Flexible Learning Pathways into Healthcare Occupations

1. Introduction

Context

Previous work on anticipating skills needs by the OECD and the ILO, with the contribution of the WHO and with support from the ILO-OECD-WHO Working for Health (W4H) Programme and Multi-Partner Trust Fund, has shown that labour and skill shortages, as well as mismatches, in the health and care workforce are pervasive (OECD/ILO, 2022[1]). Enabling entry into the health and care workforce is paramount to address these shortages. Labour-market entry can be facilitated through a range of policies beyond initial education, through the fostering of flexible career pathways. Flexible career pathways provide workers with multiple entry points into health and care careers. The objective of this report is to examine the policies that support flexible career and training pathways to entry-level jobs in the healthcare sector and present examples of good practices in selected OECD and low-and middle‑income countries.1

Shortages in the health and care workforce are reported in many countries across the world. Mostly due to demographic change, population ageing will likely increase the demand for health and care workers while at the same time, ageing of the health and care workforce will lead to increased strain on provision as a large number of current health and care workers will retire in the near future. Shortage in the healthcare sector exist both in terms of numbers of professionals and in terms of the skills needed to work with a new epidemiological and socio‑economic profile of populations, new technologies, and to adapt to new tasks. These shortages have been documented in detail in previous work (OECD/ILO, 2022[1]).

The consequences of skill gaps and shortages in the health and care workforce are particularly costly. They can increase patient waiting lists, create an overload of work for the staff available, increase burnout and reduce job satisfaction among medical staff, and ultimately result in poor patient care (Kane et al., 2007[2]; Jun et al., 2021[3]). These costs come in addition to the negative economic consequences usually associated with skill mismatches and shortages in other sectors of the economy, including lower productivity and growth (OECD, 2016[4]). A projected global shortage of 11.1 million health and care workers by 2030 underscores the urgent need for sustained investment in education, professional development and recognition systems, supported by stronger quality assurance mechanisms to ensure meaningful competency validation and workforce readiness (World Health Organization, 2016[5]; Noyes et al., 2020[6]).

Shortages and geographical variation in the health and care workforce are likely to explain a large part of the unmet needs for medical care. In 2021, on average across OECD countries, 2.3% of the population reported having unmet healthcare needs due to waiting times, cost and distance. However, the average masks large differences between countries, with unmet needs affecting 8% of the population in Estonia while being negligeable in Germany and the Netherlands.

In Southeast Asia, substantial advancements have been made towards achieving universal health coverage. The Universal Health Coverage (UHC) Service Coverage Index (SCI) has increased by approximately 30 points between 2000 and 2019 for the region, largely due to improvements in populous countries such as Indonesia. Despite this progress, the region’s current UHC SCI of 61 still reflects gaps in health access. In South Asia, the average UHC SCI reached 53 points as of 2020, with most countries showing improvement since 2017. Currently, approximately 3.1 billion people globally lack effective UHC coverage, with nearly one‑third of this population residing in South Asia (Lozano, Rafael et al., 2020[7]). This underscores the urgent need to address health inequalities.

In the WHO Africa region, population growth is outpacing the growth of health workers. Though there was a growth in number of health workers between 2018 and 2022 in 37 countries in the region, the workforce density per 10 000 population increased in only 29 countries (WHO, 2024[8]). This illustrates that populations are growing faster than the workforce development rate. Eight2 countries increased their stock of health workers, but population growth outpaced it, while ten3 countries saw their number of health workers and their density reduce in the same time period. Though in 2030, the health workforce is anticipated to increase by 40%, the region is still expected to face a 6.1 million needs-based shortage of health workers if its disease burden is to be tackled (WHO, 2024[8]).

Objective of this study

This study is a collaboration between the OECD and the International Labour Organization (ILO). The objective is to provide a characterisation of skill development practices to promote flexible pathways into health and care occupations across a range of countries. The study focusses on flexible training pathways in the health and care sector in South and Southeast Asia, Africa and the OECD, encompassing primary care, community health and long-term care in diverse settings such as hospital clinics, health centres and community facilities.

The study employed a mix-methods approach, combining primary and secondary research. A series of online consultation and interviews were conducted with stakeholders from selected countries. These discussions provided detailed, context-specific insights into workforce challenges and innovative strategies to address them. An extensive literature review was undertaken, focussing on publications primarily from the past five years to ensure relevance and accuracy.

This study aims to provide an insight into strategies and tools for flexible training pathways that directly target existing skill shortages and gaps. The goal is to identify innovative initiatives and programmes for training new health and care workers and identify components of those programmes that make training more accessible and achievable. However, flexible training does not exist in a vacuum and is influenced by a range of policies in the wider adult learning ecosystem, such as training leave, financial support, quality of training, policies for worker satisfaction and retention, and multi-sectoral dialogue between health providers, education providers and policymakers. As the study focusses on components of training policies in order to extract a set of tools or methods to increase flexibility in training, these contextual policies are not covered by the study explicitly, however, they remain crucial in ensuring a supportive ecosystem for adults navigating the world of work in the health and care sector.

While flexible training pathways are an opportunity to expand health and care training to new and underrepresented groups, they should not lead to low-quality jobs. All flexibility policies should include principles of decent work, ensuring fair wages, social protection, occupational safety and health standards, and career progression. This is especially true for long-term care workers and community health workers, which are often employed on an informal basis. As such, flexibility principles should be seen as a way to expand decent work to more people, and not to be misused to legitimise the under-skilling and underpaying of health and care workers.

Box 1.1. Defining adult learning for entry-level positions in health and care: Terminology

Adult learners: Adult learning is understood here as the job-related learning of adults who have left initial education and training and entered working life. Job-related learning refers to education and training undertaken for the purpose of acquiring skills for a current or future job.

Comprehensive education programme: Defined structured curriculum intended to deliver a complete set of skills and knowledge in contrast to “modular” or “flexible” programmes. There are sometimes referred to as “traditional full-length programmes” and are often multi-year full-time programmes. Examples include full-time vocational degree programmes or bachelor’s degree studies.

Entry-level positions: Occupations that fall within the categories of health associate professionals that require an formal qualification but in some cases relevant experience and prolonged on-the‑job training may substitute the formal education, or person care workers in health services which do not always require formal qualification but do require relatively advanced literacy and numeracy skills and good interpersonal communication skills (WHO, 2019[9]). Also referred to as “support-level health and care roles” or “foundational health and care roles”. These occupations have a hands-on, essential function in patient care, often with less stringent educational prerequisites. This includes several categories of health associated professionals,1 such as paramedical practitioners, nursing and midwifery associate professionals, ambulance workers, as well as personal care workers engaged in the healthcare sector such as healthcare assistants.

1. Core occupations in the healthcare workforce as defined by ISCO‑08 (WHO, 2010[10]).

Source: OECD (2023[11]), “Flexible adult learning provision: What it is, why it matters, and how to make it work”, https://www.oecd.org/content/dam/oecd/en/topic/policy-sub-issues/adult-learning/booklet-flexibility-2023.pdf.

Alone, initial education policies are not sufficient to address these challenges

Policymakers in most countries have attempted to address shortages in the healthcare sector through initial education policies, notably increasing the number of graduates for the occupations most in need. Many countries impose numerus clauses on comprehensive education programmes for doctors, nurses and other highly specialised health professions. In Southeast Asia countries have made significant investments of the past decade to enhance the supply of doctors, nurses and midwives, which has increased by 69.3% since the 2015. In India, for instance, 379 new medical colleges have been established since 2014 (WHO, 2024[12]).

Most of the accreditations provided by higher education institutions (such as physicians, nurses, midwifes, dentists and other) are strictly regulated within each country. International regulatory standards have also been developed over the last decades.4

Given the length of education programmes for health and professionals, adjusting student enrolment in comprehensive qualification programmes is not a short-term solution to shortages. It is also costly as it involves training new health and care workers using lengthy degree programmes, and policymakers risk over-correcting the number or students in response to fluctuations in perceived or real shortages or surpluses (Ono, Lafortune and Schoenstein, 2013[13]). On average, with slight variations across countries, undergraduate training lasts 3 years for registered nurses and most allied health professionals, such as midwives, physiotherapists and occupational therapists. Undergraduate training for doctors and dentists usually takes 5‑6 years, and further postgraduate training for doctors varies from 3 to 8 years, depending on the specialty (Anderson et al., 2021[14]). Consequently, there is a significant time lag in the effects of the policies due to the long duration of the training programmes. Because of their length, these higher education programmes are unlikely to attract adult learners who have left initial education and already have considerable work experience, unless they recognise and credit candidates’ existing knowledge and skills. Similarly, the introduction of new technologies could reduce some shortages, but cannot eliminate them or fill the skills gaps (Box 1.2).

Actions to retrain and up-skill adults already in the labour market or working informally in long-term care occupations through shorter and flexible training programmes can play a crucial role in addressing pressing shortages in the healthcare sector. They can help address shortages in entry-level positions directly, but they can also help address shortages of higher-skilled health and care occupations, such as doctors and nurses. Evidence using the Survey of Adult Skills (OECD, 2016[15]), suggests that tertiary-educated health and care workers spend a considerable part of their time doing tasks that require lower level of skills/competences than they are actually qualified for. As a result, flexible upskilling pathways provide an opportunity to address shortages by concentrating doctor/nurse/dentist time on doing the tasks for which they are mostly qualified for, leaving new/other categories of workers to do tasks/jobs not requiring several years of formal healthcare training.

Box 1.2. New technologies bring new solutions, but they also create demand for new competencies among health and care workers, calling for more flexible training pathways

In addition to the growing need for health and care workers, technological innovation, workforce mobility and reorganisation of work is impacting skill demand. Technology can be viewed as a valuable tool to improve the quality and coverage of healthcare services, but, alone, technological innovation cannot fill skills gaps and eliminate health and care workforce shortages.

In some countries there is a growing awareness of digitalisation and integration of new healthcare technologies as a tool to improve the quality and coverage of healthcare services and to reduce skill gaps in the sector. In Germany, the Digitalisation Strategy for Health and Care identifies shortage of skilled workers as an area which will be positively improved by the digitalisation of the healthcare sector, as services such as teleconsultations enable health and care workers to save time and see more patients (German Federal Ministry of Health, 2023[16]). For example, the introduction of teleconsultation may change the skill requirements of health and care workers by reducing the frequency of administrative tasks, while increasing the need for digital literacy, time management skills and care delivery.

However, other evidence suggests that the incorporation of certain technologies into healthcare may have little or negative impact. For example, the Norwegian Health Workforce Commission finds that there are few examples of technology development that have made healthcare service more productive (by reducing the number of workers needed to carry out the service) but rather that technological innovation often leads to increased labour and skill requirements, partly because workers are not given the training necessary to use the technology (Norwegian Health Workforce Commission, 2023[17]).

The use of artificial intelligence in healthcare opens big opportunities. But it also has the potential risk of de‑humanising healthcare: if AI begins making decisions without a professional involved, it risks de‑humanising care and eroding patient trust. For example, in the United States, three in five persons are uncomfortable with AI in healthcare. Additionally, there are concerns about workforce disruption due to automation (Sutherland, 2023[18]).

It is also important to note that many health and care workers, especially in LMIC, continue to struggle with accessing and effectively using digital tools. For example, internet penetration across South and Southeast Asia varies considerably by country, reflecting broader disparities in digital access. As of 2023, internet usage rates ranged from 45% in Bangladesh and 56% in both India and Nepal, to much higher levels in Southeast Asia, with 84% in the Philippines, 90% in Thailand and 78% in Viet Nam (World Bank, 2023[19]). These imbalances are also felt between rural and urban areas. Across Asia Pacific countries, internet usage stood at 80% in urban areas compared to just 52% in rural areas, further illustrating the divide in digital access (ITU, 2023[20]).

Gender disparities also remain: in South Asian and Asia Pacific countries, on average, have a gender parity score of 0.91 for internet usage, meaning that women are still less likely to use the internet than men (ITU, 2025[21]).1 Addressing some of these gaps is essential to ensuring that all health and care workers, regardless of gender or location, can participate fully in an increasingly digital healthcare environment.

1. The score is calculated by dividing the proportion of women who use the internet by the proportion of men who do. A value below 1 indicates that women are less likely than men to use the internet.

The diversification of jobs and tasks in the healthcare sector has the potential to open up opportunities for adults already in the workforce

Health and care workers are facing new tasks and change in composition of tasks. An analysis of online job vacancies in the United States shows an increase in health and care vacancies where the job title is not explicitly linked to an occupation in the US Standard Occupation Classification, but rather to a skill. This suggests that there are new and emerging health and care jobs that are based on specific skills rather than traditional occupations such as nurses, physiotherapists, dentists, and similar occupations (Frogner, Stubbs and Skillman, 2018[22]). Recent evidence on demand for digital skills in the health sector from Canada, the United Kingdom and the United States. For example, in Canada, there is an increased demand for data collection skills (traditionally not a strong requirement for health and care workers); in the United Kingdom, a rise in demand for cybersecurity skills has been observed, suggesting a stronger focus on protecting patient data; in the United States, the generalisation of electronic health records has become essential to manage patient data, enhance care co‑ordination, and improve clinical outcomes, and it has increased the demand on information management skills (OECD, forthcoming[23]).

The shift in responsibilities and tasks in the healthcare sector is also observed in the over-skilling in certain medical professions. According to evidence reported in (Batenburg and Kroezen, 2022[24]), more than three‑quarters of all doctors and nurses report over-skilling in their current job, particularly advanced nurses (Master’s degree or above), an indication that despite being qualified to do more technically advanced tasks many highly educated health and care professionals are still performing tasks that are below their competence level. Other studies, based on the Survey of Adult Skills, show that physicians consistently report over-skilling for some tasks and under-skilling for others (OECD, 2016[15]). Any changes in the distribution of tasks for existing health and care workers could efficiently be supported by targeted up-skilling and re‑skilling programmes.

In parallel, the diversification of tasks in the healthcare sector has the potential to open up opportunities for low-skilled adults already in the workforce. Strengthening career pathways for these adults into entry-level positions in the health and care workforce has the potential to alleviate shortages not only in entry-level roles but also among more advanced professionals such as doctors and nurses, as entry-level staff can take on foundational tasks that are currently being performed by highly trained clinicians. Such a redistribution of tasks would require a mindset change to enable a reorganisation of tasks and responsibilities. For this potential to be realised, new entry points and pathways are needed for those entry-level positions to boost recruitment. A major barrier preventing adults already in the workforce from pursuing healthcare careers is the length of training courses, their cost and strict entry requirements, particularly for those from underserved communities or with limited financial resources.

Flexible pathways to entry-level occupations would help address labour-market shortages in the healthcare sector

The transition of workers already in the labour market or informally working in care occupations into health and care professions is critical to help address shortages in the short term by boosting supply and enabling an evolution in the way different tasks are delivered within the health labour market. This will require effective systems to assess and recognise the skills of the available workforce, to identify skills gaps and to provide services and support that will address the barriers to upskilling and reskilling, as well as shorten the career pathways into the healthcare sector. Countries could provide guidance and training opportunities for workers to acquire the skills and qualifications needed to enter the health and care workforce. In addition, adults with experience of informal care could have their skills certified.

If education and training policies are to truly address skill gaps and be responsive to the labour-market needs of the healthcare sector they must be flexible, competence‑based and inclusive. In fact, a number of innovative policy avenues can be exploited to address these shortages, bridge the skill gaps and enable career pathways into health and care occupations both for those already employed in the healthcare sector (either formally or informally) and those who wish to enter the health and care workforce. Traditional, multi-year, comprehensive higher education programmes are the main pillar in the supply of highly skilled workers in the health and care sector, but with the diversification of roles and tasks in the sector there is an important role for flexible training programmes and other policies that might bring aboard those for whom traditional education pathways are inaccessible. Flexible training systems, recognition of prior learning and career guidance are also policy tools that, if designed and managed correctly, can be highly responsive to shifts in labour demand such as new tasks, technological advances, migration and demographic changes.

Beyond designing flexible training programmes, equipping the health and care workforce with the right skills will also depend on successfully identifying (i) which adults can be transitioned into the healthcare sector from other sectors, (ii) which health and care workers need upskilling, and (iii) which health and care workers working informally can be transitioned into formal work contracts through flexible training programmes.

Notes

← 1.  Selected countries will be those who have implemented relevant policies to provide flexible pathways into healthcare professions. A comprehensive review of education and training policies in the health sector is out of the scope of this project.

← 2.  Botswana, Burundi, the Democratic Republic of Congo, Malawi, Mali, Niger, Rwanda and Senegal.

← 3.  The Central African Republic, Chad, Eritrea, Gabon, The Gambia, Guinea, Lesotho, Liberia, Madagascar and Mauritius.

← 4.  To support the development of accreditation bodies around the world, the World Federation of Medical Education, in collaboration with the WHO and an international task force, published the Guidelines for Accreditation of Basic Medical Education, which later served as the basis for the 2013 WHO policy briefing on medical accreditation. These standards were updated in 2015 and 2020, and the World Federation of Medical Education subsequently developed a set of criteria for accreditation bodies and established a programme for the international recognition of accreditation agencies (Amaral and Norcini, 2022[88]).