Background: In the context of the recent Greek economic crisis and its detrimental impact on healthcare system as well as the complete absence of a mechanism to map and plan human resources, a need for rethinking healthcare workforce management at a national level was emerged. Objectives: The aim of the study was to identify factors that influence the current and future demand for and supply of human resources in the Greek health system by specifying and empirically testing a projection model over the period 2015-2017. Methods: The projection model constituted a combination between a stock-and-flow model and a workforce-to-population ratio approach. This model was applied twice, once concerning total workforce and full track of new graduates and once concerning only public sector. Results: The first application of the model underpinned a sound and rampant oversupply of health professionals. On the other hand, the second application revealed a need for reinforcing public sector in terms of new hires especially of nursing and midwifery staff, and re-distribution of all. Conclusions: The main results indicate that health policy makers could reach an optimal matching between future supply of and demand for healthcare workforce by adjusting the flexible supply components. This presupposes an accurate and stable system of data collection. On the demand side, it is also important to collect demographics and other health-related data that are more indicative of health needs than population metrics.
Healthcare provision is a highly labor-intensive production process and constitutes one of the most significant sectors to the European economy. Hence, the human resources for health (HRH) planning is of great importance (in Europe, HRH occupy between 5% and 10% of total workforce) [
HRH planning requires the dual performance of supply and demand projections, which ideally should be equivalent at any given time in the future. Regarding the supply side, the vast majority of international literature proposes a stock-and-flow methodology [
In Greece, comprehensive data on human resources were not available in any one repository as there is not a na- tional system tracking at the same time graduates of health professions education programs, international immi- gration of workers with health-related skills or exits due to career change. This means that any attempt to deter- mine the size and core characteristics of the health workforce requires some level of analysis and synthesis of available information from multiple sources. The first step of our study focused on systematically identifying the supply of workforce in Greek NHS, through gathering and synthesizing data from different available sources and encompassing flows into and out of the health manpower. In particular, we conducted MoH and other gov- ernment agencies with HRH roles [e.g. Ministry of Education, Ministry of Labour, Ministry of Administrative Reform and e-Government and Hellenic Statistical Authority (EL.STAT.)], in order to combine different types of information scattered across different sources. HRH data mapping template (WHO, version 2.2 [
Components | Dimensions | Sub-dimensions | Availability | (Potential) source | Last available year | |
---|---|---|---|---|---|---|
Stock | Public sector | Educational level; Medical specialties | YES | Ministry of Health | 2014 | |
Private sector | - | YES | Health Map | 2012 | ||
Military service | - | NO | Ministry of National Defense | - | ||
Inflows | New graduates | University education | Public | YES | Ministry of Education | 2013 |
Military | YES | 2013 | ||||
Technological education | YES | 2012 | ||||
Secondary education | YES | 2014 | ||||
Returning international graduates | YES | DOATAP (Ministry of Education) | 2013 | |||
Trained staff returning to work | Permanently | NO | Ministry of Health | - | ||
Temporarily | NO | Ministry of Health or OAED (Manpower Employment Organization) | - | |||
Outflows | Retirements | Public sector | YES | Ministry of Health | 2012a | |
Private sector | NO | Insurance funds (Ministry of Labour, Social Security and Welfare) | - | |||
Deaths | - | NO | Insurance funds (Ministry of Labour, Social Security and Welfare) | - | ||
Career change | Public sector | NO | Ministry of Health | - | ||
Private sector | NO | Ministry of Labour, Social Security and Welfare | - | |||
Out-migration | EU countries | NO | Health professionals’ associations/chambers | - | ||
Non-EU countries | NO | - | - |
a. Including projections based on eligibility for retirement over the period 2015-2017.
ble to obtain insightful and thorough evidence of outflows. The main reason consists that out-migrants are not recorded at all, whereas insurance funds still fall short of management information systems. Another obstacle is that data were collected from different sources hence there is a little chance to achieve integration, interoperability, unified data format and same reference year.
On the demand side, we only had access to population-related data, and more specifically population projections by Eurostat’s EUROPOP2013 (European Population Projections, base year 2013) [
According to the adequacy and quality of domestic data combined with the projection alternatives presented above, we applied the workforce-to-population ratio concerning demand projections complementarily to the stock- and-flow model concerning supply projections.
The modeling of the workforce-to-population ratio method lies upon the last available population-based indicators (base year 2014) as well as the expected population growth (or decline) rate (2015-2017). The main concept of the examined methodology is that the population-based indicators in national level must meet the international standards. Secondly, apart from the international standards (minimum accepted thresholds), the national average density of each health professional category will constitute the threshold density among health regions that is assumed to correspond with the health system’s ability to deliver essential health services. Hence, this approach underpins both adjustment in total numbers and geographical reallocation.
Year | Total population |
---|---|
2014 | 11.028.135 |
2015 | 10.977.945 |
2016 | 10.929.715 |
2017 | 10.876.375 |
Regarding the stock-and-flow model, the stock/number of trained health professionals (S) in a future year (t + 1, t + 2 etc., where t is the base year) depends on the stock of the current year (St) plus the sum of i inflow cases under which health professionals join the workforce (It+1) and minus the sum of j outflow cases under which they leave (Ot+1). This model is quantified by Equation (1).
The current situation (October 2014) of the Greek health system is presented in
However, this situation is rather misleading in terms of the entire NHS since total physicians (including solo practice) account for approximately 69 thousands according to the most recent (2011) figures of EL.STAT. [
In terms of inflows, the domestic education system produces over 9000 new professionals every year (
Professions | Public sector | Private hospitals and clinicsc | Total | ||||
---|---|---|---|---|---|---|---|
Hospitalsa | Health centresa | Subtotal | Per 1000 populationb | Total number | Per 1000 populationb | ||
Medical doctors/physicians | 20,530 | 1851 | 22,381 | 2.0 | 10,875d | 33,256 | 3.0 |
Nursing and midwifery professionals | 17,709 | 748 | 18,457 | 1.7 | 8332 | 26,789 | 2.4 |
Other health professionals | 2470 | 612 | 3082 | 0.3 | 1778 | 4860 | 0.4 |
Total health professionals | 40,709 | 3211 | 43,920 | 4.0 | 20,985 | 64,905 | 5.9 |
Medical and pharmaceutical technicians | 3233 | 465 | 3698 | 0.3 | 0 | 3698 | 0.3 |
Nursing & midwifery associate professionals | 16,382 | 476 | 16,858 | 1.5 | 0 | 16,858 | 1.5 |
Other health associate professionals | 4662 | 308 | 4970 | 0.5 | 0 | 4970 | 0.5 |
Total health associate professionals | 24,277 | 1249 | 25,526 | 2.3 | 0 | 25,526 | 2.3 |
Personal care workers | 1347 | 177 | 1524 | 0.1 | 0 | 1524 | 0.1 |
Administrative | 8018 | 455 | 8473 | 0.8 | 2880 | 11,353 | 1.0 |
Technical & other | 8115 | 118 | 8233 | 0.7 | 2810 | 11,043 | 1.0 |
Health management and support personnel | 16,133 | 573 | 16,706 | 1.5 | 5690 | 22,396 | 2.0 |
Health services providers not elsewhere classified | 45 | 0 | 45 | 0.0 | 0 | 45 | 0.0 |
Total | 82,511 | 5210 | 87,721 | 8.0 | 26,675 | 114,396 | 10.4 |
a. 2014 data retrieved from Ministry of Administrative Reform and e-Government. b. Based on the 2014 population scenario of
Professions | Domestic graduates | International graduatesd | Total | ||||
---|---|---|---|---|---|---|---|
Universitya | Technicalb | Secondaryc | Subtotal | Total number | Per 100 existing staff | ||
Medical doctors/physicians | 1017 | - | - | 1017 | 112 | 1129 | 3.4 |
Nursing and midwifery professionals | 196 | 1379 | - | 1575 | 15 | 1590 | 5.9 |
Other health professionals | 491 | 1203 | - | 1694 | 123 | 1817 | 37.4 |
Total health professionals | 1704 | 2582 | 0 | 4286 | 250 | 4536 | 7.0 |
Medical and pharmaceutical technicians | - | 461 | 541 | 1002 | - | 1002 | 27.1 |
Nursing & midwifery associate professionals | - | - | 881 | 881 | - | 881 | 5.2 |
Other health associate professionals | - | 472 | 369 | 841 | - | 841 | 16.9 |
Total health associate professionals | 0 | 933 | 1791 | 2724 | 0 | 2724 | 10.7 |
Personal care workers | 0 | 0 | 0 | 0 | 0 | 0 | 0.0 |
Administrativee | - | 242 | - | 242 | - | 242 | 2.1 |
Technicale & other | 1809 | - | - | 1809 | 68 | 1877 | 17.0 |
Health management and support personnel | 1809 | 242 | 0 | 2051 | 68 | 2119 | 9.5 |
Health services providers not elsewhere classified | 0 | 0 | 0 | 0 | 0 | 0 | 0.0 |
Total | 3513 | 3757 | 1791 | 9061 | 318 | 9379 | 8.2 |
a. 2013 data retrieved from Ministry of Education. b. 2012 data retrieved from Ministry of Education. c. 2014 data retrieved from Ministry of Education. d. 2013 data retrieved from DOATAP (National Academic Recognition Information Centre). e. There are not any university undergraduate programs to produce administrative staff or engineers that are exclusively intended to healthcare despite several general management and technical schools exist.
corded 318 of them mainly consisting of physicians and pharmacists (“other health professionals”). The ratio of graduates to 100 existing employees shows an average production of 8.2 which is extremely high in case of “other health professionals” (37.4 graduates per 100 existing staff) and “medical and pharmaceutical technicians” (27.1 graduates per 100 existing staff). The former, perforce, choose the freelancing alternative (dentists, pharmacists, dieticians, speech therapists, physiotherapists, etc.), but the latter cannot be absorbed in salaried positions unless approximately ¼ of existing staff retires annually. However, during the last five years of economic crisis, Greek graduates from abroad are very less compared to previous years.
Concerning outflows (
The first application of the projection model concerns only salaried staff of public and private sector along with medical freelancers collaborating with private hospitals. The main assumptions made are listed below:
1) The starting stock of the model is the current workforce i.e. 114,396 employees at the end of 2014 (see
Professions | Eligible for retirement | Total (potential) retirements (2015-2017) | % of total retirements | % of total staff in public sector | Graduates per eligible for retirement (2015-2017)d | ||
---|---|---|---|---|---|---|---|
2015 | 2016 | 2017 | |||||
Medical doctors/physicians | 401 | 518 | 527 | 1,446 | 40.7 | 6.5 | 2.3 |
Nursing and midwifery professionalsa | 129 | 158 | 234 | 521 | 14.7 | 2.8 | 9.2 |
Other health professionalsb | 16 | 27 | 36 | 79 | 2.2 | 2.6 | 69.0 |
Total health professionals | 546 | 703 | 797 | 2,046 | 57.6 | 4.7 | 6.7 |
Medical and pharmaceutical techniciansb | 19 | 32 | 43 | 94 | 2.6 | 2.5 | 32.0 |
Nursing & midwifery associate professionalsa | 117 | 145 | 213 | 475 | 13.4 | 2.8 | 5.6 |
Other health associate professionalsb | 25 | 44 | 58 | 127 | 3.6 | 2.6 | 19.9 |
Total health associate professionals | 161 | 221 | 314 | 696 | 19.6 | 2.7 | 11.7 |
Personal care workersc | 8 | 2 | 10 | 20 | 0.6 | 1.3 | 0.0 |
Administrative | 125 | 183 | 316 | 624 | 17.6 | 7.4 | 1.2 |
Technical & other | 34 | 48 | 84 | 166 | 4.7 | 2.0 | 33.9 |
Health management and support personnel | 159 | 231 | 400 | 790 | 22.2 | 4.7 | 8.0 |
Health services providers not elsewhere classifiedc | 0 | 0 | 0 | 0 | 0.0 | 0.0 | - |
Total | 874 | 1,157 | 1,521 | 3,552 | 100.0 | 4.0 | 7.9 |
a. The MoH incorporates them into the “Nursing” staff category the retirements of which account for 246, 303 and 447 respectively (2015-2017). The total retirements were proportionally allocated to sub-categories based on the proportions extracted from
2) Eligible for retirement staff in public sector (
3) Domestic and international graduates over the examined period were supposed to be equal to that of the most recent available year.
4) Demand projections were adjusted in order to stabilize the current (
The results of
In this mode, we applied the projection model again, now including only the NHS public sector, since the so called Troika Memorandum of Understanding included only this type of staff. The main assumptions of this application are as follows:
Professions | 2015 | 2016 | 2017 | ||||||
---|---|---|---|---|---|---|---|---|---|
Supply | Demand | Deviationa | Supply | Demand | Deviationa | Supply | Demand | Deviationa | |
Medical doctors/physicians | 33,789 | 33,105 | 684 | 34,148 | 32,959 | 1189 | 34,494 | 32,798 | 1696 |
Nursing and midwifery professionals | 28,192 | 26,667 | 1525 | 29,553 | 26,550 | 3003 | 30,803 | 26,420 | 4383 |
Other health professionals | 6652 | 4838 | 1814 | 8426 | 4817 | 3609 | 10,186 | 4793 | 5393 |
Total health professionals | 68,634 | 64,610 | 4024 | 72,131 | 64,326 | 7805 | 75,489 | 64,012 | 11,477 |
Medical and pharmaceutical technicians | 4681 | 3681 | 1000 | 5651 | 3665 | 1986 | 6610 | 3647 | 2963 |
Nursing & midwifery associate professionals | 17,622 | 16,781 | 841 | 18,358 | 16,708 | 1650 | 19,026 | 16,626 | 2400 |
Other health associate professionals | 5786 | 4947 | 839 | 6583 | 4926 | 1657 | 7366 | 4902 | 2464 |
Total health associate professionals | 28,089 | 25,410 | 2679 | 30,592 | 25,298 | 5294 | 33,002 | 25,175 | 7827 |
Personal care workers | 1516 | 1517 | −1 | 1514 | 1510 | 4 | 1504 | 1503 | 1 |
Administrative | 11,428 | 11,301 | 127 | 11,425 | 11,252 | 173 | 11,244 | 11,197 | 47 |
Technical & other | 12,874 | 10,993 | 1881 | 14,687 | 10,944 | 3743 | 16,451 | 10,891 | 5560 |
Health management and support personnel | 24,302 | 22,294 | 2008 | 26,111 | 22,196 | 3915 | 27,694 | 22,088 | 5606 |
Health services providers not elsewhere classified | 45 | 45 | 0 | 45 | 45 | 0 | 45 | 44 | 1 |
Total | 122,635 | 113,875 | 8,760 | 130,505 | 113,375 | 17,130 | 137,900 | 112,822 | 25,078 |
a. Supply minus demand.
1) The starting point of the model is the current workforce i.e. 87,721 employees at the end of 2014 (see
2) Eligible for retirement staff (
3) Domestic and international graduates’ numbers were not taken into account since they constitute potential inflow into the labour market.
4) Demand projections were readjusted in order to exclude the contribution of private sector in covering health needs.
The results of
In order to stabilize the current (2014) density of each professional category, these newly recruited staff should consist of 1442 health professionals (physicians: 1,138; nurses & midwifes: 267; other: 37), 345 health associate professionals (medical & pharmaceutical technicians: 43; nursing & midwifery associate professionals: 243; other: 59), 1 personal care worker, 507 administrative and 53 technical staff, and 1 provider not elsewhere classified. However, the analysis of the previous section showed that there is poor compliance to international density standards especially among medical and nursing staff (oversupply of doctors and undersupply of nurses). In the case of public sector and after the proposed hires, physicians are expected to account for 22,073 whereas nurses (including midwifes) for 18,203 and total nursing staff (including associates) for 34,819. So, the corresponding ratio of nurses to physician remains at 0.82 and 1.6 respectively (compared to
Professions | 2015 | 2016 | 2017 | ||||||
---|---|---|---|---|---|---|---|---|---|
Supply | Demand | Deviationa | Supply | Demand | Deviationa | Supply | Demand | Deviationa | |
Medical doctors/physicians | 21,980 | 22,279 | −299 | 21,462 | 22,181 | −719 | 20,935 | 22,073 | −1138 |
Nursing and midwifery professionals | 18,328 | 18,373 | −45 | 18,170 | 18,292 | −122 | 17,936 | 18,203 | −267 |
Other health professionals | 3066 | 3068 | −2 | 3039 | 3054 | −15 | 3003 | 3040 | −37 |
Total health professionals | 43,374 | 43,720 | −346 | 42,671 | 43,528 | −857 | 41,874 | 43,316 | −1442 |
Medical and pharmaceutical technicians | 3679 | 3681 | −2 | 3647 | 3665 | −18 | 3604 | 3647 | −43 |
Nursing & midwifery associate professionals | 16,741 | 16,781 | −40 | 16,596 | 16,708 | −112 | 16,383 | 16,626 | −243 |
Other health associate professionals | 4945 | 4947 | −2 | 4901 | 4926 | −25 | 4843 | 4902 | −59 |
Total health associate professionals | 25,365 | 25,410 | −45 | 25,144 | 25,298 | −154 | 24,830 | 25,175 | −345 |
Personal care workers | 1516 | 1517 | −1 | 1514 | 1510 | 4 | 1504 | 1503 | 1 |
Administrative | 8348 | 8434 | −86 | 8165 | 8397 | −232 | 7849 | 8356 | −507 |
Technical & other | 8199 | 8196 | 3 | 8151 | 8160 | −9 | 8067 | 8120 | −53 |
Health management and support personnel | 16,547 | 16,630 | −83 | 16,316 | 16,557 | −241 | 15,916 | 16,476 | −560 |
Health services providers not elsewhere classified | 45 | 45 | 0 | 45 | 45 | 0 | 45 | 44 | 1 |
Total | 86,847 | 87,322 | −475 | 85,690 | 86,938 | −1248 | 84,169 | 86,514 | −2345 |
a. Supply minus demand.
This was the first effort to provide comprehensive evidence of HRH in Greece and further delineate its current and future situation. The main concept was to incorporate the workforce-to-population ratio method into a standard stock-and-flow model in order to initially perform projections over the period 2015-2017 (estimated to finalize the “mid-term program”) and afterwards locate any discrepancies from the labour market’s equilibrium. The major limitation pertains to the poor evidence of outflows and therefore the first application of the model, that included both public and private sectors’ employees and presupposed that health graduates constitute pure inflows, revealed a sound oversupply of health professionals. Furthermore, the second application, that isolated the human capital of private sector and the graduates’ effect, showed that the public sector needs reinforcement in terms of new hires especially of nursing and midwifery staff. However, the model’s sensitivity to population developments is extremely high and therefore the demand projections should be revised appropriately in an annual basis. Another emerging issue is whether population developments reflect health needs adequately. In any case, demographics, epidemiological and financial data do it better and it is urgent for the Greek MoH to collect such data in 2015 through its core information systems. Thus, the population-oriented projections applied above should be gradually upgraded to a patient’s needs-oriented approach presupposing the existence of a mechanism to record and quantify health needs [
The greatest challenge is not to apply the model but to produce metadata in the realm of complete lack of a fully comprehensive mapping tool as regards the Greek health workforce. The existing databases are not only fragmented but also confusing since there are several discrepancies and variations in definitions and proposed indicators between them and the WHO’s mapping template. Another critical point relates to the fact that Primary Health Care units have been partially recorded in these databases, because regional health authorities have recently undertaken their management from the National Organization for Healthcare Provision (EOPYY). Hence, developing reliable and accurate projection scenarios is impractical under the described circumstances. Even if the existing data (workforce “stock”) were updated, adequate and well-fitted, it would be naive to project future supply once again, due to lack of minor data regarding outflows (i.e. career change). A next step of this application should categorize the aforementioned professionals into groups based on, inter alia, working hours, gender, age and other workforce’s characteristics in order to combine them with several workloads and efficiency at- tributes [
To GIZ and Research Committee of DUTH who are contracted to proceed HR studies on which this article is based under Pr. Polyzos’ coordination and these authors’ participation.
To Pr. J. Yfantopoulos, Pr. C. Kastanioti, Dr. H. Karanikas, and Mr. Ch. Kakaras for their contribution to the studies.
To Dr. F. Von Renne (GIZ) and V. Kontozamanis (SG of MoH) for their collaboration.
Nikolaos Polyzos,Stefanos Karakolias,George Mavridoglou,Panagiotis Gkorezis,Christos Zilidis, (2015) Current and Future Insight into Human Resources for Health in Greece. Open Journal of Social Sciences,03,5-14. doi: 10.4236/jss.2015.35002