of
surgeries/screenings/consultations performed, etc.
Low to high
countries. Therefore, such countries may start by using
simple techniques such as the worker-to-population ratio
or service-based benchmarks to tackle their present
imbalances. Developed countries should continue collect-
ing data and enhancing their models, adding less tangible
and yet relevant dimensions, such as productivity or skill
mix if they are not present already.
Conclusion
In this paper, we reviewed over 60 years of publications
in HHR planning. While doing so, we observed the evolu-
tion of the field, when and how methodologies emerged,
how they have been applied and the robustness of the
results, and we also identified the current trends in the
field. This work was called for because there is still no
accepted methodology to address HHR planning. Given
the rampant costs in the health-care sector and the over-
all influence that health care has on the general welfare
of society, as well as the potential impact of shortages on
the worldwide supply of medical professionals, an assess-
ment of what has been done and achieved and what
remains to be done was necessary to properly guide fur-
ther developments in this relevant field. Moreover, when
we contemplate the complex training process required
to earn a licence as a practitioner, we understand that
a shortage in medical professionals cannot be accom-
modated fast enough by decree, either by increasing the
number of intakes to medical schools or by inviting more
foreign-trained doctors or nurses.
Despite the abundance in approaches and techniques to
determine supply and need for professionals, none of the
methodologies has ultimately proved to be superior [85].
Recent studies testing current forecasting models show
that there is still plenty of room for improvement given
the gap between projected and actual results [12].
It becomes even clearer that workforce planning should
be accurate and performed in due time given the attri-
tions and the delays in enacting policies in the health-care
Amorim Lopes et al. Human Resources for Health (2015) 13:38 Page 17 of 19
sector. Adapting medical schools, altering legislation and
changing roles is an effort that may take years to bring
forth. Therefore, planning has to target a long enough
time horizon if it is to be useful and applicable and has to
be done pre-emptively.
It now seems obvious that, like any other complex prob-
lem, all the determining pieces of the system and their
interdependent relationships must be duly accounted for.
Therefore, pressing for integrated approaches is still a
valid and up-to-date concern. Furthermore, envision-
ing the health worker in its entire complexity makes
it possible to address the problem more comprehen-
sively, leaving room to improvements in productiv-
ity and in the distribution of work without having to
directly interfere with the training process or with the
health providers. Operations research and lean manage-
ment are particularly relevant in this area. This strat-
egy may be, in fact, a first attempt to solve the lack of
professionals.
The results of our review point in one clear direc-
tion: accurate HHR planning requires an approach that
is both integrated and flexible, featuring supply and
demand (potential and effective) and incorporating less
tangible factors, such as skill mix and productivity.
The road to accurate HHR planning cannot abstain
from this.
aHenceforth, the term ’approach’ is used loosely to refer
to the conceptual methodology employed rather than to
the technical and scientific apparatus used to obtain a
projection or forecast.
HHR: Health-care human resources; OECD: Organisation for Economic
Co-operation and Development; WHO: World Health Organization.
The authors declare that they have no competing interests.
Authors’ contributions
MAL proceeded with the literature review and drafted the paper, with BAL and
ASA providing guidance, critical assessment and peer review of the writing.
The three authors read, reviewed and approved the final manuscript.
We are extremely grateful to all the reviewers for their insightful comments
and contributions, as they significantly contributed to the improvement of this
paper. Also, we would like to thank several members of the European
Operations Research Society and the scientific committee of the EURO
Operational Research applied to Health, which provided insightful ideas and
feedback on the ongoing work.
1INESC TEC, Faculdade de Engenharia, Universidade do Porto, Porto, Portugal.
2Faculdade de Economia, Universidade do Porto, Porto, Portugal.
Received: 10 November 2014 Accepted: 2 May 2015
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- Abstract
- Authors’ contributions
Background
Methods
Results
Conclusion
Keywords
Introduction
Literature search method
Scope
Background
Supply
Methodologies for modelling supply
Demand
Methodologies for modelling demand
Evolution of the field
First phase: factor of production
Supply-based methodologies
Demand-based methodologies
Second phase: economic agent
Supply-based methodologies
Demand-based methodologies
Integrated methodologies
Third phase: fundamental resource
Integrated methodologies
Discussion
An integrated approach
Data requirements
Conclusion
Endnote
Abbreviations
Competing interests
Acknowledgements
Author details
References
Labour Market Integration of Refugee Health
Professionals in Germany: Challenges and
Strategies
Sidra Khan-G€okkaya* and Mike M€osko*
ABSTRACT
Refugee health professionals are a vulnerable group in a host country’s labour market as they
experience several barriers on their path to labour market integration. This study aims to iden-
tify challenges refugee health professionals and their supervisors experience at their work-
places and strategies they have developed to overcome these barriers. Semi-structured
interviews were conducted with refugee health professionals who have been living in Germany
for an average of four years and their supervisors (n = 24). The interviews were analysed
using qualitative content analysis. Nine themes were identified: (1) recognition of qualifica-
tions, (2) language competencies, (3) differing healthcare systems, (4) working culture, (5)
challenges with patients, (6) challenges with team members, (7) emotional challenges, (8) dis-
crimination and (9) exploitation. Results indicate the need to implement structural changes in
order to improve the labour market experiences of refugee health professionals.
BACKGROUND
The global healthcare workforce is facing skilled labour shortage. The World Health Organization
(WHO) estimates a global shortage of 14.5 million health professionals by 2030 (World Health Orga-
nization, 2006). The European Commission estimates a shortfall of 1 million health workers in Europe
by 2020 (European Commission, 2012), and employment agencies in Germany predict a nationwide
lack of health professionals (Bundesagentur f€ur Arbeit, 2018). In order to address this shortage, nearly
all European countries depend on the recruitment of foreign-trained health professionals (Organisation
for Economic Co-operation and Development (OECD), 2017). Another strategy that has been imple-
mented by the German government to address this shortage is the so-called “activation of domestic
potential” (Bundesregierung, 2018). With that, the German government aims to address those groups
that have difficult access to the labour market, such as refugees in order to improve their employability
and use them to fill shortages (Bundesregierung, 2018). As the number of refugees in Germany has
increased since 2015, the German government has recognized the need to address their labour market
integration (Bundesregierung, 2016). However, refugees belong to a particularly vulnerable group in
the labour market facing unemployment or underemployment (Tanay et al., 2016).
University Medical Center Hamburg-Eppendorf, Hamburg,
This paper is part of a special issue on the “Labour Market Integration of Highly Skilled Refugees in Sweden, Ger-
many and the Netherlands”
doi: 10.1111/imig.12752
© 2020 The Authors. International Migration
published by John Wiley & Sons Ltd on behalf
of International Organization for Migration
International Migration
ISSN 0020-7985
This is an open access article under the terms of the Crea
tive Commons Attribution-NonCommercial-NoDerivs
License, which permits use and distribution in any medium,
provided the original work is properly cited, the use is non-
commercial and no modifications or adaptations are made.
http://creativecommons.org/licenses/by-nc-nd/4.0/
http://creativecommons.org/licenses/by-nc-nd/4.0/
The barriers and difficulties that refugees face in the context of their labour market integration
are multidimensional and manifold. First, their access to the labour market in Germany is restricted
and depends on their legal status and the likelihood of getting a residency permit which in turn
depends on the country of origin (Bundesministerium f€ur Arbeit und Soziales, 2019). In Germany,
there is a ban on employment for all refugees within the first three months. After three months,
their access to the labour market is dependent on the individual residency status. As of the fourth
month, refugees need work permission from the foreign authority office in Germany and the local
employment agencies in order to work (Bundesministerium f€ur Arbeit und Soziales, 2019). Their
access to language courses depends on their legal status and the likelihood of receiving a residence
permit (Bundesministerium f€ur Arbeit und Soziales, 2019). Moreover, participating in job-related
language courses is described as challenging either due to long waiting times or course availability
(United Nations High Commissioner for Refugees-Organisation for Economic Co-operation and
Development (UNHCR-OECD), 2016). Second, refugee health professionals need to go through a
difficult and long recognition process (K€ortek, 2015; Desiderio, 2016) which is described as the
starting point for permanent downward mobility (Hawthorne, 2002). Moreover, refugees may not
be able to provide identity documents (Bucken-Knapp et al., 2019) or official documents about
their education (Bloch, 2008) due to the flight which impedes the recognition process. Third, a lack
of information about career pathways (Cohn et al., 2006), such as knowledge about job search
strategies (Willott and Stevenson, 2013) and unfamiliarity with the healthcare system of the host
country (Ong et al., 2004), are reported barriers. Fourth, due to their flight they may have had a
break in their professional career and/or experienced the loss of their professional status (Willott
and Stevenson, 2013) which is related to the loss of professional identity (Peisker and Tilbury,
2003). It may also result in deskilling (Stewart, 2003), loss of self-confidence (Willott and Steven-
son, 2013), high levels of frustration (Mozetic, 2018) and negative psychological impacts (Cohn
et al., 2006). Additionally, the lack of recognition of their previously gained experiences leads to a
feeling of being disadvantaged compared to locally trained team members (Mozetic, 2018) which
might be intensified by the experience of multiple forms of discrimination (Jirovsky et al., 2015)
and exclusion (Bloch, 2008).
Studies in Germany have also focused on the working experiences of migrant physicians and
international nurses from within the European Union as well as from non-European countries. They
report similar barriers as the above-mentioned. A study on migrant physicians (Klingler and Marck-
mann, 2016) describes difficulties in three fields. The first field refers to the organization of health-
care institutions and other institutional difficulties such as insufficient support or being assigned to
tasks below their level of expertise. Moreover, difficult career advancement opportunities and unfair
treatment of migrant physicians were mentioned as institutional difficulties. The second field relates
to experienced difficulties with own competencies such as language competencies and knowledge
about the healthcare system. The third field relates to difficulties in interpersonal relations and inter-
actions such as inadequate treatment of patients and co-workers. In this context, a study on the
workplace integration of internationally recruited nurses in Germany points out that conflicts often
arise between migrated nurses and locally trained team members. These conflicts arise because
locally trained team members either hold back or do not comprehensively share key information in
order to organize their work. Thus, the incorporation of migrated nurses into daily work routine is
impeded and the potential for conflicts in everyday work is increased (P€utz et al., 2019). These
studies illustrate that international healthcare professionals and refugee healthcare professionals
experience similar barriers at their workplaces. However, refugees were forced to flee by the cir-
cumstances of their home countries (Yarris and Casta~neda, 2015), whereas internationally recruited
health professionals may be considered as voluntary migrants. This distinction between refugees
and voluntary migrants has effects on the barriers they experience. While voluntary migrants were
most likely able to prepare for their migration, refugees had to flee under extreme conditions (Jack-
son et al., 2004). Stressors of the flight, the loss of family members, traumatic experiences and the
2 Khan-G€okkaya and M€osko
© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration
uncertainty about their residency permit (Carlsson and Sonne, 2018) may also influence their pre-
requisites to work. Rather, in comparison to other highly qualified migrants, highly qualified refu-
gees are more likely to stay in jobs they are overqualified for which mainly relates to the fact that
documentation of their education is missing (Tanay et al., 2016). Moreover, some other barriers,
such as housing, health, absence of networks or childcare, may indirectly influence employment
outcomes (OECD/UNHCR, 2018).
The European Parliament recommends qualification programmes to prepare refugees for work
and strengthen their employability (Konle-Seidl, 2016). These recommendations comprise individu-
ally tailored programmes to the specific needs of refugees. Amongst others, it is recommended to
provide (occupational specific) language courses combined with working opportunities, skills
assessment, mentoring and career advice. For highly skilled refugees, it is especially recommended
to increase availability of on the job trainings, recognize existing qualifications and offer vocational
training. However, in order to implement tailored programmes that match the host countries’ legal
and social requirements it is essential to identify and analyse the barriers refugee health profession-
als face when entering the labour market. While the legal situation of refugees and their access to
the labour market in Germany is documented through policy papers (European Commission, 2012;
Platonova and Urso, 2012; Konle-Seidl, 2016; Tanay et al., 2016; UNHCR-OECD, 2016; OECD,
2017; United Nations Department of Economic and Social Affairs Population Division, 2017;
UNHCR, 2017; Bundesministerium f€ur Arbeit und Soziales, 2019), little attention has been paid to
the challenges they face in everyday working life and their own perspective and strategies. Thus, in
this study, refugee health professionals and their supervisors across Germany were interviewed
about the challenges they faced at their workplaces as workplaces are a “key site of sociocultural
incorporation” (van Riemsdijk et al., 2016). Moreover, this paper advances this field by giving rec-
ommendations for healthcare providers and organizations based on the experiences of refugee
health professionals and their supervisors in order to implement changes on structural levels and
improve the working environment. These changes refer to establishing supporting structures as well
as measures of diversity management and anti-discrimination.
METHODS
The reporting of methods is in accordance with the consolidated criteria for reporting qualitative
research (COREQ) guidelines (Tong et al., 2007).
Researcher characteristics
Qualitative research depends on the personal qualities of the researcher and the theoretical sensitiv-
ity that the researcher brings to a research (Strauss and Corbin, 1990). Thus, it is important to
reflect on the researcher’s characteristics and its impact on the interview situation. All interviews
were conducted in person by the first author, female, person of color, PhD student of the Depart-
ment of Medical Psychology at the University Medical Center Hamburg-Eppendorf. The first author
is trained in cultural studies, international migration and intercultural studies and has several years
of training in conducting qualitative studies. For transparency reasons, participants were informed
that the study was part of a PhD study.
Recruitment
Major educational organizations and projects for the labour market integration of refugee health
professionals (RHPs) across Germany were identified through internet research. The organizations
Labour market: Refugee health professionals 3
© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration
(n = 15) were contacted and informed about the study. Their consent was obtained. Three of the
major organizations agreed to participate in the study. Participants were divided into RHPs and
supervisors as the refugees’ self-perception about their experiences might differ from the supervi-
sors’ perception. Since the group of RHPs comprises different professions, we decided on subdivid-
ing the stratum of RHPs into two groups: physicians and other health professions. In terms of data
saturation, it is recommended to conduct six to twelve interviews per stratum (Guest et al., 2006).
Thus, 24 interviews were conducted in three major cities in Germany (Hamburg, Hannover and
Frankfurt). All three organizations provided persons that matched the inclusion criteria with infor-
mation on this study and either arranged appointments or provided participants with the research-
ers’ contact information. Inclusion criteria for participants referred to the following aspects:
Target group1.:
• Refugees (regardless of their residency status and form of protection) who have obtained a
qualification in a health profession in their home country or a country other than Germany;
• Supervisors that were responsible for the integration of refugee health professionals, their
supervision or support
Language competencies:
• Required minimum level of German language competencies on the European Reference
level of A2-B12.
Working experiences in Germany:
• RHPs must have had contact with the German healthcare system with a minimum duration
of one month – be it a steady job, an internship or job shadowing
• Supervisors had to work in jobs with close contact with refugee health professionals regard-
less of their hierarchical status. They must have had supervised RHPs at their ward or as an
external supervisor
Context:
• RHPs and supervisors in all healthcare institutions comprising primary, secondary and ter-
tiary care were included
Providers were informed about the inclusion criteria and selected fitting participants. All inter-
views were conducted in German. In one case the inclusion criteria did not match as the participant
was a student of the educational organization without sufficient working experience. Participants
that matched the inclusion criteria were approached via phone followed by an invitation to live
interviews. Participants received two consent forms: one for their participation in the study and one
for their consent to audio recording. The consent form and the study information were orally
explained prior to the interview.
Data collection
The interview guide was developed based on literature focused on the daily work experiences of
refugee health professionals using the SPSS3. approach by Helfferich (2009). The interview guide
was sent to experts in the field of migration research to be critically reviewed. Based on this
review, the authors discussed and adapted the interview guide. Finally, the interview guide was
4 Khan-G€okkaya and M€osko
© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration
piloted with two migrant nurses that resulted in the specification of some questions. The interview
guide was structured into six main themes:
(1) General experiences while working in a hospital
(2) Experiences with team members and supervisors
(3) Experiences with patients
(4) Experiences with the working culture
(5) Experiences with the healthcare system
(6) Suggestions for improvement
In each interview, the same semi-structured guide was used. After the interview was finished and
the audio recorder was switched off, demographic data were retrieved. The interviews lasted from
00:18 to 00:55 min with a median range of 00:40. Some (n = 4) interviews were transcribed by a
student researcher but the majority (n = 20) of the interviews were transcribed verbatim by a pro-
fessional agency. All transcripts were proofread by the first author.
Data analysis
The interviews were analysed using content analysis (Mayring, 2015). The first author coded all
interviews by means of a computer-based coding programme (MAXQDA, version 10). Deductive
codes were derived from the interview guide but as an explorative approach was preferred more
inductive categories were derived from the material. Code memos were created for all codes includ-
ing a description of the code and typical quotes. For the purpose of quality assurance, a research
assistant coded a random selection of one-quarter of all interviews. Differences in coding were dis-
cussed until a consensus was reached that led to the creation of some new sub codes and a revision
of the category system. Results were presented and discussed with other experts in an interdisci-
plinary research colloquium to ensure comprehensibility and intersubjective reproducibility. The
revised system was then crosschecked by the main author in a second round of coding taking all
interviews into consideration.
Description of sample
Sixteen RHPs and 8 supervisors participated in the study. Two interviews were conducted via tele-
phone due to reduced mobility of the participants. The sample is described in Table 1.
RESULTS
In general, nine major challenges could be identified which either RHPs or supervisors described as
relevant: (1) the recognition of professional qualifications, (2) language competencies, (3) different
healthcare systems, (4) working culture, (5) challenges with patients, (6) challenges with team
members, (7) emotional challenges, (8) discrimination, (9) exploitation. Table 2 provides an over-
view of the identified fields and their specifications.
Recognition4. of professional qualifications
Both supervisors and RHPs pointed out the challenges they faced with regard to the recognition
process of their professional qualifications. Supervisors especially emphasized the difficulties
regarding the recognition process. They criticized the long waiting times for the recognition process
Labour market: Refugee health professionals 5
© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration
TABLE 1
SAMPLE DESCRIPTION (REFUGEE HEALTH PROFESSIONALS AND SUPERVISORS)
Refugee health professionals (RHPs)
Participant Sex Age
Country
of birth Occupation
Working
experience
in Germany
Working experience
in birth country
A1 m 26 Iran Nurse 1 month 6 years as a nurse
A2 m 23 Iraq Physician 3 months 2 years as a general
physician and
3 years as a
surgeon
A3 m 28 Syria Physiotherapist 2 years 4 years as a physio-
therapist
A4 m 28 Syria Physician
(specialized
in Anaesthesia)
8 months 2,5 years as a medi-
cal assistant in sur-
gery
A6 m 33 Syria Physician 5 months 5 years as a physi-
cian
A7 m 38 Afghanistan Physician one year 1 year as a medical
assistant, 3 years in
public health depart-
ment
A8 w 29 Syria Physician 1,5 years 1 year as a physician
A9 m 30 Afghanistan Physician 3 months 1 year as a medical
assistant
A10 m 44 Syria Physician
(specialized
in anaesthesia)
3, 5 years 4 years as a medical
assistant, two years
as a senior physi-
cian, 9 years as a
chief physician
A11 w 52 Afghanistan Physician (specialized
in gynaecology)
6 months 23 years as a gynae-
cologist (also as a
chief gynaecologist)
A12 m 39 Yemen Physician 4 months 10 years as a physi-
cian
A13 m 45 Afghanistan Physician 2 years 2,5 years as a physi-
cian
A14 m 51 Syria Dentist 3 months 21 years as a dentist
A15 m 39 Afghanistan Physician
(specialized
in
otorhinolaryngology)
6 weeks 3 years as an ear-
nose-throat (ENT)
specialist
A16 w 33 Senegal Midwife and Nurse 3 months eleven months as a
midwife, 15 years
as a nurse
A17 w 36 Azerbaijan Nurse 3 months 2 years as a nurse
Supervisors
Participant Sex Age
Country
of birth Education Current job Experience
B1 m 34 Germany Physiotherapist Part time
physiothera-
pist, part
time supervi-
sor for RHPs
and migrants
5 years as a
physiotherapist,
1 year as a
supervisor
6 Khan-G€okkaya and M€osko
© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration
(B2-B4, B8) and noted that the bureaucratic procedures for recognition in Germany were not clear
and prolonged the recognition process (B4, B7, B8). RHPs also criticized the length and complex-
ity of the recognition process (A4, A7, A8, A11, A12). Two supervisors (B4, B8) criticized that
former positions such as leadership titles of RHPs were not recognized in Germany. They also criti-
cized that RHP’s specialist medical training or their internships in Germany were not considered
for recognition as working experiences. Furthermore, in one case there was confusion about the
legal foundations of the responsible authorities’ bodies:
One colleague receives a temporary work permit [from the recognition authority] but federal medi-
cal council law and health insurance company’s law contradict each other which inhibits him from
working as a physician unless he has a full licence to practise medicine. But he can only acquire
the full license after taking an exam. Taking that exam is on hold because the [recognition] authori-
ties are understaffed. (B3)5.
RHPs (A1, A11, A13, A15) also indicated their anxiety regarding the licensing examinations as
they feared the examination would be too difficult.
Language competencies
Supervisors and RHPs considered acquiring German language proficiency and German technical
and medical language as a major topic. Supervisors emphasized especially the need to learn the
TABLE 1
(CONTINUED)
Supervisors
Participant Sex Age
Country
of birth Education Current job Experience
B2 m 64 Germany Librarian and editor Commissioner
for refugees
at the medi-
cal associa-
tion in lower
Saxony
2,5 years as
a commissioner
B3 m 64 Germany Physician Physician and
Supervisor
for RHPs
34 years as a
physician,
one year as
a supervisor
B4 m 73 Germany Physician Supervisor for
RHPs/
retired
47 years as
a physician,
2 years as
a supervisor
B5 w 50 Germany Nurse and
professional
advisor
Professional
advisor
15 years as
an advisor
B6 w 54 Germany Nurse Nurse and
supervisor
37 years as nurse
and supervisor
B7 w 38 Germany Nurse and
Psychologist
Psychologist seven years as a
psychologist
B8 m 52 Germany Physician,
Medical
journalist
Managing
director of
refugee and
migrant edu-
cation centre
2 years as
managing director
Labour market: Refugee health professionals 7
© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration
technical language. They (B1, B5, B8) described that RHPs were afraid to admit there were
parts they did not understand and continued to say “yes” in order to maintain the conversation
flow. This has often led to misunderstandings. RHPs described difficulties in speaking everyday
language and technical language. They (A1, A2, A4) found it difficult to understand handover
reports from physicians or keep up in meetings and written documentation. They (A1, A3, A7,
A12) were also afraid of not being able to understand the language which influenced their
behaviour:
I am afraid if [a patient] someone rings the bell. [. . .] Because my language is not [well] enough
and I am afraid of understanding something wrong or not being able to answer [the patient’s ques-
tion]. That’s why I remain seated and others [colleagues] keep asking me “why are you always sit-
ting?” (A1)
One of them also expressed their fear of being deemed to be incompetent due to their language
competencies: “They think I have learned it wrong in Iran. But in fact I couldn’t understand what
they were asking me” (A1). Moreover, RHPs (A1, A3, A12) felt their language competencies held
them back as they were reluctant to share their opinion: “If we discuss a patient’s case and some-
one has a contradicting opinion on that patient’s case I am afraid to discuss our opinions as I fear
they will say ‘I can’t express myself’” (A3).
Different healthcare systems
Supervisors and RHPs described challenges that derived from differing standards in the home
and host countries’ healthcare system. All supervisors described that RHPs would have to
familiarize themselves and catch up with the healthcare system in Germany. Eleven RHPs (A1,
A2, A8, A9, A11-17) emphasized the difference in the medical equipment, the names of
TABLE 2
CHALLENGES EXPERIENCED BY REFUGEE HEALTH PROFESSIONALS
Recognition of professional
qualifications
Difficulties in the context of the recognition process
Non-recognition of former experiences
Examinations for recognition
Language competencies Knowledge of everyday language
Knowledge of technical language
Feelings and consequences of lacking language competencies
Different healthcare systems Unfamiliarity with and differences between the healthcare systems
Unfamiliarity with bureaucratic procedures within the healthcare system
Consequences of differences and unfamiliarity
Working culture Adaption to formal aspects of work
Adaption to cultural aspects of work
Intercultural and interpersonal differences
Difficulties with patients Language difficulties
Difficulties in delivering bad news
Distrust from patients
Difficulties with team members Difficulties during internships
Interpersonal and interprofessional difficulties
General Emotional Difficulties Discouragement
Negative feelings of RHPs in the context of labour market integration.
Discrimination Discrimination by patients
Discrimination by team members
Exploitation Financial exploitation of RHPs in the context of work.
Professional exploitation of RHPs in the context of work
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International Organization for Migration
medication and working habits and the feeling to need to familiarize themselves with these dif-
ferences. In this context, supervisors referred especially to the differing professional role of
nurses in Germany:
They mostly come from countries where nursing care is much higher regarded as a profession, it
gets a very high recognition. And here they have to understand this in such a way that the job
description or the professional role is not so highly regarded. (B6)
RHPs (A1-4, A7, A9-A10, A12-A15) criticized bureaucratic procedures in hospitals in Germany
as it was challenging to keep up with all the procedures of them. They (A4, A17, A16) did not
know about occupational law and were also insecure about their rights and obligations in their pro-
fessional duties. During internships or work, they (A2, A3, A8, A9, A10, A13-17) felt held back
as some of them were not allowed to work either because of their status as interns or because they
did not have their license yet:
Yes, the situation was unpleasant that I could not do anything alone. And if I wanted to do some-
thing, someone had to stay with me, a senior physician or chief physician. That was a bit uncom-
fortable for me because I already graduated from university and I also worked as an assistant
physician in my home country for a year. But I didn’t have a solution. I had to come to Germany
and here, the rule is if someone doesn’t have a license he has to cooperate with a chief physician
or with a senior physician. (A9)
Working culture
Supervisors described two facets of working culture that they found important in the context of
their experiences with RHPs: formal and cultural aspects of work and RHPs adaption to these
aspects. They emphasized formal aspects such as being punctual, submitting holiday applications
correctly, calling in sick, being polite and committed to work. Some of the supervisors (B1, B2,
B3, B6, B7, B8) criticized some of these aspects in the context of RHPs as deficits. With regard to
cultural aspects, supervisors mentioned that RHPs had different values that sometimes inhibited
their integration such as examining other-sex patients (B1, B6-B8), taking off headscarves for sev-
eral reasons (B1, B8), dealing with homosexuality (B1) or accepting female superiors (B1-B4, B7).
These values were often attributed to cultural differences although they may result from context-
specific causes, as one supervisor who had a mediatory role describes:
The [female] colleague shouted at him [the RHP] in front of the patients [. . .] Luckily, we heard
about it and picked it up [. . .] she said he was a macho and suggested women were worth less than
men. The trigger was a basic nursing situation which is difficult for our participants as they haven’t
learned it in their home countries. And she gave instructions that were too brief, for example
“wash” and he didn’t know what to do with that instruction. […] And that caused the escalation
spiral. (B7)
RHPs were also asked about their experiences in the context of working culture. They pointed
out that formal aspects of work, such as being punctual and committed, were universal. However,
they (A1, A3, A8, A13, A16) experienced differences on the intercultural and interpersonal level,
such as the value of families and treating other sex patients, and developed several strategies to get
adapted to it:
I was born in an Islamic country. I am not Muslim but born there and I grew up there. And some-
times I think, maybe the [female] patient is embarrassed. Or I ask may I look, may I do. Because
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© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration
maybe the other colleague does not say anything at all but for me it is a bit ok – maybe she has
problem with men and so on, so I ask. (A1)
Challenges with patients
RHPs experienced difficulties with patients especially if patients did not speak clearly due to their
illness, their age or their way of speaking:
The problem was that I couldn’t understand. For example, the patient said “bring me this and that”.
And the problem was that they spoke very unclearly and for German people it [is] also difficult to
understand and for me of course [it is] especially difficult. (A1)
Some described that talking to patients’ relatives was a new challenging experience especially if
they were furious (A8) or if they had to pass bad news to them (A7). Another challenge was asso-
ciated with distrust from patients: “Maybe they don’t trust the foreign physicians as much but that’s
general [generally the case]. All patients are like that, almost all of them. […] You can tell, they’re
a little scared or something” (A4).
Challenges with team members
Almost all supervisors (B2, B4-8) mentioned the important role of internships in the context of
team integration. However, one supervisor reported that finding internship placements became more
and more difficult due to lower capacities of the hospitals (B4). During some internships, partici-
pants were not given appropriate tasks or were not supervised (B2, B5, B7, B8) as “it is associated
with effort to take along someone” (B7). Sometimes local trained team members were not aware of
what RHPs were allowed or permitted to do which often led to misunderstandings (B5, B7, B8).
Almost all of the RHPs mentioned several other challenges in the context of teamwork, such as a
distanced relationship towards local trained team members (A8, A11, A15, A16), their expectation
that RHPs could do and know everything and wrong ideas of them and their education (A1, A9,
A10).
General Emotional challenges
Some of the RHPs (A3, A8, A16) experienced discouragement on their path to reintegration. They
were told by their employment agency consultants that they could not succeed as health profession-
als in Germany and were advised to pursue other career options:
I wanted to go to the hospital and see how this works. And I wasn’t sure if I could do that again. I
thought it is not possible. Because everywhere where I had asked [they said]: “No, you can’t do
that. Do another one. Do a retraining and so on. Do some care. But you can’t do midwife.” And I
came to my ward. I saw it, it is the same thing. (A16)
Additionally to being discouraged, supervisors thought RHPs felt impeded (B4), afraid (B5, B7,
B8), frustrated (B1, B6), under pressure and isolated (B1) as a consequence of the experienced bar-
riers. Moreover, they acknowledged RHPs’ loss of their professional status and mentioned that
RHPs were reduced to their language deficits (B1, B6, B7) which influenced their self-perception
and made them question themselves (B7).
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Discrimination
RHPs experienced several forms of discrimination. One supervisor reported that RHPs were some-
times rejected and ignored in decision-making. He describes a situation between a refugee physi-
cian and a locally trained nurse:
I can give you an example: my [refugee] physician is treating a patient. Another [locally trained]
nurse has a question about that patient. He [the nurse] is standing in front of my [refugee] physi-
cian and tells him: “I don’t want to clarify this with you. I will talk to your colleague who under-
stands me.” And that is a nice form of rejection. There are even more blatant cases. (B1)
Five supervisors (B1, B5, B6, B7, B8) and six RHPs (A1, A2, A3, A7, A10, A15) also reported
discrimination from patients towards foreign health professionals: “I was in the room, I had to take
[a] blood [sample] and the patient and also her husband said: ‘No, you may not come here. We do
not want a foreign physician here’” (A15). However, supervisors differentiated between open dis-
crimination and subtle racism from patients. They also differentiated between patients who did not
fully trust RHPs and patients who treated them in a racist manner from the beginning. In the con-
text of foreign-trained health professionals, one supervisor described intersectional discrimination as
some patients racially and sexually harassed female nurses from Thailand:
There was a situation where an older “fascist grandfather” in quotation marks somehow said he
didn’t want that or the Thai ladies – how shall I say, perhaps sexualised? So, with Thai participants
or Asian looking participants, the gentlemen often become a little bit, how can you say, more
cheeky. (B1)
Although this quote does not explicitly refer to refugee health professionals, it is likely that
RHPs also experience intersectional discrimination.
Additionally, RHPs (A3, A4, A8, A10-A13, A15) experienced discrimination from senior team
members as one female physicians describes:
I was at that interview with the chief physician and at the end he said: “Your German is well, […]
but there is something negative. [. . .] You have this headscarf. You are Muslim and there are a lot
of (tourist? terrorists? [incomprehensible]). How can the patients be sure that you are not a (tourist?
terrorist?)?” That moment was horrible for me. (A8)
The physician described that she refused the position afterwards due to this experience and
started working in a catholic hospital as her headscarf is not a problem there “because nuns also
wear a headscarf” (A8).
Exploitation
In addition to the discrimination faced by patients and team members, two supervisors (B2, B8)
described experiences of exploitation:
There are hospitals who misuse the situation of RHPs. There are hospitals that pay below the pay
scale (Tarifvertrag), very far below the scale. I will give you an example. There are hospitals in the
[anonymized] region who employ physicians from Afghanistan, Syria, Iraq. They hire them for-
mally as assistants, pay them 800 to 1200 Euros for a full time job, but they work as normal physi-
cians and are involved in normal hospital routine. No plaintiff, no judge6.. For the RHP it is at
least something. He can work as a physician after a long time and familiarize with procedures,
improve his language and do what he is qualified to do. But, by our standards, that is exploitation.
(B8)
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© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration
This would also affect RHPs’ claims for benefits after terminating the employment (B8). Addi-
tionally to financial exploitation, one supervisor also mentioned that RHPs were sometimes hired as
gap fillers not correspondingly to their qualifications and did not have a long-term perspective
(B8). RHPs did not explicitly mention being exploited. However, many of them were not yet per-
manently working and one reported doing unpaid overtime, as he did not know about working
rights in Germany (A4).
Resources and strategies
RHPS and supervisors described several strategies they had developed in order to address the experi-
enced barriers. These strategies refer to individual strategies of RHPs, strategies in the context of edu-
cation and support, strategies on the team level and strategies on the organizational and societal level.
Individual strategies
All RHPs described several individual strategies to cope with challenges they had faced such as being
patient (A1, A2, A6, A9), trusting and believing in their own power resources (A3, A13, A16) or pre-/
post-processing relevant professional content (A1, A7, A12, A16). They also actively engaged with
their colleagues, asked them questions, demanded feedback (A9, A16) in order to cope with language
deficits. Furthermore, RHPs developed several strategies to cope with patients’ discrimination. They
either tried to reassure patients (A10, A12), accepted patients’ wishes and called a team member (A4),
ignored (A7) or avoided patients that rejected them (A16). In dealing with discrimination from team
members, some RHPs would focus on their goal instead of focusing on conflicts and try not to think
too much about these experiences (A12, A15). Others would use humour in order to unburden a
tensed situations with jokes (A10). Staying silent was described as a strategy as well:
I didn’t do anything and I didn’t say anything because I knew that if I said something, the situation
would get worse and I didn’t want that to happen. Yes, I was very calm and I wanted this nurse to
go home and think for herself, then she would understand. […] Yes, later she was a little better. All
beginnings are difficult. (A9)
Supervisors pointed out individual competencies of RHPs in dealing with the barriers. They
emphasized RHPs’ great commitment and their positive working attitudes. They also highlighted
the competencies of RHPs such as their intercultural competence (B4, B8), their openness to new
experiences (B1, B6, B7), a high motivation to work (BB7, B4, B3, B2), their cooperation capabil-
ity (B3), their gratefulness (B5) and their fighting spirit (B7).
Strategies in the context of education and support
In the field of education, supervisors demanded: mandatory, well organized, on the job programmes for
all RHPs that are funded (B8), career advice services (B6, B7), follow-up support (B7), more resources
and equipment for the training of RHPs (B4, B6, B7), material and support for language training.
Strategies on the team level
Generally speaking, positive contact towards patients and team members was perceived as very
helpful. One supervisor described RHPs’ and patients’ relationships as “a mutual connection as
they are stronger dependent on each other” (B7) than in other cases. Likewise, team members were
described by all RHPS to be open, interested and supportive: “They were all friendly and every
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International Organization for Migration
morning when I came to work they smiled at me and said ‘good morning’. And that I find really
important for a newly arrived” (A12). Almost all of them (A1-A4, A7-A9, A11-A14, A16-A17)
emphasized that colleagues were forthcoming if they had questions and that they benefitted from
their induction and their feedback. Two of them (A8, A11) pointed out the role of other (locally
trained) interns and students who helped them in their free time. Supervisors focused more on
structural resources for teams. They suggested training for local team members and mediators (B1,
B7), more personnel and more time to induct RHPs (B3, B6, B7), clear contact persons that RHPs
can talk to (B1, B4) and clear instructions of team members (B3). They also mentioned time to
familiarize for RHPs (B1, B2, B6, B7), less patients to care for at the beginning (B7) and sensitiza-
tion and reflexivity of locally trained team members (B1, B3, B7).
Strategies on an organizational and societal level
On an organizational and societal level, supervisors suggested enhancing an overall integration
approach so that RHPs can have a quick arrival in the system (B1), build up networks (B1, B6)
and earn their own money (B1). They also mentioned an opening welcoming culture (B1), public
sensitivity actions and support from the management boards (B7):
But we also need the attitude from above [the management board] that says: “We want that [the
labour market integration of RHPs], and we also provide time and resources, and teams also get a
benefit for getting involved”. (B7)
One supervisor referred to the commitment of supervisors and the healthcare providers when
observing racism and sexism: “If the hospital positions itself clearly and says ‘take your documents
and go home because we are not going to treat you’. Great, because that is a clear line. But if they
talk around the issue the patient will continue to show racist behaviour” (B8).
DISCUSSION
This paper aimed to explore the barriers and resources RHPs faced at their workplaces. The broad
range of identified barriers and difficulties indicates that their experiences depend very much on their
employers and their working environment. Moreover, as understaffing is a common problem in
health care (Angerer et al., 2011; Deutscher Gewerkschaftsbund (DGB), 2018), it is questionable to
what extent only RHPs are affected by these experiences or if they are a consequence of the precari-
ous staffing situations. Moreover, it remains open to what degree the migration status influences the
experienced challenges. Since no questions were asked about their flight, their psychological well-
being or their residency permit and none of the participants mentioned it in the context of their
workplace experiences, it is not possible to state whether only refugees experience these barriers.
Instead, our results indicate that when focusing at their workplaces, RHPs face similar barriers as
internationally recruited professionals and voluntary migrants (Humphries et al., 2013; Jirovsky
et al., 2015; Klingler and Marckmann, 2016; P€utz et al., 2019). Nine major challenges were identi-
fied: 1) recognition of qualifications, (2) language competencies, (3) different healthcare systems, (4)
working culture, (5) challenges with patients, (6) challenges with team members, (7) emotional chal-
lenges, (8) discrimination and (9) exploitation. These challenges illustrate that hiring RHPs should
not be a quick response to filling shortages. Instead, the integration process should be carefully pre-
pared in order to prevent some of these challenges. Labour market integration is a two-sided process
that requires not only a welcoming culture but also welcoming structures (Knuth, 2019). Educational
providers, employers as well as authorities need to address these barriers and implement structural
changes in order to contribute to a sustainable labour market integration of RHPs.
Labour market: Refugee health professionals 13
© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration
Both RHPs and supervisors emphasized the challenges with the recognition process. This is con-
sistent with previous findings that many legal and formal barriers inhibit a successful labour market
integration and prevent organizations to invest in RHPs integration (Schmidt, 2019).
RHPs and supervisors both stressed the role of acquiring the language and the consequences of
lacking language competencies. RHPs suffered from not speaking German fluently, and it affected
their self-esteem. Likewise, the knowledge and familiarization with the local healthcare system is
an important prerequisite in order to deliver a good working performance. Both barriers are
reported to be common challenges in the context of labour market integration of refugees as well
as other migrant groups (Cohn et al., 2006; Bloch, 2008; Leblanc et al., 2013; Klingler and Marck-
mann, 2016). This indicates a stronger need for occupational specific language courses and infor-
mation on the healthcare system of the host country. This would not only concern educational
providers but also employers. In order to maintain a good quality of care and prevent misunder-
standings or mistreatment due to language barriers (Klingler and Marckmann, 2016), employers
can invest in further education of their RHP employees. Although this would mean additional
financial investment from the employer, a corporate study indicates that those investments would
pay off within a year (Baic et al., 2017).
In the context of working culture, a fast adaptation to local standards was expected by supervi-
sors and team members. Deviations from these local standards were seen as problematic and
obstructive. This coincided with results from other studies (Klingler et al., 2018; P€utz et al., 2019)
However, it remains problematic due to several reasons. Firstly, the term “local standards” pre-
sumes shared standards (Klingler et al., 2018). However, it remains unclear if these standards refer
to professional standards, legal regulations, norms, cultural aspects or hospital routines. Secondly,
the knowledge about certain established standards may be tacit and implicit (Sakamoto et al., 2010)
thus unspoken. As RHPs are unaware of these unspoken standards, deviations in behaviour can
lead to frustration, conflicts and exclusion (Lai et al., 2017). Thirdly, most of the perceived differ-
ences in the context of working culture from the supervisors were culturalized. Supervisors saw the
causes of conflicts in cultural distinctions, although they could as well be interpreted situation and
person specifically or result from differing concepts of work. This is consistent with previous find-
ings (P€utz et al., 2019) that in the process of labour market integration differing concepts attributed
to work clash. These concepts may be influenced by stereotypes and prejudices. As a result, on the
one hand immigrated employees identify themselves as the “outsiders” contrary to local employees.
On the other hand, an enhancement of the existing working culture that could have been adaptable
to a new environment is excluded (Steinberg et al., 2019). Fourthly, the performance of RHPs is
measured according to their adaption and stabilization to the system. But the potential that RHPs
bring along is wasted if adaption and stabilization are the only possible and acceptable outcomes
since they bring along important working experiences and attitudes that may enrich local standards.
Thus, it is important to verbalize standards and address them before or ideally concomitant to
RHPs labour market integration (Sakamoto et al., 2010). At the same time, it is important to offer
local team members opportunities to reflect on their own standards of work and their expectations.
This could also contribute to an overall improvement of the working atmosphere and reduce the
challenges experienced with team members. However, difficulties with team members were also
attributed to a lack of supervision during internships. Results indicate that most of the time, indi-
vidual team members were intrinsically motivated to support RHPs and engaged in their induction.
But the responsibility of integrating RHPs should not only be outsourced to committed employees
or in the worst case, as described in the results, to unwilling employees. The support of RHPs
should be implemented on a structural level. It is estimated that a one and a half additional hours
of individual support per month are sufficient to generate good integration prospects (Baic et al.,
2017). However, it remains open to question if team members who provide individual support
should be further trained and/or remunerated for their effort. In order to expand the support possi-
bilities, mentoring programmes could also be helpful in supporting RHPs. These findings are
14 Khan-G€okkaya and M€osko
© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration
consistent with recommendations given by the German Employer Association stating that mentor-
ing programmes are a classical approach towards integrating foreign workers (Robra and B€ohne,
2013).
In general, more acknowledgement and empowerment for RHPs is needed. This is consistent
with previous findings describing the loss of RHPs’ professional status (Leblanc et al., 2013) result-
ing in deskilling (Stewart, 2003), the loss of self-confidence (Jirovsky et al., 2015), feelings of frus-
tration (Mozetic, 2018) and negative psychological impacts (Cohn et al., 2006). Results in this
study further indicate that RHPs experience several forms of discouragement, discrimination as well
as disparagement, although they are fully educated and bring along valuable human capital (A9).
Although RHPs have already developed several strategies in dealing with negative feelings and the
barriers they face, organizations and educational institutions could further engage in strengthening
RHPs’ professional identity, acknowledge their strategies and/or make the potential of RHPs visible
in order to empower them.
In the light of the discrimination that RHPs faced by team members and patients, healthcare pro-
viders need to promote measures of diversity management as discrimination may be one result of
poor diversity management (Dickie and Soldan, 2008). Discrimination influences the motivation
and job satisfaction of RHPs and in the long term, it can also have negative psychological impact
and lead to leaves of RHPs (Bouncken et al., 2015). On the contrary, a diversity climate within the
organization can enrich the psychological capital of refugee employees and contribute to their com-
mitment (Newman et al., 2018). Nevertheless, several forms of discrimination from patients and
colleagues were commonly mentioned topics consistent with previous findings on RHPs’ experi-
ences (Cohn et al., 2006; Bloch, 2008; Jirovsky et al., 2015). According to the federal German law
“General Act on equal Treatment,” employers are legally obliged to protect their employees from
discrimination (Allgemeines Gleichbehandlungsgesetz, 2006). But especially experiences of racism
are often denied in health care as “the illusion of non-racism” exists and impedes progressive poli-
cies (Johnstone and Kanitsaki, 2008). Progressive policies may refer to promoting equal opportu-
nity policies (Wrench, 1999) and prevent any form of discrimination (B8). Condemning racist
comments (B8), establishing anti-discrimination commissioners, setting up transparent complaint
systems and offering anti-discrimination and empowerment workshops could be first steps (Wrench,
1999) towards an inclusive and healthier working environment for both staff and patients.
Similarly, the exploitation of RHPs needs to be addressed and employers as well as policymakers
should take responsibility for it. Due to their uncertain legal status, foreign workers are at high risk
of being exploited (Rights, 2010). Labour unions have recognized that and demanded that refugees
must be given access not only to the labour market but also to career advice services (Deutscher
Gewerkschaftsbund (DGB), 2015) in order to increase awareness of their working rights. Another
way for employers to prevent exploitation could be to appoint an integration commissioner for their
organizations. These commissioners could monitor the integration process and ensure compliance
with working rights. Educational providers working with clinics could inform RHPs as well as clin-
ics on the legal rights and duties of RHPs. In any case, this finding points to a severe grievance
that has not been reported in previous studies in this context. Further research is necessary to find
out if these are selective experiences or structural problems in the health care sector.
In general, results indicate the need to reflect on the term integration itself. Several migration
scholars criticize the term for numerous reasons. Firstly, in Germany the term “integration” mostly
refers to regulatory policies which focus on integrating migrants into the existing social orders
(Karakayali and Bodjadzijev, 2010). However, social orders are predefined and shaped by members
of the majority group (Essed, 2000). Secondly, the term is based on negative narratives about the
unwillingness or failed integration of migrants which contributes to the fact that new demands are
constantly being claimed on migrants (Mecheril, 2011). Hence, the term puts migrants into the
focus while structural and institutional deficits as well as power asymmetries within the host coun-
tries are ignored. Subsequently, the experiences of racism and exploitation that RHPs describe in
Labour market: Refugee health professionals 15
© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration
this study point to the need to focus research on structural and institutional inequalities, power
asymmetries and intersectional discrimination. For further research in this context, it would be help-
ful to consider the Critical Race Theory (CRT) as it is based on principles of race equity and social
justice and provides tools in order “to elucidate contemporary racial phenomena, expand the vocab-
ulary with which to discuss complex racial concepts and challenge racial hierarchies” (Ford and
Airhihenbuwa, 2010). Furthermore, activists and scholars who contributed to the CRT study and
transform the relationship between race, racism and power (Delgado and Stefancic, 2017). How-
ever, for the purpose of this study it can be concluded that equal participation in the labour market
and society requires equal treatment, equal opportunities and protection against discrimination
(Uslucan, 2017).
Policy recommendations
Refugee health professionals face personal, structural and institutional barriers at their workplaces.
Although they have developed strategies to overcome these barriers, structural and institutional
changes are needed in order to improve the working environment. In the following, the most impor-
tant conclusions from this study are pointed out as recommendations in order to contribute to a bet-
ter labour market and workplace integration of refugee health professionals. First, there is a need to
offer job-specific language courses and courses addressing formal and cultural aspects of work (as it
is done for example in Sweden (Ministry of Employment and Sweden, 2016)). Similarly, local team
members need to be sensitized for cooperation with refugee health professionals in order to decrease
the potential for conflict. Second, structural changes within teams need to be implemented in order
to supervise refugee health professionals and ensure a proper induction at the beginning. Third, in
light of the experienced barriers, the discrimination and the exploitation, there is a need to empower
refugee health professionals and make their qualifications and their potential visible. Fourth, mea-
sures of diversity management and anti-discrimination need to be implemented and supported by the
management board. Fifth, compliance with working rights must be ensured and team members as
well as refugee health professionals need to be informed about their working rights.
Strengths and limitations
This study identified major challenges in the context of the working experiences of RHPs. By
choosing an explorative approach, a broad range of topics could be identified which provide a basis
for further research and in-depth analysis of the difficulties in the identified fields. The perspective
of RHPs and their supervisors were integrated in order to get an insight into the field of health pro-
fessions and the labour market integration into health professions. For further research, it could also
be helpful to interview colleagues of RHPs and focus on specific healthcare settings. Participants in
this study were selected from rural as well as urban areas and comprised several health professions.
Another strength of this study lies in the methodology. Discussing data with an interdisciplinary
group ensures comprehensibility and critical reflection. Nevertheless, as participants were not
recruited representative and most participants worked only for a short time in Germany, there might
be a selection bias and results are questionable in terms of generalizability. Another limitation is
the compilation of the sample as more physicians and more men in urban areas were interviewed.
Intersectional barriers, language competencies, training experience and other demographic-specific
aspects were neglected. Hence, no conclusions could be drawn for subgroups. Furthermore,
although a certain language competency was required, language barriers and socially desirable
answers may have influenced the interview process. However, due to the researchers’ background
and the reflection of her characteristics, a trustful interview situation could be created and reflected
afterwards.
16 Khan-G€okkaya and M€osko
© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration
ACKNOWLEDGEMENT
We are grateful to the participants and to the organizations who have made this study possible
through their support. Open access funding enabled and organized by Projekt DEAL.
FUNDER INFORMATION
The study was funded by the European Social Fund. SKG and MM received the funding. The fun-
ders did not play any role in the study design, data collection, decision to publish or preparation of
the manuscript.
DECLARATION OF INTERESTS
We have no conflicts of interest to disclose.
Peer Review
The peer review history for this article is available at https://publons.com/publon/10.1111/imig.
12752.
NOTES
1. The terms “refugee health professionals” and “supervisors” were selected as they describe a shared experi-
ence. However, it should be noted that both terms reduce these persons to only one aspect of identity. The
terms do not reflect the multiple aspects of identity and the social and ethical dimensions of the workplace
identity that all interviewed person and health care professionals have.
2. The Common European Framework of Reference for Languages: Learning, Teaching, Assessment (CEFR)
is a reference system to describe six levels (A1, A2, B1, B2, C1, and C2) of language proficiency from
beginners (A1) to experts (C2).
3. SPSS is an abbreviation for Sammeln, Pr€ufen, Sortieren and Subsumieren (Collect, Check, Sort, Subsume).
4. Health professions are registered professions in Germany which is why foreign health professionals need
to have a full or temporary license before they can practise. In order to obtain a license, they have to
go through a recognition process. The first step of the recognition process is an equivalence assessment.
Based on this assessment, recognition bodies grant full recognition, no recognition or partial recognition.
If qualifications are only partly recognised, foreign health professionals can participate (professional
groups like nurses must participate) in adaption training programmes or internships and prove their
required knowledge through language and proficiency tests. The proficiency tests covers internal medi-
cine and surgery. However, based on the equivalence assessment authorities may also evaluate other
subjects.
5. As the interviews were conducted in German, citations in this section were translated one-on-one from Ger-
man to English. If terms were not equivalent in English, then those terms were translated one-on-one and
supplemented with further explanations in the reference mark (Koller, 2011 Einf€uhrung in die €Uberset-
zungswissenschaft [Introduction to translation science], Francke, T€ubingen; Basel.).
6. “No plaintiff, No judge” (German translation: Wo kein Kl€ager, da kein Richter) is a common phrase in
German. It describes that certain irregularities or grievances remain uncovered as no one complains about
them.
Labour market: Refugee health professionals 17
© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration
https://publons.com/publon/10.1111/imig.12752
https://publons.com/publon/10.1111/imig.12752
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22 Khan-G€okkaya and M€osko
© 2020 The Authors. International Migration published by John Wiley & Sons Ltd on behalf of
International Organization for Migration
GLOBALIZATION AND THE HEALTHCARE
WORKFORCE
Leah E. Masselink
CHAPTER
3
47
Learning Objectiv
es
After completing this chapter, the reader should be able to
• describe the history and current trends in international migration of
physicians and nurses;
• enumerate the factors that motivate physicians and nurses to migrate to
other countries;
• discuss the implications of physician and nurse migration for sending an
d
receiving countries;
• understand the policy context and policy interventions that attempt to
manage physician and nurse migration; and
• explain the issues of ethical recruitment, visa regulation, credentialing,
and adaptation for managers of foreign-born and -trained physicians and
nurses.
Introductio
n
In an increasingly interconnected world, the movement of people and infor-
mation across international borders has become a phenomenon that is often
taken for granted. As skilled healthcare providers, physicians and nurses hav
e
had opportunities to seek employment internationally for several decades, and
foreign-trained professionals are important parts of the healthcare systems in
many countries. In the United States alone, about 25 percent of physicians are
foreign born and educated and about 4 percent of nurses were educated over-
seas (Cooper and Aiken 2006; Aiken et al. 2004).
The implications of international migration of physicians and nurses
are complex, becoming a source of increasing debate in recent years. While
physicians and nurses who migrate to other countries can benefit from better
working conditions or salaries in their destinations, their movement can exacer-
bate inequalities in the worldwide distribution of healthcare workers. Migration
Fried_CH03.qxd 6/11/08 4:08 PM Page 47
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AN: 237620 ; Fottler, Myron D., Fried, Bruce.; Human Resources in Healthcare : Managing for Success
Account: s8993066.main.ehost
of healthcare workers from developing countries has particularly far-reaching
implications. These developing countries not only lose their investments in ed-
ucation and training, income tax revenue, and potential for national growth,
buy they also see adverse health effects on their populations. In nations where
healthcare workforce shortages are already severe, the need to replace healthcare
professionals who have left for other countries only further depletes the health
system’s resources—funds that normally go toward fighting diseases and pro-
moting public health. In addition, the lack of highly skilled care providers pre-
vents these countries from meeting their own needs for healthcare innovation
and problem solving. These factors exacerbate the existing inequalities in health-
care between developed and developing countries.
Given that foreign-trained physicians and nurses play an important role
in many healthcare organizations in the United States, healthcare managers in
this country must understand several issues related to the globalization of the
healthcare workforce:
• In what areas do international migration of physicians and nurses occur?
What can explain these patterns?
• What factors motivate the international migration of physicians and
nurses?
• What are the ethical and logistical implications of physician and nurse
migration for sending and receiving countries?
International migration of physicians and nurses is inherently difficult
to manage because policies designed to direct and oversee it must balance two
often competing objectives: (1) to protect the inherent right of people to mi-
grate and (2) to ensure that quality healthcare services are available to all. This
chapter describes past and current migration trends, causes, policy context,
and responses. It also explores several international migration issues, such
as
ethical recruitment, visa regulation, credentialing, and adaptation. All of these
topics are essential knowledge for U.S. healthcare managers.
History and Current Trends
Anecdotal accounts of international migration of physicians and nurses began
to circulate in the 1960s. Initial reports mostly documented migration be-
tween developed countries, such as from Canada to the United States (BMJ
1968). In the 1970s, the World Health Organization (WHO) commissioned
The Multinational Study of the International Migration of Physicians. This no-
table study found that, at the time, significant numbers of international med-
ical graduates (IMGs) were practicing in the United States (about one in
every five physicians), the United Kingdom (more than one in every four
physicians), and Canada (one in every three physicians). Germany also had
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substantial numbers of migrant physicians, including many from Iran and the
Middle East (Mejía 1978). In addition, the study reported that significant
numbers of international nursing graduates (INGs) worked in the United
States, European countries, and other developed nations. Sending countries
(the countries from which healthcare professionals migrate) with particularly
high proportions of nurses who go abroad to work include Haiti, Suriname,
Hong Kong, Jordan, and the Philippines. In absolute numbers, more Filipino
nurses were registered in the United States and Canada than in the Philippines
in 1970 (Mejía 1978).
The characteristics of healthcare workforce migration have shifted since
the WHO study was conducted in the 1970s. New sending countries have be-
come significant sources of migrant physicians, including Egypt, Cuba, and
nations in the Caribbean; sub-Saharan Africa; and the former Soviet Union.
New receiving countries (the destinations of migrant healthcare professionals),
such as the Persian Gulf states, have begun to draw physicians and nurses from
all over the world, including Europe and India. Migration between the Euro-
pean Union and African countries has also increased (Martineau, Decker, and
Bundred 2004). Some countries—particularly South Africa—have emerged as
“holding grounds” for migrant workers who stay temporarily on their way to
their final destination country (Vujicic et al. 2004).
According to Mullan (2005), the countries that send the largest num-
bers of physicians abroad are India, the Philippines, and Pakistan, while the
countries that receive the greatest numbers of IMGs are the United States, the
United Kingdom, Canada, and Australia. IMGs compose approximately
25 percent of the physician workforce in the United States, 28 percent in the
United Kingdom, 23 percent in Canada, and 27 percent in Australia (Mullan
2005). In the United States, the three largest sending countries or regions for
INGs are the Philippines, Canada, and Africa (especially South Africa and Nige-
ria). Between 1997 and 2000, 33 percent of foreign-born nursing-licensure ap-
plicants were Filipino, 22 percent were Canadian, and 7 percent were African
(Buchan, Parkin, and Sochalski 2003).
Migration streams, particularly between English-speaking countries,
appear to be well established: While IMGs make up more than 20 percent of
the total physician workforces in the United States, the United Kingdom,
Australia, and Canada, they represent only a tiny proportion of the physician
workforces in France (3 percent) and Japan (1 percent) (Mullan 2005). In
sub-Saharan Africa, rates of nurse migration are also markedly higher in An-
glophone countries than in French- and Portuguese-speaking countries
(Dovlo 2007). Many sending countries tend to have historical relationships
with English-speaking receiving countries. For example, physicians from India
and Pakistan make up the largest and third-largest groups, respectively, of IMGs
in the United Kingdom, and doctors from the Philippines are the second-
largest group of noncitizen IMGs in the United States (Mullan 2005).1
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Many policymakers in both sending and receiving countries have ex-
pressed concern about the fact that the largest receiving countries draw sig-
nificant proportions of their IMG workforces from lower-income countries.
More than 75 percent of the IMGs in the United Kingdom come from lower-
income countries, and other receiving countries have substantial proportions
as well: Sixty percent of IMGs in the United States and about 40 percent of
those in Canada and Australia are from developing nations (Mullan 2005).
Causes of International Migration
Determinants of physician and nurse migration are often discussed in terms of
“push” and “pull” factors. Push factors motivate physicians and nurses to leave
their home countries, while pull factors cause them to choose particular receiv-
ing countries. The reasons are chiefly discussed within an economic framework,
considering a variety of factors as potential determinants. These include per
capita gross domestic product, physician coverage, manpower production rates,
rural/urban distribution of physicians and nurses, and workforce imbalances.
Push factors cited by the majority of studies include low pay, poor
working conditions, political instability and insecurity, inadequate housing
and social services, and lack of educational opportunities and professional de-
velopment. Job dissatisfaction, lack of motivation, and weak professional lead-
ership are also mentioned as contributing factors (Saravia and Miranda 2004).
Pull factors, on the other hand, include opportunities for professional train-
ing, better job opportunities, and higher wages (Forcier, Simoens, and Giuf-
frida 2004). Other pull factors relate to workforce-supply issues that have cre-
ated an imbalance between the demand for services and the supply of workers
in receiving countries, such as aging of both the general population and the
nursing workforce and the slowdowns in enrollment in training programs
(Buchan and Sochalski 2004). The nursing workforces in receiving countries
are vulnerable to such shortages, particularly with the opening of male-dom-
inated careers to women (Marchal and Kegels 2003). IMGs and INGs are par-
ticularly needed in some receiving countries where domestically trained
providers are reluctant to serve in certain capacities, such as in remote areas or
in nursing homes.
Sending Country/Region Trends
Physician and nurse migration can be managed to varying degrees by sending
countries. Some regions (such as sub-Saharan Africa and the Caribbean) con-
tinue to lose workers in the face of severe shortages, while other nations (such
as Cuba, India, and the Philippines) purposely train surplus physicians and
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nurses for overseas employment. Still other countries (particularly China) are
currently looking to shift into a training-for-export mode. This section sheds
light on the diverse situations faced by sending countries and describes in de-
tail the factors that contribute to each situation.
Brain Drain: Sub-Saharan Africa and the Caribbean
The situation in sub-Saharan Africa and the Caribbean is often referred to as
brain drain—the widespread, uncontrolled departure of physicians and
nurses from countries that already suffer healthcare worker shortages.
In sub-Saharan Africa, the largest sending countries are South Africa and
Nigeria. In 2005, nearly 7,000 South African physicians and more than 4,000
Nigerian physicians were practicing in the United States, the United Kingdom,
Canada, and Australia (Mullan 2005). Ghana has also experienced high rates
of physician and nurse emigration: In 2000, that country lost more practicing
nurses than the number of nursing graduates it produced (Dovlo 2007). As a
relatively wealthy sub-Saharan African state, South Africa is unique in that it
acts as both a sending and a receiving country for migrant physicians and
nurses, many of whom come from other countries in the region.
In Africa, among the factors that influence health professionals’ deci-
sions to leave are low quality of life, high crime rates, conflict, political repres-
sion, and lack of educational opportunities for children. The HIV/AIDS epi-
demic has seriously depleted the healthcare workforce through death and
attrition, and caring for growing numbers of patients with HIV/AIDS has
overburdened the remaining providers. Nurses in this region are poorly paid,
and this lack of adequate compensation also contributes to the workforce
shortage. Sub-Saharan Africa suffers from a serious maldistribution of healthcare
workers, with uneven supply between the public and private sectors, urban and
rural areas, and tertiary and primary levels of care (Padarath et al. 2004).
A lack of higher education and career-development opportunities is an-
other major push factor in this region. This dearth reflects a pattern of under-
investment in higher education by governments and outside donors. Health-
professional education and training not only subsist on very limited material
resources but are also plagued by a shortage of qualified teachers.
Similarly, countries in the Caribbean are overwhelmed by extremely
high rates of HIV infection that are second only to the epidemic in sub-Saharan
Africa. This region has also experienced crippling losses of nurses in recent
years: 42 percent of all nursing positions across the Caribbean are vacant, and
the lack of nursing educational capacity serves only to perpetuate the massive
losses of nursing educators and experienced nurses. Jamaica is particularly af-
fected, with a 58 percent average nursing vacancy rate in 2003. Many Ja-
maican nurses left to work in the United States, the United Kingdom, and
Canada, and Jamaican healthcare leaders have begun to recruit from other
countries in the Caribbean to make up for losses (Salmon et al. 2007).
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Strategic Deployment: Cuba, the Philippines, and India
Some developing countries train surplus physicians and nurses for overseas
employment, and both state and business interests promote and manage
this practice. Cuba has a long-standing program of physician deployment,
and the Philippine government has worked to manage nurse migration for
many years. Recently, strategic deployment programs have also arisen in
India.
For several decades now, Cuba has made the provision of healthcare
workers to developing countries a part of its foreign policy, sending physicians
to developing countries as participants in a Peace Corps–style international
medical-aid program (Feinsilver 1989). These efforts are part of a larger ef-
fort by the Cuban government to promote its political agenda and to position
itself as a “world medical power.” Dozens of countries have received Cuban
physicians over the years, including Algeria, South Africa (Lee 1996), and
more recently Venezuela (Muntaner et al. 2006). Cuban physicians who par-
ticipate in the program often provide services in isolated rural areas and are
often involved in training their host countries’ indigenous healthcare workers
(Feinsilver 1989).
The Philippine government has been particularly active in establishing
policies that aim to make the country the niche producer of nurses in the
global economy (Ball 1996). The Philippines produces about 20,000 new
nurses every year (Lorenzo et al. 2007), and the vast majority of these grad-
uates eventually find work overseas: In 2004, 85 percent of all Filipino nurses
practiced abroad (Aiken et al. 2004). A government agency regulates recruit-
ment of Filipino overseas workers and processes documents for those bound
to work in other countries. The emergence of nursing as a pathway to migra-
tion has led to unprecedented demand for nursing education in the Philip-
pines. The number of nursing schools has grown exponentially in the past few
decades, from 40 schools in the 1970s to 460 schools in 2006 (Lorenzo et al.
2007). This growth has led to concerns about the quality of nursing educa-
tion, as schools compete with each other for faculty and hospital training space
(Lorenzo et al. 2007).
Historically, India has been one of the largest sending countries of
physicians to developed nations, including the United States and the United
Kingdom (Mullan 2006). In recent years, it has also become a popular source
country for nurses. Since the 1990s, it has moved from sixth to second posi-
tion (after the Philippines) among countries that send nurses to the United
States. Like the Philippines, India has a huge overall labor surplus, although
it also has a very low nurse-to-population ratio. It has also become the site of
increasing commercial activity around nursing education and migration. In-
dian hospitals have become involved in recruiting and training nurses for over-
seas markets, and local recruitment agencies that partner with U.S.-based re-
cruiters have appeared in many urban areas. In recent years, some state
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governments have also begun to engage in international deployment of nurses
(Khadria 2007).
The most frequently cited reason for the strategic deployment of physi-
cians and nurses is the remittance income that migrant workers send to their
home countries. Remittances can be a substantial source of revenue for send-
ing countries. For example, Filipino migrant workers remitted $10.7 billion
in 2005 (Lorenzo et al. 2007). Remittance income is often considered a po-
tentially positive outcome of emigration. However, while such income m
ay
offset sending countries’ financial losses, it may not make up for the staffing
issues and poor outcomes associated with workforce migration.
Up-and-Coming Player: China
China is a relative newcomer to the global nursing market. It has sent nurses
abroad for about 15 years, when the government began deploying groups of
English-speaking nurses to Singapore and Saudi Arabia under temporary gov-
ernment-arranged contracts (Fang 2007). Since the early 2000s, this migra-
tion has shifted to countries such as Australia and the United Kingdom, where
it is usually arranged by private agencies. U.S. healthcare organizations have
begun to express interest in recruiting nurses from China.
For some Chinese nurses, the desire to seek employment abroad is in-
fluenced by several domestic factors. First, China has not invested enough in
healthcare to employ all of its trained and educated nurses. Like the Philip-
pines, China has a surplus of nurses based on the number of budgeted posi-
tions. Many nurses are unable to find work, or they are forced to retire early
to make room for new graduates who are entering the workforce. Also, China
has more physicians than nurses, contrary to recommendations by the WHO.
In this context, overseas markets are becoming a desirable alternative for some
Chinese nurses.
Consequences for Receiving Countries
The presence of IMGs and INGs has several important consequences for re-
ceiving countries. Some of the consequences of physician and nurse migration
relate to larger issues of recruitment and retention. International recruitment
is suggested to be a quick fix for recruitment and retention problems in re-
ceiving countries, allowing domestic supply lines to avoid developing their
own solutions to unmet health-system needs. International migration may
help receiving countries to fill positions in areas that are not as attractive to
domestic workers. This leads to concerns that foreign-trained professionals
may be subject to exploitation or may be forced to work in positions that are
below their expertise—a phenomenon referred to as “brain waste” (Marchal
and Kegels 2003).
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The effects of having immigrant physicians and nurses on accessibility
and quality of care are unclear: Some suggest that the quality and safety of care
provided by internationally trained providers may be cause for concern, while
others argue that the presence of these professionals may improve access to
care, lower prices, and induce competition and higher quality (Forcier,
Simoens, and Giuffrida 2004). The “safety net” use of immigrant healthcare
workers has been demonstrated to be a real phenomenon (Forcier, Simoens,
and Giuffrida 2004). The presence of immigrant health workers may prevent
receiving healthcare systems from solving their own training and staffing
problems. For example, while U.S. hospitals hire thousands of IMGs each
year, thousands of domestic medical-school applicants are turned away (Mar-
tineau, Decker, and Bundred 2004).
The Policy Context
International migration occurs in the context of several important trade
agreements. One such agreement that could affect future migration dynam-
ics is the General Agreement on Trade in Services (GATS), which was imple-
mented in 1995. GATS is an international treaty that governs the trade of
services, including health services, among member countries of the World
Trade Organization. GATS has three main objectives: (1) to liberalize trade
in services, (2) to encourage economic growth through liberalizing trade in
services, and (3) to increase the participation of developing countries in the
world trade in services. The four modes of trade governed by GATS are (1
)
cross-border supply (services provided by workers in one country for organ-
izations in another country), (2) consumption abroad (including medical
tourism and education of foreign students), (3) commercial presence (invest-
ment of capital from one country into another), and (4) movement of natu-
ral persons (temporary cross-border migration of workers to provide services
in another country [Kingma 2006]). While the GATS provision for tempo-
rary migration has caused concern that it would encourage further migration
of health workers from developing countries to developed countries, this el-
ement is still being negotiated, and its final effects remain unclear (Kingma
2007).
Another agreement that particularly affects migration patterns in the
United States is the North American Free Trade Agreement (NAFTA), which
was implemented in 1994. NAFTA provides for the movement of workers be-
tween Canada, the United States, and Mexico, including special visa cate-
gories and mutual recognition of nurse licensure in the United States and
Canada. This agreement has raised Canada’s profile as a sending country of
nurses in the United States, but movement between the two countries has
been mostly unidirectional: About 15,000 Canadian nurses have moved to the
United States under NAFTA, but relatively few U.S.-trained nurses have
moved to Canada (Kingma 2006; Mautino 2003).
54 H u m a n R e s o u r c e s i n H e a l t h c a r e
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Policy Responses
A broad variety of policy initiatives have been proposed and implemented by
sending and receiving countries to manage international migration of physi-
cians and nurses. These include programs instituted by worldwide bodies such
as the WHO and the International Council of Nurses (ICN), domestic policy
changes in sending and receiving countries, government-to-government bi-
lateral agreements, and proposed compensation schemes. Some countries or
regions have adopted unique policies to manage the effects of physician and
nurse migration: The Caribbean, as a sending region, has adopted a program
called Managed Migration, and the United Kingdom, as a receiving country,
has established the “Code of Practice on International Recruitment.”
The WHO (2007) has developed a variety of initiatives to manage the migra-
tion of healthcare workers. It is working with the Global Health Workforce
Alliance Task Force to support efforts to scale up health-worker education,
particularly in countries faced by workforce crises. It also provides technical
support to countries and assists regional human resources for health observa-
tories. Additionally, the WHO supports the Treat, Train, Retain (TTR) initia-
tive, begun in 2006 to curb the effects of HIV/AIDS on the healthcare work-
force and health systems in low- and middle-income countries. The goals of
TTR are threefold: (1) to provide treatment, prevention, and support to
health workers affected by HIV/AIDS; (2) to train providers (including com-
munity health workers) to maximize existing capacity to treat HIV/AIDS;
and (3) to retain health workers in rural areas and the public sector in un-
derresourced countries. The WHO will provide assistance to participating
countries in developing TTR plans and budgeting for proposed changes,
but TTR’s implementation and financing will be managed by individual
countries.
The ICN—the federation of national nurses associations (e.g., American
Nurses Association, Philippine Nurses Association)—has developed a position
statement on ethical recruitment of nurses to guide the recruitment efforts
between its member countries. While acknowledging nurses’ inherent right to
migrate, the statement also calls for receiving countries to work toward build-
ing self-sustainable, domestically trained nursing workforces. The statement
also aims to protect migrant nurses, calling for several measures such as good-
faith contracting, freedom of employment and association, and fair pay and
working conditions (ICN 2007).
Some sending countries have implemented domestic policy changes to reduce
the effects of push factors that motivate physicians and nurses to seek overseas
employment. These changes include improvement in pay, career opportunities,
and working conditions; provision of incentives to induce overseas workers to
55C h a p t e r 3 : G l o b a l i z a t i o n a n d t h e H e a l t h c a r e W o r k f o r c e
WHO Activities
ICN Statement
Domestic
Policies in
Sending
Countries
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return home; and the development of private-sector opportunities. Other meas-
ures focus more specifically on medical education, including pre-education
screening of candidates likely to stay in-country, shortening of domestic train-
ing programs, and adaptations of curriculum to local conditions.
Still other policies aim to use financial disincentives to keep workers in-
country, requiring emigrants to pay fees upon departure. For example, Eritrea
has a bond program in which departing physicians are required to make up-
front payments that guarantee their return from studies in South Africa (Mar-
chal and Kegels 2003). This type of system could be particularly useful if rev-
enues generated were used to fund human resources development in sending
countries (Saravia and Miranda 2004).
Some receiving countries have adopted domestic policy changes to address
the underlying human resources imbalances that contribute to the demand
for foreign-trained workers. In many developed countries, nursing short-
ages are exacerbated by difficulties in retaining domestically trained
nurses—difficulties that are often related to poor working conditions and
low salaries (Janiszewski Goodin 2003). Turnover rates for nurses in U.S.
hospitals were estimated at between 10 percent and 30 percent in 2000
(HSM Group 2002). To improve domestic retention, receiving countries,
such as the United Kingdom and Australia, have implemented programs to
recruit and retain domestic healthcare workers (Martineau, Decker, and
Bundred 2004). Other countries have begun recruiting nonconventional
workers, such as firefighters, to the healthcare field (Marchal and Kegels
2003).
In 2002, the U.S. Congress passed the Nurse Reinvestment Act, a
piece of legislation that uses a combination of expanded eligibility for loan re-
payment, education vouchers, and other measures to improve retention of
nurses (Andrews 2004). While this legislation represents a positive step in im-
proving retention of domestically trained nurses, its funding stream has been
subject to frequent cuts in the past few years, so its overall impact is unclear
(Janiszewski Goodin 2003).
Some sending and receiving countries have attempted to regulate the migration
of healthcare workers between them by signing government-to-government
bilateral agreements. Under this agreement, a receiving country pledges to
underwrite the costs of training additional staff; to recruit staff for a fixed pe-
riod (often providing training before staff return to the sending country); or
to recruit surplus staff from a sending country (Buchan 2007). For example,
the United Kingdom has bilateral agreements with the Philippines and Spain
that allows the United Kingdom to recruit nurses from these two countries
for temporary work in the National Health Service (Kline 2003). Bilateral
agreements can help to manage the flow of physicians or nurses between
56 H u m a n R e s o u r c e s i n H e a l t h c a r e
Domestic
Policies in
Receiving
Countries
Government-to-
Government
Bilateral
Agreements
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sending and receiving countries by mandating short-term rather than perma-
nent migration.
Another policy intervention that has been proposed requires receiving coun-
tries to compensate sending countries for the financial losses associated with
worker migration. Various versions of this plan call for remuneration of the
costs of educating migrant workers, for assistance with human resources de-
velopment in sending countries, and for additional compensation for sending
countries’ lost tax revenue. Although well intended, these measures are diffi-
cult to implement because administrative costs would likely be high and be-
cause determining payment amounts, procedures, and enforcement would
present further challenges to sending and receiving countries (Marchal and
Kegels 2003).
The Managed Migration program in the Caribbean is one of the most sophis-
ticated policy responses to the issue of nurse migration in a sending country
or region. Managed Migration aims to promote regional cooperation and
strategic planning in six critical areas:
1. Terms and conditions of work
2. Recruitment, retention, and training
3. Value of nursing
4. Utilization and deployment
5. Management practices
6. Policy development
This program was developed by a partnership among national, re-
gional, bilateral, and international stakeholders. Initiatives developed under
the program include efforts to promote temporary or part-time migration of
Caribbean-trained nurses to developed countries, agreements requiring re-
ceiving countries to invest in sending countries’ health-professions education
systems, and promotion of health tourism in Caribbean countries (Salmon et
al. 2007).
The United Kingdom is one of the few major receiving countries to develop
a specific policy to guide the recruitment of internationally trained physicians
and nurses. Its National Health Service (NHS) has created the Code of Prac-
tice on International Recruitment, which includes the following provisions
(Buchan 2007):
• Developing countries should not be targeted for active recruitment by
the NHS unless the government of that country formally agrees.
• NHS employers should only use recruitment agencies that have agreed
to comply with the Code.
57C h a p t e r 3 : G l o b a l i z a t i o n a n d t h e H e a l t h c a r e W o r k f o r c e
Compensation
Schemes
Managed
Migration in
the Caribbean
Code of
Practice on
International
Recruitment in
the United
Kingdom
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• NHS employers should consider regional collaboration in international
recruitment activities.
• Staff recruited from abroad have the same legal protection as other
employees.
• Staff recruited from abroad should have the same access to further
training as other employees.
While the Code has been touted as an example for other countries to
follow, its effectiveness is somewhat limited by the fact that it only applies to
the public sector (not to independent or private employers or recruitment
agencies), and employers and migrant healthcare workers have found many
ways to work around it. Nonetheless, the Code represents a deliberate effort
by a receiving country to reduce the negative effects of healthcare worker re-
cruitment from developing countries.
Issues for Managers
The movement of IMGs and INGs into the U.S. healthcare system raises sev-
eral important issues for managers and leaders. In particular, managers must
be aware of issues of ethical recruitment, regulation (visas), credentialing,
and adaptation for internationally trained physicians and nurses. (For a sum-
mary of the elements in these issues, see Table 3.1.) Careful consideration of
all of these areas is necessary to facilitate the successful recruitment and in-
corporation of internationally trained healthcare professionals into the U.S.
healthcare system and to minimize the migration’s negative effects on send-
ing countries.
Recruitment
Healthcare organizations can recruit workers from overseas through several
mechanisms. These include, but are not limited to, the following (Buchan and
Perfilieva 2006):
• Twinning. Hospitals in sending and receiving countries develop links,
based on staff exchanges, staff support, and flow of resources.
• Staff exchange. Healthcare workers temporarily move between
organizations in sending and receiving countries for career and personal
development opportunities or for organizational growth.
• Educational support. Educators and/or educational/funding resources
temporarily move from receiving to sending organizations.
• Bilateral agreement. Employers in the receiving country develop an
agreement with employers or educators in the sending country to help
pay the costs of training additional staff or to recruit staff for training
and development before returning staff to the sending country.
58 H u m a n R e s o u r c e s i n H e a l t h c a r e
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59C h a p t e r 3 : G l o b a l i z a t i o n a n d t h e H e a l t h c a r e W o r k f o r c e
Is
su
es
In
te
rn
at
io
n
al
M
ed
ic
al
G
ra
d
u
at
e
(I
M
G
)
I
n
te
rn
at
io
n
al
N
u
rs
i
n
g
G
ra
d
u
at
e
(I
N
G
)
R
eg
u
la
ti
o
n
—
V
is
as
TA
B
LE
3
.1
M
an
ag
em
en
t
Is
su
es
w
it
h
I
n
te
rn
at
io
n
al
ly
T
ra
in
ed
P
h
ys
ic
ia
n
s
an
d
N
u
rs
es
Te
m
p
o
ra
ry
H
-1
B
•
C
at
eg
o
ry
f
o
r
“s
p
ec
ia
lt
y
o
cc
u
p
at
io
n
s”
•
3
-y
ea
r
le
n
g
th
o
f
st
ay
, r
en
ew
ab
le
f
o
r
3
a
d
d
it
io
n
al
ye
ar
s
H
-1
C
•
C
at
eg
o
ry
f
o
r
w
o
rk
er
s
in
u
n
d
er
se
rv
ed
a
re
a
s
•
Ye
ar
ly
c
ap
o
f
5
0
0
n
u
rs
es
•
3
-y
ea
r
le
n
g
th
o
f
st
ay
TN •
Li
n
ke
d
t
o
N
A
FT
A
2
•
A
p
p
lie
s
t
o
n
u
rs
es
f
ro
m
M
ex
ic
o
a
n
d
C
an
ad
a
•
1-
ye
ar
le
n
g
th
o
f
st
ay
, r
en
ew
ab
le
E
B
-3
•
E
m
p
lo
ym
en
t-
b
as
ed
v
is
a
•
R
el
ea
se
d
t
o
In
d
ia
,
t
h
e
P
h
ili
p
p
in
es
, a
n
d
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h
in
a
fo
r
n
u
rs
es
an
d
o
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er
h
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h
w
o
rk
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s
in
2
0
0
5
P
er
m
an
en
t
La
b
o
r
C
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ti
fi
ca
ti
o
n
P
ro
ce
ss
•
R
e
q
u
ir
es
e
m
p
lo
ye
r
to
d
e
m
o
n
st
ra
te
s
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o
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e
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f
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if
ie
d
w
o
rk
er
s
in
t
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e
g
eo
g
ra
p
h
ic
a
re
a
•
IN
G
is
o
b
lig
at
ed
t
o
r
em
ai
n
w
it
h
e
m
p
lo
ye
r
fo
r
18
m
o
n
th
s
to
5
y
ea
rs
a
ft
er
a
p
p
l
ic
at
io
n
is
a
p
p
ro
ve
d
Te
m
p
o
ra
ry
J-
1 •
C
at
eg
o
ry
f
o
r
tr
ai
n
ee
s
•
S
p
o
n
s
o
re
d
b
y
E
C
FM
G
1
fo
r
re
si
d
en
t
IM
G
s
H
-1
B
•
C
at
eg
o
ry
f
o
r
“s
p
ec
ia
lt
y
o
cc
u
p
at
io
n
s”
•
3
-y
ea
r
le
n
g
th
o
f
st
ay
, r
en
ew
ab
le
fo
r
3
a
d
d
it
io
n
al
y
ea
rs
O
•
C
at
eg
o
ry
f
o
r
“o
u
ts
ta
n
d
in
g
”
re
se
ar
ch
er
s
o
r
sp
ec
ia
lis
ts
•
In
d
ef
in
it
e
le
n
g
th
o
f
st
ay
P
er
m
an
en
t
La
b
o
r
C
er
ti
fi
ca
ti
o
n
P
ro
ce
ss
•
R
eq
u
ir
es
e
m
p
lo
ye
r
to
d
em
o
n
st
ra
te
s
h
o
rt
ag
e
o
f
q
u
al
if
ie
d
w
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rk
er
s
in
t
h
e
g
eo
g
ra
p
h
ic
a
re
a
•
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M
G
is
o
b
lig
at
ed
t
o
r
em
ai
n
w
it
h
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m
p
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fo
r
18
m
o
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th
s
to
5
y
ea
rs
a
ft
er
a
p
p
lic
at
io
n
is
a
p
p
ro
ve
d
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at
io
n
al
In
te
re
st
W
ai
ve
r
•
N
o
e
m
p
lo
ye
r
lin
k
•
R
eq
u
ir
es
d
em
o
n
st
ra
ti
o
n
o
f
u
n
iq
u
e
ab
ili
ti
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t
h
at
co
n
tr
ib
u
te
t
o
n
at
io
n
al
q
u
al
it
y
o
f
lif
e
(C
on
ti
n
u
ed
)
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60 H u m a n R e s o u r c e s i n H e a l t h c a r e
1
E
C
F
M
G
:
E
d
u
ca
ti
o
n
al
C
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m
m
is
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f
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re
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n
M
ed
ic
al
G
ra
d
u
at
es
;
2
N
A
F
T
A
:
N
o
rt
h
A
m
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ic
an
F
re
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T
ra
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gr
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m
en
t;
3
U
SM
L
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:
U
.S
.
M
ed
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xa
m
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;4
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:
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;
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:
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(
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);
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(
2
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,
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);
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ie
sk
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(2
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);
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(2
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);
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re
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(2
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2
);
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d
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h
el
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(
2
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6
)
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eq
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em
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ts
•
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FN
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5
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o
f
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d
cr
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ti
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s
•
P
as
si
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co
re
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n
N
C
LE
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-R
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6
•
A
cc
ep
ta
b
le
s
co
re
s
o
n
T
O
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FL
Tr
ai
n
in
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ee
d
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•
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u
rs
in
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c
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lt
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re
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d
c
o
m
m
u
n
ic
at
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n
•
S
u
p
er
vi
si
o
n
a
n
d
d
el
eg
at
io
n
o
f
ca
re
•
H
o
sp
it
al
s
ys
te
m
s,
t
ec
h
n
o
lo
g
y,
a
n
d
d
o
cu
m
en
ta
ti
o
n
•
C
lin
ic
al
s
ki
lls
a
n
d
d
ru
g
a
d
m
in
is
tr
at
io
n
R
eq
u
ir
em
en
ts
•
E
n
tr
y
in
to
r
es
id
en
cy
p
ro
g
ra
m
s
ce
rt
if
ie
d
b
y
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C
FM
G
•
V
er
if
ia
b
le
m
ed
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al
s
ch
o
o
l d
ip
lo
m
a
•
P
as
si
n
g
s
co
re
s
o
n
U
S
M
LE
3
S
te
p
1
a
n
d
S
te
p
2
(
cl
in
ic
al
kn
o
w
le
d
g
e
an
d
c
lin
ic
al
s
ki
lls
)
•
A
cc
ep
ta
b
le
s
co
re
s
o
n
T
O
E
FL
4
Tr
ai
n
in
g
N
ee
d
s
•
C
u
lt
u
re
o
f
m
ed
ic
in
e
•
M
o
d
el
s
o
f
fa
m
ily
r
el
at
io
n
sh
ip
s
•
C
o
m
m
u
n
ic
at
io
n
w
it
h
p
at
ie
n
ts
•
C
o
m
m
u
n
ic
at
io
n
w
it
h
n
u
rs
in
g
a
n
d
s
u
p
p
o
rt
s
ta
ff
C
re
d
en
ti
al
in
g
A
d
ap
ta
ti
o
n
TA
B
LE
3
.1
C
o
n
ti
n
u
ed
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Additionally, IMGs and INGs also find jobs through informal mecha-
nisms, such as personal and professional contacts (Bagchi 2001). In all of these
models, the recruitment process can be conducted directly by the employer or
mediated by either domestic or overseas recruitment agencies. A recruitment
agency typically charges a hiring organization between $5,000 and $10,000
per nurse. In return, nurses agree to work for the hiring organization for a
fixed period of time—usually two to three years. For-profit recruitment agen-
cies represent an important and growing presence in overseas hiring of nurses
in particular; many of them set up both domestic and sending-country offices
to facilitate the process (Brush, Sochalski, and Berger 2004).
Employers in receiving countries must consider the implications of
their recruiting practices for the countries and organizations from which they
are recruiting. They must also be aware of the rights of the workers them-
selves. The United States has no overarching code of practice for international
recruitment of healthcare workers, so the decisions about how to balance eth-
ical concerns with domestic staffing needs are the responsibility of individual
employers and the recruitment agencies with which they work. Recruitment
agencies’ behavior has improved since a rash of abuses was documented in the
1980s. Today, efforts toward better practice are fueled by market competition
between agencies (Kingma 2006). Employers and recruiters must take re-
sponsibility for not recruiting from countries with severe shortages and for
providing a safe and transparent recruitment process for migrant workers.
Regulation (Visas)
Because most IMGs enter the United States as residents, the first type of visa
that they commonly obtain is the J-1 visa, a category for trainees. The Edu-
cational Commission for Foreign Medical Graduates (ECFMG 2007) is au-
thorized by the U.S. Department of State to sponsor J-1 visas for IMGs. Af-
ter completing their training, some physicians obtain permanent residency
status, while others remain in the country on H-1B or O temporary visas.
H-1B visas apply to immigrants in “specialty occupations,” which usu-
ally require at least a bachelor’s degree. These visas allow for a three-year
length of stay, which can then be extended for three additional years. O visas
can be obtained by physicians who have “outstanding” abilities in their field;
these are usually researchers or specialists. O visas are more loosely tied to em-
ployers than H-1B visas and allow their holders to stay in the United States
indefinitely (Mautino 2002).
IMGs who wish to work permanently in the United States can pursue
permanent residency through one of two main avenues: going through a la-
bor certification process or obtaining a national interest waiver. The labor cer-
tification process requires that an IMG’s employer demonstrate a shortage of
qualified workers to fill the position in the geographic area; if approved, the
physician is obligated to remain with his or her employer for 18 months to
61C h a p t e r 3 : G l o b a l i z a t i o n a n d t h e H e a l t h c a r e W o r k f o r c e
Physicians
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5 years after the application is approved. The national interest waiver requires
the IMG to demonstrate that he or she has exceptional abilities in a field, such
that his or her admission to the workforce is in the national interest of the
United States. Physicians who seek a national interest waiver need not be
linked to a specific employer, but they must demonstrate unique abilities that
contribute to the country’s quality of life, which may include service in a med-
ically underserved area for five years or more (Mautino 2002).
From 1990 to 1995, many INGs entered the United States under H-1A visas,
which were aimed at encouraging the migration of overseas-educated nurses.
This visa category was withdrawn after many U.S. healthcare organizations
downsized in the mid-1990s. Since 1995, nurses have entered the country un-
der one of four visa categories:
1. H-1B: See the provisions described in the physicians visa section earlier.
2. H-1C: Established under the Nursing Relief for Disadvantaged Areas Act
of 1999, this visa allows INGs to work in underserved areas. It has a
yearly cap of 500 nurses and permits a three-year length of stay (Bieski
2007).
3. TN: Linked to NAFTA, this visa applies to nurses from Mexico and
Canada. It is good for a one-year stay in the United States and is
renewable.
4. EB-3: A permanent employment-based visa, this was made available in
2005 to nurses and other healthcare workers from sending countries
such as India, the Philippines, and China. Although the EB-3 visa quotas
had been reached, the visa was extended to 50,000 more workers,
enabling U.S. healthcare organizations to hire many overseas-trained
nurses (Kingma 2006). Employers that hire nurses are not subject to the
usual provision that requires them to prove that no U.S. workers are
available to take jobs to be filled by visa recipients (Arends-Kuenning
2006).
Many of these visa categories either have very specific requirements or are
difficult to obtain. Thus, many INGs apply for permanent residency permits
(green cards) when coming to the United States (Kingma 2006). INGs can pur-
sue permanent residency through the employer-dependent labor certification
process, which is described earlier in the IMG visa section (Mautino 2003).
Credentialing
IMGs who desire to work as physicians in the United States must complete
their residency training in a U.S. healthcare organization before they can prac-
tice. Their entry into these training programs must be certified by the
ECFMG, which has been managing the entry of IMGs into the U.S. work-
force since 1958 (Whelan et al. 2002). Applicants must submit a verifiable
62 H u m a n R e s o u r c e s i n H e a l t h c a r e
Nurses
Physicians
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diploma from a medical school listed in the International Medical Education
Directory published by the Foundation for Advancement of International
Medical Education and Research. They must also show a passing score on
Step 1 and Step 2 (clinical knowledge and clinical skills) of the U.S. Medical
Licensing Examination (USMLE), along with acceptable scores on the Test
of English as a Foreign Language (TOEFL). The USMLE Step 1 and Step 2
examination and the TOEFL are given at test centers worldwide, while the
USMLE Step 2 examination is given at regional test centers in the United
States (ECFMG 2007).
IMGs must obtain a USMLE/ECFMG identification number to take
the required examinations. They are certified by the ECFMG after comple-
tion of (and acceptable scores in) all examinations and meeting all other re-
quirements, including school/diploma verification. Candidates may apply to
residency programs before their certification is completed, but they must be
fully certified before their programs begin. IMGs follow the same residency
application and matching process as followed by U.S. medical graduates, al-
though IMGs are also eligible to sign residency contracts outside of the
matching system (ECFMG 2007).
Credentialing of INGs in the United States is managed by the Commission
on Graduates of Foreign Nursing Schools (CGFNS), which was established in
1977 to standardize the examination process for internationally trained
nurses. The CGFNS conducts mandatory reviews of incoming nurses’ educa-
tional backgrounds and credentials, documentation of English proficiency,
and successful completion of the National Council Licensure Examination for
Registered Nurses (NCLEX-RN) (Bieski 2007). The CGFNS credential re-
view ensures that nurses have at least the minimum credentials required for li-
censure within the United States, although precise licensing requirements are
still managed by state boards of nursing and may vary. The English-language
proficiency requirement can be fulfilled through the submission of test scores
on the TOEFL or another test of English proficiency.
The CGFNS offers a pre-immigration examination in more than 30
countries around the world. While the examination is not a substitute for the
NCLEX-RN, it is an important predictor of success on the NCLEX-RN,
which is required for employment in the United States. The NCLEX-RN is
given at testing locations nationwide and in testing centers throughout Eu-
rope, Asia, and South America.
Adaptation
IMGs in the United States face a variety of barriers that may inhibit their
successful adaptation to working in the healthcare system. These barriers in-
clude the culture of medicine in this country—for example, patient-centered
care and more accepting views of mental illness—that is most likely different
63C h a p t e r 3 : G l o b a l i z a t i o n a n d t h e H e a l t h c a r e W o r k f o r c e
Nurses
Physicians
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from that in the IMG’s homeland. The IMG will also need to adjust to var-
ious models of the American family—for example, single-parent and step
families—that can influence physician–patient/family interactions (Whelan
2006). Also, some IMGs may encounter language difficulties when commu-
nicating with patients, some of whom may be suspicious of being treated by
“foreign” physicians, and when working with nursing and support staff.
IMGs’ professional experiences, attitudes, and practices in their home coun-
tries may also cause misunderstanding or conflict with American staff mem-
bers (Kuczkowski 2004).
Managers must take into account these and other potential adaptation
issues when designing orientation and ongoing support programs to help for-
eign-trained physicians to adapt to their new roles within the U.S. healthcare
system.
Once INGs, who have a broad variety of job experiences and expectations, ar-
rive at their jobs in the United States, their organizations must provide ade-
quate information and training to ensure that they can successfully perform
their new roles within the American healthcare system. Managers who hire
INGs have found the following areas in which training is especially useful:
• Culture (e.g., relative independence of nurses, work with professional
care staff rather than with patients’ family members) and communication
• Supervision and delegation of care
• Hospital systems, technology, and documentation
• Clinical skills and drug administration
Many healthcare organizations have found that INGs require addi-
tional orientation relative to U.S.-trained nurses, and to this end, organiza-
tions have initiated longer orientation programs that include elements such as
those listed above. Nurse managers who supervise INGs will also benefit from
educational programs that address many of the same areas. Such training will
enable managers to facilitate the quick adaptation of their nurses and head off
potential problems (Sherman 2007).
The Future of International Health Workforce Migration
The international migration of physicians and nurses is a long-standing phe-
nomenon that is likely to continue for many years in the future. Healthcare
organizations in many developed countries rely on these physicians and nurses
to offset domestic staffing shortages. In some cases, this migration can exac-
erbate healthcare workforce shortages in sending countries. In other cases,
however, this migration is anticipated, moving sending countries to educate
and train surplus physicians and nurses for export.
64 H u m a n R e s o u r c e s i n H e a l t h c a r e
Nurses
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While some receiving countries, such as the United Kingdom, have
taken steps to minimize the negative effects of international recruitment on
sending countries, the United States has not enacted similar policies. American
healthcare workforce planners have made little effort to ensure that the supply
of U.S.-trained physicians and nurses is self-sufficient. As a result, at least for
the moment, this country will likely continue to need foreign-trained health-
care professionals to meet the demand. Although this reliance on international
migration is unlikely to be a sustainable long-term strategy, it is and will be an
essential part of the U.S. healthcare system for many years to come. Because
the federal government has yet to develop a coherent workforce policy on this
issue, the responsibility for managing the effects of international recruitment
lies with leaders of individual healthcare organizations.
Issues of ethical recruitment will also continue to be important for
healthcare workforce planners and organizational managers. These leaders
must carefully consider how domestic needs place burdens on other countries’
healthcare systems, healthcare professions’ educational needs, and healthcare
workforce supplies. They must also provide adequate support to IMGs and
INGs once they arrive to work and train in the United States.
Summary
This chapter discusses several aspects of a critical issue to U.S. healthcare man-
agers: the globalization of the physician and nursing workforces. Given the es-
sential role that foreign-trained physicians and nurses play in many U.S.
healthcare organizations, an understanding of the history, current patterns,
and factors that motivate physician and nurse migration is vital for managers.
Physicians and nurses have sought work across international borders for sev-
eral decades, and their movement is likely to continue long into the future,
particularly in light of current healthcare workforce shortages in many receiv-
ing countries.
Many internationally trained physicians and nurses who work in the
United States and other developed countries are trained in developing coun-
tries. Some of these sending countries—particularly those in sub-Saharan
Africa and the Caribbean—face an uncontrolled “brain drain” of skilled health
workers, while other countries such as India, Cuba, the Philippines, and pos-
sibly China purposely train physicians and nurses to work overseas. While
these workers play a vital role in the health systems of many developed coun-
tries, their departure can have serious implications for the healthcare system
in their home countries. Several international bodies and individual countries
have adopted policies that attempt to manage the movement of physicians and
nurses from developing to developed nations, but thus far no universal prac-
tices have been adopted.
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In this context, U.S. healthcare organizations can recruit internation-
ally trained physicians and nurses through a variety of mechanisms. Because
the United States has not yet established a specific code of practice that gov-
erns international recruitment, employers themselves are responsible for pro-
viding a safe and transparent recruitment process for migrant workers. Addi-
tionally, managers must understand visa and credentialing regulations that
apply to internationally trained healthcare workers as well as the challenges
that these newly hired workers face as they adapt to working in the United
States. Careful consideration of all these issues will help to ensure the fair hir-
ing and successful incorporation of internationally trained physicians and
nurses into the U.S. healthcare workforce.
66 H u m a n R e s o u r c e s i n H e a l t h c a r e
Discussion Questions
1. Why is it important for healthcare
managers to be aware of the trends in
international migration of physicians
and nurses?
2. What impact do these trends have on
the U.S. healthcare system?
3. Sending countries experience two
distinct situations as a result of
international migration—brain drain and
strategic deployment. What are the
differences between the two? What are
the advantages (if any) and
disadvantages of each situation?
4. Suppose that U.S. policymakers are
developing ethical international
recruitment guidelines based on the
National Health Service’s Code of
Practice on International Recruitment.
What elements of the Code can be
included in the guidelines, and what can
be implemented in the context of the
U.S. healthcare system?
5. What are the ethical issues that
healthcare leaders and managers must
consider when recruiting IMGs and
INGs? What steps can be taken to deal
with these issues?
6. Discuss the importance of orienting
IMGs and INGs to their roles in the
U.S. healthcare system. What obstacles
(cultural, organizational, and
professional) do they face, and what are
the implications if these barriers are not
addressed?
Experiential
Exercise
For the Philippines, ex-
porting nurses has been a
long-standing government strategy, part of a
broad and concerted program of labor migra-
tion introduced in the 1970s during the ad-
ministration of President Ferdinand Marcos
(Tyner 2004). Although intended initially as
a short-term solution to domestic unemploy-
ment and high foreign debt, this program has
become a permanent strategy for generating
Case
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income for the country through regular re-
mittances from migrant workers.
The Philippines has a net surplus of
nurses because of high production and rela-
tively low demand, mainly because of under-
funding of the country’s health system. Be-
cause of nurse migration, the country has lost
many of its most skilled nurses. For the last
several years, the Philippines has been expe-
riencing two trends that are causing concern
among nursing leaders:
1. An explosive growth in the number of
nursing programs. In the 1980s, only 40
nursing schools were in existence
throughout the country; in 2007, the
number was much higher: 460
programs in total. Some schools have
sought rapid, drastic expansions to their
enrollment, contributing to the vast and
steady increase in the number of nursing
students. The Philippines currently
produces about 20,000 nurses per year
(Lorenzo et al. 2007).
2. A movement of physicians into “second
course” nursing education. Physicians are
leaving their posts in public hospitals and
rural areas to work abroad as nurses.
Demand for medical education has
declined, and some nursing schools have
created special programs that allow
physicians to pursue nursing education
while continuing to practice as physicians.
67C h a p t e r 3 : G l o b a l i z a t i o n a n d t h e H e a l t h c a r e W o r k f o r c e
Policymakers in the Philippines are
concerned that the growth in the number of
nursing programs has been accompanied by a
decline in quality of education: In recent
years, fewer than half of the nursing graduates
passed the nursing licensure examination.
This means that many nursing graduates can-
not even work as nurses in the Philippines,
much less in the United States and other
overseas markets. Nonetheless, thousands of
students enter nursing programs every year.
In this context, nursing leaders in the
Philippines are struggling to maintain quality
education and a sense of public service in a
profession that is increasingly governed by
business interests and influenced by individual
aspirations for overseas employment. The
country’s Department of Health (DOH) has
developed the Master Plan for Health Human
Resources to address domestic healthcare hu-
man resources distribution, motivation (com-
pensation—provision of living wages for gov-
ernment workers), and production. The DOH
has attempted to be directly involved in im-
proving the quality of nursing education and
the process of nurse migration, but the de-
partment’s efforts have been rebuffed by the
president, who wants these issues to be han-
dled by the Philippine Overseas Employment
Administration, the division of the Depart-
ment of Labor and Employment that manages
overseas deployment of Filipino workers.
You are a consultant to a
task force charged with
overhauling nursing education and migra-
tion practices in the Philippines. You have
been asked to recommend short-term and
long-term strategies to achieve sustainable
improvements in nursing education and to
harmonize the nursing-deployment policy
with domestic health system needs.
1. Who are your stakeholders, and from
whom will you seek perspectives? What
questions will you ask each of them?
Exercise
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2. Which issue—explosive growth of
programs, declining quality, training of
physicians to be nurses—will you
address first? How will you engage the
labor and health departments to
68 H u m a n R e s o u r c e s i n H e a l t h c a r e
implement your recommendations
successfully?
3. What obstacles do you expect to face in
this process? What strategies will you use
to overcome them?
Note
1. IMGs who are U.S. citizens make up approximately 3 percent of the physician work-
force in the United States (Mullan 2005). Many of these physicians are trained in “off-
shore” medical schools in the Caribbean or Central America. This phenomenon is not
discussed in this chapter.
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Turnitin Report
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Title Page
Citation
Outline
