OECD countries face a challenge in responding to the demand for health workers over the next 20 years. This challenge arises in a world which is already characterised by significant international migration of health workers, both across OECD countries and between some developing countries and the OECD area. Whether these migration flows increase or decrease over the next 20 years is likely to depend largely on what combination of human-resource management policies and migration policies is adopted by OECD countries.

This chapter presents data on the health workforces in OECD countries, including cross-country variation, past trends, and projections over the next 20 years. On average, there has been a prolonged growth in physician and nurse density in OECD countries over the past 30 years but the growth rates have slowed sharply since the early 1990s. Cost containment policies, such as control of entry into medical school in the case of doctors, and closure of hospital beds in the case of nurses, may explain much of the slowdown. By 2000, several OECD countries were reporting shortages of doctors and nurses and some countries published projections of the supply and demand for doctors suggesting that as a result of the anticipated retirement of health workers and increasing demand for their services, shortages would increase unless training rates were raised. Meanwhile, UN population projections suggest that between 2005 and 2025, younger age cohorts in the population will shrink in many OECD countries.

Despite differences in their approach to medical and nursing education, most OECD countries exercise some form of control over student intakes. In the 1980s and 1990s, several OECD countries introduced tighter student enrolment policies with an objective of cost containment. As a result, nursing and medical graduation rates decreased. Around the turn of the last century, many OECD countries found themselves facing shortages in health workers that were partly met by increasing migration flows. The contribution of foreign-trained doctors to changes in stocks of physicians is significant and has been increasing over time in many OECD countries. There are however important cross-country differences in migration of health workers that can be explained by structural and unforeseen factors. The former reflects long standing migration trends while the latter arise from unforeseen imbalances in the health labour market, largely attributable to lags between business, political and training cycles. While international recruitments of health workers can play a role in addressing short-term shortages, in a longer term perspective there is a clear choice between using migration and other policies, such as increasing domestic training or improving productivity, to address structural imbalances between supply and demand.

Chapter 3 reviews other health workforce policies aiming at an efficient use of the available health resources. A better use and mobilisation of available health workforce skills is possible through a portfolio of policies, including: improving retention, enhancing integration, developing more efficient skill mix, and improving productivity.

Growing international mobility of health professionals needs to be better monitored. Intra-OECD movements of health professionals account for an important share of health worker immigration to OECD countries, inducing cross-OECD interdependency in the management of health human resources. Ultimately there is a risk of exporting shortages within or beyond the OECD area, including to the poorest nations. Migration from countries which train to supply the world market cannot be a complete solution if all receiving countries turn to a limited number of origin countries which also have to respond to an increasing domestic demand in the near future. The global health workforce shortage, which goes far beyond the migration issue, calls for a shared responsibility between sending and destination countries. Origin countries must strength their health systems, improve domestic working conditions and encourage better management of their workforce. Host countries, on the other hand, must be aware of the impact of their policies on the health systems of impoverished nations. However, good practice for an ethical management of international recruitment raise several implementation and conceptual challenges, making the concept of shared responsibility difficult to operationalise. There is a need for greater international sharing of knowledge about useful examples with a view to their assessment and if appropriate, replication.

It has been reported that many OECD countries are facing potential shortages of health workers over the next 20 years. The demand for health workers is expected to increase because of rising incomes, continuing technological change in medicine and the ageing of OECD populations. The stock of health workers will fall, as the “baby boom” generation is beginning to reach retirement age. Individual OECD countries will face four main options to close the prospective gap between the demand for and supply of health workers over the next two decades. These are: to train more staff at home; to improve the retention and delay the retirement of existing OECD health workers; to raise productivity of existing health workers; and to recruit health workers internationally from other OECD countries or from outside the OECD area.