Matching the number and types of students to a country’s needs
The number of students admitted to study medicine in a different country has been a matter of speculation and controversy.
Anticipating physician supply for future health needs is crucial for policy planners, the public and for medicine itself. However it is a complex and complicated issue for which there have been no clear answers. There is no universal norm or standard for a minimum density or coverage of human resources for health recommended by the World Health Organization (WHO). However, the 2006 World Health Report estimated that countries with a density of fewer than 2.28 doctors, nurses and midwives per 1,000 people generally fail to achieve a targeted 80 per cent coverage for skilled birth attendance and child immunisation (WHO 2006). In 2009, the High Level TaskForce (HLTF) on Innovative International Financing for Health Systems offered two estimates of the number of health workers required to achieve the health-related Millennium Development Goals (MDGs) (Taskforce on Innovative International Financing for Health Systems 2009). One, developed by the WHO, found that 3.5 million more health workers (including additional managers and administrators) across 49 low-income countries were required to accelerate progress towards – and in many cases to achieve – the health-related MDGs, while also expanding coverage for other diseases and contributing to the hunger target in the first MDG (WHO 2013). The other set of calculations, by the World Bank and other institutions, found that these 49 countries required 2.6–2.9 million additional health workers, including managers, whose critical role is too often overlooked (World Bank et al. 2009). Dreesch et al. (2005) have proposed a methodology in human resource planning aimed at achieving the WHO’s MDGs.
The number of physicians in any country is often driven by government to create more healthcare activity or to control public expenditure. Moreover, whether more doctors improve patients’ health outcomes is still unclear. What is more certain is that more doctors will increase healthcare expenditure.
Who determines the number of medical students in a country is often not clear. In many countries medical schools come under the purview of the ministry responsible for higher education, while planning for health manpower is the responsibility of the ministry responsible for health. Ideally the planning of medical schools and medical school numbers should be undertaken collaboratively between the two ministries so that the provider organisation can give input into decisions on student intakes, but this may not always be the case.
The number of doctors needed to be trained by the country depends on many factors, including demographic patterns; disease pattern; level of medical technology and worker productivity; changing roles of support staff; affordability; distribution of doctors; gender issues; and migration of doctors.
Demographic patterns
The number of doctors required is driven to a great extent by the population in the country, although it is difficult to ascertain what an ideal doctor-to-population ratio should be. According to WHO (2013), the world mean for the period 2005–2012 is 14.2 physicians per 10,000 population or approximately one physician to 704 persons. There is considerable variation from country to country. Afghanistan has only 1.9 physicians per 10,000 population, while the Russian Federation has 43.1 physicians per 10,000 population (WHO 2013).
Although, as a tool, a worker-to-population ratio is easy to understand and to apply, it has important limitations. It provides no insight into personnel utilisation and does not allow any explorations into interactions between numbers, mix, distribution, productivity and outcomes. Moreover, any base-year maldistribution will likely continue into the target year.
The number of doctors required will also depend on the age profile of the population. Countries with a higher proportion of the elderly would require more medical services. In the USA more than three-quarters of persons over the age of 65 have at least one chronic disease that would require regular medication and care. In 2011 the first of the 78 million baby-boomer generation reached the age of 65 and concern has been raised that the health system in the USA may not be adequate to meet the demands of increasing numbers of the elderly (Institute of Medicine 2008).
Disease pattern
The pattern of disease seen in a country has an impact on the demand on health services. This is particularly so in the case of chronic diseases, which become more prevalent as the population ages. Worldwide there is an increasing prevalence of chronic diseases like hypertension, diabetes and coronary heart disease. In the USA the percentage of healthcare spending that is associated with people with chronic conditions has increased from 78 per cent to 84 per cent in the 7 years between 2002 and 2009 (Robert Wood Johnson Foundation 2010).
Level of medical technology and worker productivity
Advances in medical technology, including genetics, nanotechnology and information technology, will radically alter the practice of medicine. It is difficult to predict what number of doctors or which skills are required for optimal functionality in the new age of medicine. Technological advances may lead to greater productivity. Productivity can have a profound effect on numbers. A study by Birch et al. (2007) on predicting the number of nurses to be trained illustrates the effect of productivity in determining the optimum number of nurses to be trained in Canada. In their simulation study, they calculated that they would need to increase the number by 2,975 places per year to avoid future shortages. However, if a productivity improvement of 0.5 per cent per year was achieved, the required intake increase would drop to 825 places.
Changing roles of support staff
Health workforce planning is not merely a numbers game. The future functionalities of supporting staff will also play a role in determining the number of doctors required. The rise of the allied health professions would mean that tasks previously considered the exclusive purview of physicians can now be performed as effectively, safely and, importantly, more cheaply by allied health professionals.
Affordability
A country must be able to afford to employ all the doctors it produces. According to the Action for Global Health (2011), in El Salvador in 2008 as much as 53 per cent of the population had no access to healthcare, not because there was a lack of trained and prepared professionals – hundreds of doctors qualify every year but are unable to find a position in the public health system.
Distribution of doctors
In many countries, both developed and developing, the primary challenge may not be the number of doctors but the maldistribution of doctors. There is a tendency for doctors to gravitate to the more affluent urban centres. A study from Ghana revealed that, although most Ghanaian medical students are motivated to study medicine by the desire to help others, this does not translate into willingness to work in rural areas. Students from families with higher parental education and professional status are significantly less willing to serve in rural areas (Agyei-Baffour et al. 2011).
Gender issues
A report from the Royal College of Physicians published in 2009 predicted that within 8 years most doctors in the UK will be women (Elston 2009). Forty per cent of doctors in the UK were already women. In general practitioner (GP) clinics, 42 per cent were female. The General Medical Council reported that in 2013 women made up 44 per cent of all licensed doctors in the UK. Women accounted for 49 per cent of GPs and 32 per cent of specialists. Between 2010 and 2013, there had been a significant increase in the number of women on the Specialist Register and this increase was twice the increase in numbers of male doctors. In surgery, the number of women increased by 42 per cent compared with 12 per cent for men, although 90 per cent of surgeons were still male in 2013. In Emergency Medicine the number of female doctors grew by 44 per cent, compared with 28 per cent for males, and women accounted for a third of doctors in emergency medicine in 2013 (General Medical Council 2013).
These changes raise some major planning issues for the National Health Service (NHS) as, among female GPs, almost half (49 per cent) work part-time. Nearly a third (30 per cent) of female hospital consultants also work part-time. This could mean that more doctors will need to be trained and employed to ensure adequate care for patients.
The shift of the medical profession from a male-dominated profession to a female one is a pattern not only in the UK but also in many other countries, including Malaysia.
The gender issue reported in the UK is important and research is needed to assist in national planning of human capital development in the health sector. This issue may reflect concerns beyond the health sector, as Easton points out in her commentary on ‘America’s wayward sons’ (2013), citing research by Autor and Wasserman (2013) from the Massachusetts Institute of Technology (MIT) and work done by other social scientists. There are broader social issues for which much research needs to be done.
Migration of doctors
The migration of trained healthcare personnel from less-developed to more-developed countries is an issue faced by the poorer developing countries. In France, the Netherlands and Germany, increasing immigration of medical practitioners is seen as a means to maintain an adequate stock of physicians. German hospitals recruit abroad for doctors, particularly in Eastern Europe (Bourassa Forcier et al. 2004).
The UK has also been a country that used migration in a significant way to meet staffing needs. The Department of Health explicitly described international recruitment as a sound and legitimate strategy for the development of its workforce. In 2002 a third of the 71,000 doctors working in NHS hospitals had their primary medical qualification from outside the UK. In 2003, two-thirds of the 15,000 new registrants with the General Medical Council were from other countries (Buchan 2006).
In 2010, the sixty-third World Health Assembly adopted the WHO Global Code of Practice on International Recruitment of Health Personnel (WHO 2010). Ministers of health agreed to stop recruiting health workers from developing countries unless agreements are in place to protect the health workforce, and to provide technical and financial assistance to these countries as they strengthen their health systems. Whether this measure will alleviate the challenges faced by developing countries remains to be seen. Implementation of the WHO code by itself may not stop the ‘brain drain’ completely unless other factors are also addressed.
Tools for forecasting physician supply
A number of forecasting tools are available and have been used to predict the future supply of physicians needed, but the methods employed and the benefits and shortcomings of these tools have not been well appraised. There is currently no universal agreement or ‘magic formula’ for this purpose. Health workforce planning is particularly complex because of the long lead times associated with the training of health professionals – in particular, doctors. This has an important consequence, as what might be considered best evidence or best judgement at a given time might be dramatically wrong at some time in the future as a result of unforeseen changes in the financial, political or clinical environments.
In a review of forecasting tools by Roberfroid et al. (2009), four main approaches have been identified.
1 The supply projection model is based on doctor-to-population ratios and takes into account total health services currently delivered by the entire pool of doctors. The total number of physicians needed in the future is calculated on the premise that the current level of services will be met on a per capita basis. This model can be further refined to take into account other parameters like anticipated changes in demographic profiles, future health service targets, changes in worker productivity and skills mix.
2 In the demand-based approach the quantity of health services demanded by the population is determined. The number of required doctors is estimated based on the number and types of projected services.
3 The needs-based approach projects the number of health workers and the quantity of services needed to maintain an optimum level of healthcare in the country and to keep the population healthy. Information required for this approach would include the local prevalence of disease, demographic patterns and defined appropriate standards of care.
4 In the benchmarking approach a reference country or region is identified and planning for workforce resources is made after adjustments for factors like demography, health system and population health. In the past Malaysia had used Canada as a benchmark in health workforce resource planning.
In practice a combination of the four above approaches is often employed. However, forecasting the required number of doctors remains an inexact science. Many assumptions have to be made in the forecasting model. It is no surprise that many countries perform rather poorly in this. As O’Brien Pallas et al. (2001) have lamented, ‘Health human resources planning in most countries has been poorly conceptualized, varying in quality, professions specific in nature, and without adequate vision or data upon which to base sound decisions’ (2001: 2).
The following case studies illustrate the different approaches taken by four countries: Malaysia, the Netherlands, South Africa and Saudi Arabia.
Case study 4.1 Malaysia
Malaysia is an emerging economy in Southeast Asia, with a population of 28.8 million in 2011. The gross domestic product (GDP) for 2012 was slightly over USD 300 billion, with a per capita gross national income purchasing power parity of nearly USD 17,000. Healthcare in Malaysia is provided by both public and private sectors. The major provider is the Ministry of Health, with funding through general taxation. In 2011, the 132 government hospitals and six medical institutions provided a total of 33,812 acute beds and 4,582 chronic beds respectively. In addition, there are 985 health clinics and around 2,000 community clinics that provide adequate cover for both urban and rural populations. The private health sector complements the government health services. In 2011 there were 220 private hospitals with 13,568 beds. Private healthcare is funded primarily through out-of-pocket payments and third-party payers. Around 6,500 private GP clinics also provide a range of primary healthcare services.
Healthcare in Malaysia is generally adequate, as demonstrated by marked improvements in vital health statistics since becoming an independent nation in 1957. Notwithstanding the improvements in health indices over the last six decades, Malaysia faces new health challenges in its transition from a developing to a developed nation. With improvements in health and socio-economic indicators, the elderly population will increase with anticipated increases in healthcare spending. There is also an increase in the prevalence of chronic diseases.
Malaysia has employed the doctor-to-population ratio in health resource planning. The target is to achieve a ratio of 1:600 by 2020. This figure has improved steadily over the last decade, from 1:1,490 in 2000 to 1:791 in 2011. As of December 2013, this ratio was 1:633 based on 46,916 doctors in the country (Ministry of Health Malaysia 2014). Consequent to the number of medical schools in the country increasing dramatically over the last 10 years, the 1:600 ratio is expected to be achieved earlier. To ensure the quality of medical education an accreditation system for medical programmes has been established jointly by the Malaysian Medical Council and the Malaysian Qualifications Agency (Lim 2008).
Using a benchmark target of doctor-to-population ratio on its own is a simple but rather crude tool for health resource planning. Other factors, like the changing demographic profile, future service targets and the varying functionalities of the different categories of future healthcare professionals, have not been taken into account. There has been a lack of coordination between the Ministry of Higher Education, which grants licences for the establishment of medical schools, and the Ministry of Health, which is responsible for health resource planning. The rapid increase in medical schools in Malaysia raises the possibility of Malaysia producing more doctors than it requires. This will also have implications for placement of interns and opportunities for employment and postgraduate training. Concern has also been raised on the quality of medical education. There is a shortage of qualified faculty as well as a heavy reliance on Ministry of Health facilities for clinical training places, which are becoming increasingly scarce. The main challenge in Malaysia is no longer that of producing an adequate number of doctors but the capacity to produce quality doctors who can best serve the health needs of Malaysia’s transformed healthcare system.
Case study 4.2 The Netherlands
The Netherlands has a relatively long tradition of workforce planning in healthcare. Workforce planning is an important instrument in controlling shortages (or oversupply) within the Dutch healthcare labour market. The Dutch government is advised by the Capacity Body (Capaciteitsorgaan) regarding all issues related to the intake of medical students and the training capacity in all recognised medical specialties (including general practice). The Capacity Body, which was established in 1999, is the exclusive advisory body to the government on the inflow into all undergraduate medical and specialised postgraduate training programmes.
The Capacity Body employs a stock-and-flow model that was developed by NIVEL (Netherlands Institute for Health Services Research). The model is used in planning the required number of doctors to be trained to meet the projected demand for doctors in the Netherlands. This model is based on setting an equilibrium year. Statistics, as well as expert estimations about future developments on the demand and supply sides for doctors, are collected until the target year. To project the supply of doctors, surveys are undertaken among different cohorts of doctors, to measure their working capacity, primary activities and expected age of retirement. To estimate the demand for doctors, trends in the demand for healthcare services based on demographic and epidemiological factors are predicted. The difference between the required and available supply of doctors is then used to calculate the number of doctors that are required to be trained until the target year. This calculation takes into account the length of study and drop-out rates. Forecasting and planning data are also calculated, using scenarios with different demand growth parameters, as well as factors that include the shortening of working hours and task delegation.
This model was evaluated after 10 years of use and appears to have been successful in stabilising the labour market for physicians in the Netherlands (Van Greuningen et al. 2012). The model also appears suitable for use in the projection of training needs of other categories of healthcare workers. A weakness of this model is that it is unable to take into account substitutions between different categories of healthcare professionals from a skill-mix perspective.
The Netherlands appears to have succeeded in developing a model that meets most requirements for health workforce planning. The model takes into account many of the factors that determine the number of doctors required by a country. Application of this model would require some amount of expertise, as many parameters are based on expert estimations. Resources are also needed to conduct surveys. Equally important is access to good-quality data on demographics and inflow and outflow patterns of trained personnel. All these are crucial for the calculation of projections and estimates. Developing countries may not have the resources or the necessary data in order to utilise this model effectively.
Case study 4.3 South Africa
South Africa is an emerging economy, witha population of 51 million people. In 2010 it had a GDP of USD 363.7 billion and a per capita GDP of USD 7,254. The overall population growth was 1.87 per cent between 2010 and 2011 and more than 60 per cent of the population is under 30 years. South Africa faces a major challenge in human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS). The infant mortality rate is 35 deaths per 1,000 live births. The under-5 mortality rate is 47 deaths per 1,000 live births (40 per cent due to HIV infection). The maternal mortality rate is 310 deaths per 100,000 births (50 per cent due to HIV infection). In 2010 the prevalence of HIV was 17.9 per cent (5.575 million). Of these. an estimated 518,000 were children under 15 years and 2.95 million were adult females over 15 years. HIV prevalence measured among pregnant women attending public health antenatal clinics has increased from 0.7 per cent in 1990 to 30.2 per cent in 2010. It was reported that 73 per cent of tuberculosis patients were HIV-positive. Around 35 per cent of all deaths in South Africa result from non-communicable conditions and 31 per cent result from AIDS (National Department of Health 2013).
According to the WHO World Health Statistics report for 2013, there are only 7.6 doctors per 10,000 population. There is a maldistribution of physicians, with some provinces having as few as 2.6 doctors per 10,000 population, while in some other provinces there are as many as 14.7 doctors per 10,000. In October 2011, there was a shortfall of all healthcare professionals in the country of over 80,000 (Human Resources for Health South Africa 2011). In 2006 a total of 33,220 medical practitioners were registered. This represented a 14 per cent increase since 1999 and an annual average growth of 1.76–1.9 per cent. However, among African countries, South Africa has the highest number of doctors abroad, with 12,136 working in the USA, Canada, the UK and other developed countries. This is equivalent to one-third of its total workforce at home (Breier 2007). Since 1996, 37 per cent of South African doctors and 7 per cent of nurses have migrated (Naicker et al. 2009). Conversely, South Africa is the most popular destination for migrating health workers within Africa and, in 2004, 16 per cent of registered medical practitioners were graduates from other African countries.
South Africa has eight medical schools which at any one time train close to 7,500 students. The medical schools in the country have been asked to increase their intake to overcome the shortage of doctors in the country. The University of Witwatersrand increased their intake of medical students by an additional 38 students in 2012.
Unlike Malaysia, South Africa faces the challenge of inadequate number of doctors. It has a low doctor-to-population ratio (around 1:1,500). This problem is aggravated by marked maldistribution of doctors, a high prevalence of HIV infection and significant outflows of trained personnel due to migration to developed countries. The solution would appear to be to increase the number of medical students through higher intakes in each school and the establishment of new schools. It would be equally important to put in place measures to retain trained personnel in the country.
Case study 4.4 Saudi Arabia
Medical education in Saudi Arabia is relatively new. Prior to 1967 most physicians working in the Kingdom were expatriates. The few exceptions were Saudi citizens who were educated in other parts of the world, mainly in Egypt, the UK, Germany, France, the Indian subcontinent and the USA.
The first medical college was established at King Saud University, Riyadh in 1967. The college was affiliated with London University, and the affiliation agreement lasted until 1979. The first student intake was enrolled in 1969 and 23 students graduated 6 years later. The medical college in Riyadh later facilitated the establishment of two new colleges, which opened in 1975 at King Abdulaziz University: Jeddah on the west coast and at King Faisal University in Dammam on the east coast. A fourth medical college was established in Abha in the southern part of Saudi Arabia in 1980 and all of their founding deans were former faculty members of King Saud University. Fifteen years later a fifth medical college was established at Um AlQura University, Mecca.
In the mid-1990s, these five medical colleges produced about 450 medical graduates per year and only 15 per cent of this workforce was local doctors. With an annual growth rate of 3.6 per cent, it was estimated that the local medical colleges would need to produce at least 1,000 graduates per year to maintain the status quo and increase the number of doctors. The mass media highlighted the issue and medical educators were in the hot seat, which placed pressure to admit more students into the medical schools. Certainly there was no shortage of applicants among high-school graduates, but there were significant challenges. Local faculty members or educators were in short supply; the importance of maintaining a reasonable staff-to-student ratio was recognised; and there were a limited number of teaching hospitals and clinical facilities available.
Recognising this, the medical colleges took several steps. The Medical Colleges Deans’ Committee of the Gulf Cooperation Council (GCC) countries and the Saudi Medical Colleges Deans’ Committee were formed and later in 2002 the Saudi Society for Medical Education was established; several national and GCC-wide meetings, seminars and workshops were held; and forums and committees were formed. It was suggested that the country needed up to 12 new medical colleges and the consensus was to establish more medical colleges in different parts of the country to meet the shortage of medical doctors.
By 2005, 21 per cent of physicians in the country were local. A new strategic plan organised by the Ministry of Higher Education suggested that the targeted physician-to-population ratio should be 1:500 population, with 60 per cent Saudization by the year 2030. The adopted physician-to-population ratio was midway between 1:334 (of high-income countries) and 1:685 (of intermediate-income countries). The WHO recommends a ratio of 1:600. To meet the target, the Kingdom needs to graduate 2,500–3,000 doctors per year. The estimations were based on the Kingdom’s population of 22 million and an annual growth rate of 2.5 per cent in 2005, and an estimated population of 40 million in 2030.
By 2011, the government had established 29 medical colleges in the Kingdom, including for the first time six private colleges that are run by either for-profit or non-profit private bodies. Private medical colleges are expected to play an important role in the future development of medical education in the Kingdom.
The number of medical colleges that were established in such a short period will most likely have a very positive effect on the number of Saudi physicians in Saudi Arabia in the future. But it brought with it some new challenges. Staffing, infrastructure issues and clinical facilities are some of the challenges facing these colleges. Private medical education is a new experience in the country. Accreditation, certification and licensing are some of the issues that are currently being worked out.
Thus, it seems that the problems related to the shortage of Saudi doctors are on the way to being solved, but maintaining quality with this number of medical colleges established in such a short period and the introduction of private medical education are new challenges.
Like South Africa, Saudi Arabia faces the challenge of an inadequate number of doctors. In addition to this, the majority of doctors in the country had been, and are still, non-Saudis. The country has therefore embarked on an ambitious plan to increase the number of locals to be trained as doctors. From a single school in 1967 there are now 29 medical schools in the country. The plan appears to be working but, as in Malaysia, the rapid increase in medical schools over a relatively short period of time has led to new challenges, such as having an adequate number of qualified trainers as well as training facilities. Equal emphasis should be placed on ensuring the quality of the medical graduates.
An additional complexity is the globalisation of medical education and healthcare services. Besides the international migration of doctors and nurses, there has been an increase in various types of health-related flows, including international accreditation, financing, patient movements and trade in health services. Chapter 8 discusses some of the problems and opportunities that arise from medical student mobility.
Patients have always travelled to developed countries for high-quality medical treatment, and now patients are travelling for quality low-cost treatment (Frenk et al. 2010). In a recent and interesting development, innovative hospitals in India are moving to the developed countries, such as the Cayman Islands, to deliver world-class care affordably (Govindarajan and Ramamurti 2013).
Some proposals for an approach to determining future number of medical students
From the case studies above, it would seem that any solution, if there is one, is probably unique for each country. The first step would be to estimate the number of doctors the country needs. This planning will have to take into account the health philosophy of the country; the emphasis given to ‘curative vs preventive’ as well as the health financing model and its sustainability. Other factors would include the pattern of population growth and the demographic profile, the pattern of disease and case-mix. The functionality of the doctors would have to be clearly defined based on the need for primary care doctors as opposed to specialists and subspecialists. The planning should also take into cognisance the country’s policy on upgrading and enhancing the roles of nurses and other healthcare professionals.
The number of medical students to be trained is based on the number of doctors required (calculated as full-time equivalents instead of a head count), but taking into account:
• attrition rates in medical schools;
• gender bias in medical students;
• capacity of the country to produce intended number of doctors without compromising on quality;
• capacity to provide internship training for all the medical graduates and subsequently to provide employment for them;
• capacity to provide specialist and subspecialist training.
Planning for the number of medical students to be admitted requires the engagement of all key stakeholders: education and health sectors, industrial and professional organisations and consumers. The interests of the various stakeholders may not all coincide, but the approach must be transparent in terms of potential policy choices and their consequences, and the assumptions that have to be made in the workforce forecasting model.
There is no universally accepted approach to planning for physician demand and therefore the number of medical students to be trained. All approaches are based on many assumptions and therefore have limitations and inaccuracies. Each country needs to be explicit in its health vision and philosophy of access and equity, taking into account the social, political and financial realities. Forecasting models have to be responsive to the rapid changes taking place. It is clear that no one hat will fit all, and each nation has to adopt an approach that is pragmatic and best meets its needs.
Take-home messages
• Estimating the future number of physicians required by a country is a complex issue and requires the consideration of demographic patterns, disease patterns, the level of medical technology and worker productivity, the changing roles of support staff, affordability, the distribution of the workforce, the gender composition of the workforce and the migration of doctors.
• Various forecasting approaches are available, including the supply projection model, the demand-based approach, the needs-based approach and benchmarking.
• The solution to future physician needs is likely to be unique to each country. Planning would take into consideration the health philosophy of the country, whether the emphasis is on preventive or curative medicine, the health financing model and its sustainability.
• Planning requires the involvement of all key stakeholders: education, health, industrial and professional organisations and healthcare users.
Bibliography
Action for Global Health (2011) Addressing the global health workforce crisis: Challenges for France, Germany, Italy, Spain and the UK. Online. Available HTTP: http://www.actionforglobalhealth.eu/fileadmin/AfGH_Intranet/AFGH/Publications/HRH_REPORT_-_SCOPE_WEB_LORES_.pdf (accessed 13 May 2013).
Agyei-Baffour, P., Kotha, S.R., Johnson, J.C., Gyakobo, M., Asabir, K., Kwansah, J., Nakua, E., Dzodzomenyo, M., Snow, R.C. and Kruk, M.E. (2011) ‘Willingness to work in rural areas and the role of intrinsic versus extrinsic professional motivations: A survey of medical students in Ghana’, BMC Medical Education, 11: 56. Online. Available HTTP: http://www.biomedcentral.com/1472-6920/11/56 (accessed 13 May 2013).
Autor, D. and Wasserman, M. (2013) Wayward sons: The emerging gender gap in labour markets and education. Thirdway. Online. Available HTTP: http://content.thirdway.org/publications/662/Third_Way_Report_-_NEXT_Wayward_Sons-The_Emerging_Gender_Gap_in_Labor_Markets_and_Education.pdf (accessed 23 March 2015).
Birch, S., Kephart, G., Tomblin-Murphy, G., O’Brien-Pallas, L., Alder, R. and MacKenzie, A. (2007) ‘Health human resources planning and the production of health: A needs based analytical framework’, Canadian Public Policy, 33(Supp): S1–S16.
Bourassa Forcier, M., Simoens, S. and Giuffrida, A. (2004) ‘Impact, regulation and health policy implications of physician migration in OECD countries’, Human Resources for Health, 2(12): 1–11.
Breier, M. (2007) The shortage of medical doctors in South Africa. Case study report forming part of the HSRC study: A multiple source identification and verification of scarce and critical skills in the South African labour market. Online. Available HTTP: http://www.labour.gov.za/DOL/downloads/documents/research-documents/Medical%20Doctors_DoL_Report.pdf (accessed 23 March 2015).
Buchan, J. (2006) ‘Migration of health workers in Europe: Policy problem or policy solution?’ In C. Dubois, M. McKee and E. Nolte (eds) Human resources for health in Europe, Maidenhead: Open University Press.
Dreesch, N., Dolea, C., Dal Poz, M.R., Goubarev, A., Adams, O., Aregawi, M., Bergstrom, K., Fogstad, H., Sheratt, D., Linkins, J., Scherpbier, R. and Youssef-Fox, M. (2005) ‘An approach to estimating human resource requirements to achieve the Millennium Development Goals’, Health Policy and Planning, 20(5): 267–76.
Easton, N. (2013) ‘America’s wayward sons: Why they can’t carry on’, Fortune, Asia Pacific Edition, 11 April 2013 Online. Available HTTP: http://fortune.com/2013/04/11/americas-wayward-sons-why-they-cant-carry-on/ (accessed 15 June 2015).
Elston, M.A. (2009) Women and medicine: The future. A report prepared on behalf of the Royal College of Physicians, London: Royal College of Physicians.
Frenk, J., Chen, L., Bhutta, Z.A., Cohen, J., Crisp, N., Evans, T., Fineberg, H., García, P.J., Ke, Y., Kelley, P., Kistnasamy, B., Meleis, A., Naylor, D., Pablos-Mendez, A., Reddy, S., Scrimshaw, S., Sepulveda, J., Serwadda, D. and Zurayk, H. (2010) ‘Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world’, The Lancet, 376(9756): 1923–58. Online. Available HTTP: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61854-5/fulltext?_eventId=login (accessed 15 May 2013).
General Medical Council (2013) The state of medical education and practice in the UK 2014. Online. Available HTTP: http://www.gmc-uk.org/publications/25452.asp (accessed 24 March 2015).
Govindarajan, V. and Ramamurti, R. (2013) ‘Delivering world class health care, affordably’, Harvard Business Review, November. Online. Available HTTP: https://hbr.org/2013/11/delivering-world-class-health-care-affordably (accessed 15 June 2015).
Human Resources for Health South Africa (2011) HRH strategy for the health sector 2012/13–2016/17. Online. Available HTTP: http://www.gov.za/sites/www.gov.za/files/hrh_strategy_0.pdf (accessed 23 March 2015).
Institute of Medicine (2008) Retooling for an aging America: Building the health care workforce, Washington, DC: National Academies Press.
Lim, V.K.E. (2008) ‘Medical education in Malaysia’, Medical Teacher, 30(2): 119–23.
Ministry of Health Malaysia (2014) Health facts, Planning Division, Health Informatics Centre. Online. Available HTTP: http://www.moh.gov.my/images/gallery/publications/HEALTH%20FACTS%202014.pdf (accessed 6 April 2015).
Naicker, S., Plange-Rhule, J., Tutt, R.C. and Eastwood, J.B. (2009) ‘Shortage of healthcare workers in developing countries – Africa’, Ethnicity and Disease, 19(1 Supp 1): S1–60–4.
National Department of Health; South Africa (2013) Annual performance plan 2012/13–2014/15. Online. Available HTTP: http://advocacyaid.com/images/stories/rrdownloads/Health_annual_performance_plan_2012–2014.pdf (accessed 10 June 2014).
O’Brien-Pallas, L., Birch, S., Baumann, A. and Murphy, G.T. (2001) Integrating workforce planning, human resources, and service planning, Geneva: World Health Organization. Online. Available HTTP: http://www.who.int/hrh/documents/en/Integrating_workforce.pdf (accessed 13 May 2013).
Roberfroid, D., Leonard, C. and Stordeur, S. (2009) ‘Physician supply forecast: Better than peering in a crystal ball?’ Human Resources for Health, 7:10. Online. Available HTTP: http://www.human-resources-health.com/content/7/1/10 (accessed 13 May 2013).
Robert Wood Johnson Foundation (2010) Chronic care: Making the case for ongoing care, Princeton, NJ: Robert Wood Johnson Foundation. Online. Available HTTP: http://www.rwjf.org/content/dam/farm/reports/reports/2010/rwjf54583 (accessed 11 June 2014).
Taskforce on Innovative International Financing for Health Systems (2009) More money for health and more health for the money. Online. Available HTTP: http://www.internationalhealthpartnership.net/fileadmin/uploads/ihp/Documents/Results___Evidence/HAE__results___lessons/Taskforce_report_EN.2009.pdf (accessed 13 May 2013).
Van Greuningen, M., Batenburg, R.S. and Van der Velden, L.F.J. (2012) ‘Ten years of health workforce planning in the Netherlands: A tentative evaluation of GP planning as an example’, Human Resources for Health, 10:21. Online. Available HTTP: http://www.human-resources-health.com/content/10/1/21 (accessed 13 May 2013).
World Bank/UNICEF/UNFPA/Partnership for Maternal, Newborn and Child Health (2009) Background document for the Taskforce on Innovative International Financing for Health Systems. Working group 1: Constraints to scaling up and costs. Online. Available HTTP: http://www.internationalhealthpartnership.net/fileadmin/uploads/ihp/Documents/Results___Evidence/HAE__results___lessons/Working%20Group%201%20Technical%20Background%20Report%20%28World%20Bank%20UNICEF%20UNFPA%20PMNCH%29.pdf (accessed 11 June 2014).
World Health Organization (2006) Working together for health: The world health report 2006, Geneva: World Health Organization. Online. Available HTTP: http://www.who.int/whr/2006/whr06_en.pdf (accessed 13 May 2013).
World Health Organization (2010) WHO global code of practice on international recruitment of health personnel. Online. Available HTTP: www.who.int/hrh/migration/code/WHO_global_code_of_practice_EN.pdf?ua=1 (accessed 10 June 2014).
World Health Organization (2013) World health statistics 2013, Geneva: World Health Organization. Online. Available HTTP: http://apps.who.int/iris/bitstream/10665/81965/1/9789241564588_eng.pdf (accessed 23 October 2013).