Flexible Learning Pathways into Healthcare Occupations

2. Enabling flexible pathways into health and care occupations

The main objective of this section is to look at career pathways into entry-level health and care occupations (such as paramedical practitioners, nursing and midwifery associate professionals, and ambulance workers) and personal care occupations (including home‑based long-term care). That is, entry-level positions that are not subject to the same rigorous professional licensing process as doctors, nurses and dentists. In addition, this section looks at informal workers, for whom a formal recognition of their experience would improve their working conditions and the value of their service.

These entry-level positions include a large and diverse group of staff, and has a significant impact on health service delivery and patient experience. These workers are more likely to be recruited from the general education system and labour market, rather than from clinical training pathways. Although some members of this diverse group might have had career development plans and become managers, most have had inconsistent (or no) formal training and supervision, resulting in varying levels of competence (OECD, 2023[25]).

This section reviews policies on flexible education and training pathways into entry-level jobs of the health and care workforce. It includes innovative examples from OECD and low- and middle‑income countries. It is difficult to establish a strict categorisation of the examples cited because some of the policy examples presented are very comprehensive and can cover multiple categories (e.g. flexible training, recognition of previous learning and career guidance).1 However, for the sake of readability, the presentation is structured according to the main categories of flexible pathways instruments:

• Flexible training, including modular learning, work-based learning and online learning programmes;

• Policies enabling and facilitating the recognition of prior learning of health and care workers;

• Career guidance; and

• Programmes for the recruiting and retaining health and care professionals in medical deserts.

Impact assessment is a crucial aspect of policy implementation. Although a full review of the monitoring and evaluation frameworks for flexible pathways to the health and care workforce is beyond the scope of this project, a brief discussion on this topic is also included in this report.

Flexible training programmes

PIAAC data shows that across the OECD, lack of time for work or family reasons are the two main barriers to participation in training for adults (OECD, 2023[11]). Lack of financial resources is the third most cited reason for not participating, while inconvenient time or place comes as the fourth largest barrier. In addition, the Adult Education Survey shows that 22% of low-skilled adults, 18% of medium, and 17% of high-skilled adults mentioned the lack of suitable learning opportunities as a barrier (European Commission, 2021[26]). To address these challenges, adult learning systems need to give individuals greater choice and make adult learning provision more flexible (Box 2.1).

Box 2.1. What do we mean by flexible adult learning provision?

Flexible adult learning refers to educational and training opportunities tailored to the circumstances of adult learners, who often juggle work, family and other responsibilities while seeking to improve their skills. Unlike traditional, rigid education systems, flexible learning allows adults to move more easily between education, training, and employment throughout their lives.

Current adult learning systems still resemble formal education, requiring learners to attend classes at specific times and places, often in a traditional classroom setting. However, more flexible options are emerging globally, offering increased adaptability across four key areas: time, place, mode, and content.

• Time flexibility accommodates adults’ busy schedules by allowing them to choose when to learn, how long to engage, and how much time to dedicate. Courses can offer part-time options, asynchronous learning, and flexible start and finish dates.

• Place flexibility addresses the challenge of inconvenient locations. Distance and online learning allow adults to participate from anywhere, reducing barriers related to physical attendance. Distance learning was initially limited but expanded significantly during the COVID‑19 pandemic.

• Mode flexibility caters to different learning preferences, combining online and in-person elements. Blended or hybrid learning environments, where instruction is delivered both online and face‑to-face, are becoming more common. This approach reduces commuting time and offers learners flexibility in how they engage with course material.

• Content flexibility allows for personalised learning pathways. Modular courses offer learners the choice to study topics in a sequential or concurrent order, and advances in learning analytics are enhancing personalised education. This flexibility enables adult learners to pursue specific skills relevant to their career and personal goals.

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.

Modular learning can enable adults to obtain healthcare qualifications in their own time

Training for entry-level jobs in the healthcare sector needs to be relevant, job-related and accessible to adults. A tool for diversifying learning pathways is through the provision of modularised learning opportunities. Modularising adult learning provision means breaking down a learning programme into several self-contained parts each with their own learning outcomes. The modules are linked to a national qualification framework so that each part can be separately certified. As a result, learners may be able to obtain partial qualifications on completion of each module, and thus gain recognition of training without having to complete a full programme. In addition to being linked to national qualification frameworks, good-practice training modules should align with the WHO global competency framework for universal health coverage. Micro-credentials, for example, are a form of modularised learning and can be stackable to achieve a full programme and portability across institutions.

Currently, flexible training for adults who are not yet have a qualification for a health and care profession is rare. Most training providers focus short, targeted modules to professionals that have already completed their foundational entry-level degree but want to top-up their expertise, also known as upskilling (as opposed the reskilling which enables workers to enter a new sector). Modular learning and micro-credentials are becoming more prevalent in upskilling programmes in higher education institutions, offering specialised certifications for the existing health and care workforce. For example, in Ireland, public universities are expanding their offerings of shorter, standalone courses for healthcare professionals, such as nurses and doctors, who seek to acquire new specialisations as part of their lifelong learning. Similarly, the Australian National Qualification Framework enables training providers to offer modular training courses to become a registered nurse (skilled healthcare professional with a Bachelor of Nursing), with the prerequisite being that the candidate is already an enrolled healthcare professional with a Diploma of Nursing from a technical and further education institution. This sets the healthcare sector apart from other sectors, which are offering flexible learning also for entry-level jobs. However, some initiatives to enhance flexible training for entry-level healthcare jobs are emerging.

In Denmark, reforms to the wider VET sector have had positive spillover effects, as they have enabled a more flexible learning and career pipeline in the health and care sector, as well as other sectors. The adult vocational training programmes (Arbejdsmarkedsuddannelser, AMU) offer short, flexible and modular training programmes for labour-market entry in the pedagogical, social and health area. Adults can undertake training to work within seven occupations in the health and social sector, including the audiological and neurophysiological field and health and nursing tasks in both municipal health service and the hospital system.2 These training programmes are available at all levels of vocational adult education (Levels 2‑5 in the National Qualification Framework). Several courses are grouped into one module, and the learner can receive a certificate upon the completion of a module. Each course can last between a few days and six weeks, and the learner can take all courses in one continuous training programme or one‑by-one at the leaner’s own pace. The certificates are recognised by both the education sector for further training (VET and higher VET) and the labour market for access to employment. Similarly, the modularisation of health education programmes in VET and higher education in the Philippines (the Ladderized Education Program) is allowing students and workers to transition between VET and academic degree programmes without duplicating efforts (Technical Edcuation and Skills Development Authority, 2024[27]). As higher education institutions and VET providers develop unified curricula that allow students to earn credits for specific subjects or modules, units earned in a VET course can be credited towards a college degree. Just as in Denmark, the Philippines’ system allows students to enter the labour market after obtaining a certificate for a module (as opposed to a whole degree programme), and adults can navigate the educational system according to their career needs while maintaining the potential to pursue higher qualifications later in life.

The Barangay Health Services NC II qualification in the Philippines is designed for individuals who wish to serve as frontline workers in rural communities,3 the Barangay Health Workers. The programme targets adult individuals who have completed at least ten years of basic education or its Alternative Learning System equivalent, with good communication skills, who have volunteered for barangay health work for at least one year. The competencies covered in this qualification enable a person to assist households in identifying health problems, promote health and well-being, provide information, education, and communication (IEC) on disease prevention and control, maintain health stations, safely keep supplies and records, monitor household health status, and maintain updated records of health activities. Training is learner-centred and follows a competency-based programme, totalling 463 hours. Learners adopt individualised and self-paced learning strategies, potentially utilising institution-based or enterprise‑based modalities such as Dual Training Systems or Apprenticeships. Significantly, the Barangay qualification entitles community health workers to social protection and basic rights at work, reflecting the Philippines’ ratification of ILO Domestic Workers Convention (No. 189).

Multimodal learning options allow learners to take advantage of different types of training provision to suit their individual needs

Some entry-level training programmes have strengthened the connection between adult education providers and the healthcare labour market through partnerships with healthcare providers, which offer direct training and career pathways for learners. Under such partnerships, training programmes are designed using the inputs and expertise of healthcare providers, and incorporating important components such as job-related curriculum, workplace learning, apprenticeships and mentoring programmes to emphasise the career pathway from training to employment. Implementing work-integrated learning practices can encourage adult learning as the career benefits of training are made clear throughout the training programme, and the teaching methods better aligned with adults’ learning preferences.

In Barcelona, the Eixample Clinic Vocational Training Institute offers accredited vocational training and continuing education courses that are updated to reflect daily practice in the workplace for occupations such as nursing assistant and porter.4 Since its creation in 2005, the Eixample Clinic has opted for a model of vocational training based on technological innovation, specialisation, personalisation and placements in a real professional environment. Internships are carried out from the very beginning of the course, through a model that responds to the real needs of companies in the health sector, and in continuous and collaborative learning with these companies, in order to ensure that graduates are prepared for the real demands of the healthcare sector. Learners do not need to have a background in health to enrol in the courses, and placements are undertaken in public and private health centres, hospitals and clinics following the completion of introductory theoretical classes. For example, some students can do their internships at the Hospital Clinic of Barcelona (imaging and nuclear medicine, dietetics, healthcare assistant and others). In addition, students are closely supervised during their placements by an “Internship Tutor”. In addition to the practical and career-oriented elements of the training, Eixample Clinic offers online or hybrid training modes for all the theoretical modules in the programmes.

Similarly, the NHS apprenticeship programme in the United Kingdom offers adults an opportunity to gain entry-level qualifications through a blended work-place learning and classroom training programme.5 The apprenticeship programme allows any adult over the age of 16 to obtain a qualification while working for the NHS. The NHS offers more than 100 different apprenticeships with different entry requirements, ranging from general lower secondary education (GCSE) to training equivalent to a full Bachelor’s or Master’s degree. Through the apprenticeship programme adults participate in both on-the‑job training and classroom learning, while earning a wage for the work carried out during the apprenticeship. Most apprentices spend the equivalent of four days on work placement and one day at a training centre or college. The apprenticeship can last between one and four years, and the apprentice can gain both a competence qualification (based on the learnings in the workplace) and a knowledge qualification (based on the classroom learning) that enables them to work in an NHS job that requires a certificate of training for the healthcare sector, such as physiotherapy assistant, ambulance care assistant and dental nurse. Many courses in the classroom training component are available as e‑learning courses through NHS’s eLearning for Healthcare platform.

In India, the collaboration between Apollo MedSkills and the NSDC is playing a pivotal role in promoting adaptable and sustainable career pathways in healthcare. The NSDC was established in 2008 as a not-for-profit public limited company, operating under a unique public-private partnership model within the Ministry of Skill Development and Entrepreneurship (MSDE) (National Skill Development Corporation, n.d.[28]). Its mission is to “enhance, support, and coordinate private sector initiatives in vocational training, ensuring that financial barriers do not hinder skill development”. One of NSDC’s notable partnerships is with Apollo MedSkills, a healthcare education organisation under the Apollo Hospitals Group, which was founded in 2012 (Apollo MedSkills, n.d.[29]). Apollo MedSkills operates across 22 states with 42 training centres under its management, training approximately 6 000 candidates every three months (Apollo MedSkills, n.d.[30]). To date, over 112 000 students have been trained in various healthcare courses through MedSkills’ programmes.

The organisation provides a range of entry points and modular training tailored to individuals at different stages of their healthcare careers. Both new entrants and current professionals seeking to upskill can select from a variety of skill-based and short-term courses that align with industry needs (Dubey, 2016[31]). Digital tools, such as telemedicine and virtual classrooms enhance the flexibility of these programmes, ensuring that students are well-prepared to meet the evolving demands of the healthcare sector. Furthermore, through NSDC’s RPL framework, individuals can formalise their existing skills without the need to undergo redundant training. These NSDC-certified credentials are recognised across the industry.

New technologies have opened up new ways of delivering flexible training. There is an increasing use of distance learning through online training in the healthcare sector. The COVID‑19 pandemic fostered a global investment in digital infrastructure as many education and training providers had to implement online learning. This also applied to the healthcare sector, which saw an increase in the provision in massive open online courses (MOOCs) on COVID‑19 training for health and care workers. Though the initial wave of online training was tailored for the existing health and care workforce, (who were at the frontline of the pandemic), online training is increasingly becoming the norm for adults training to enter the health and care workforce in OECD countries. For example, Health Education England’s eLearning for Healthcare platform delivers more than 400 eLearning programmes. The training programmes are available for NHS employees for the purpose of upskilling or specialising, for adults enrolled in the NHS Apprenticeship training programme, or for learners enrolled in partnership programmes with the NHS. Providing asynchronous learning, that is training in which the instructor and the learner are not interacting with each other in real time (such as pre‑recorded video lectures), can significantly reduce time barriers as the learning can be carried out from the learners’ home and at a convenient time. However, for online learning to be successful it requires autonomy and self-motivation. Evidence from MOOCs (massive open online course) show completion rates as low as 10% (Rivard, 2013[32]; Murray, 2019[33]). Training providers and employers have to put emphasis on building and maintaining motivation of online learners, such as digital badges, (digital) interaction with other students and the teacher (OECD, 2020[34]).

Similarly, the Project Extension for Community Healthcare Outcomes (ECHO) initiative in India leverages telemedicine and digital platforms to address healthcare gaps across the country, particularly in underserved areas. ECHO connects healthcare providers in remote regions with specialists in urban centres, facilitating real-time knowledge sharing and capacity building. This approach is based on tele‑mentoring, which allows local health and care workers to receive training and guidance on complex cases without having to leave their communities (Echo India, 2024[35]). Since its inception, ECHO India has facilitated over 4 800 tele‑mentoring sessions, training more than 85 000 healthcare professionals across various disciplines. By harnessing digital tools and virtual platforms, ECHO enables healthcare professionals to continuously upskill, meeting the growing demand for more tech-savvy health and care workers.

The Spanish, UK and Indian examples show multimodal learning environments, where face‑to-face teaching is complemented by online materials and activities. These learning environments allow students to experience the benefits of face‑to-face interactions with their teacher and other students, while also taking advantage of the benefits of online learning. Research indicates that such flexible learning modes are more appealing to learners who have multiple commitments and have specific learning needs. Mixing modes of learning offer learners increased flexibility, satisfaction, and active engagement with learning. Additionally, flexible learning can lead to improved test scores and pass rates, though this may partly result from higher dropout rates among academically weaker students (OECD, 2023[11]). However, challenges such as technological reliability and higher cognitive demands are also reported, and some participants may struggle with digital tools, underscoring the need for further training in this area (Panda et al., 2024[36]). These findings highlight the importance of addressing both technological and logistical challenges to maximise the potential of such programmes.

Flexible pathways can help improve the professional prospects of long-term care workers

In many countries, people facing limitations in activities of daily living (ADL) and in instrumental activities of daily living (IADL) may not always receive sufficient formal long-term care (LTC) support. Among people aged 65 and over, across 22 European countries, half of individuals living at home with at least one ADL or IADL limitation reported that they did not receive sufficient formal or informal LTC support, illustrating the longstanding difficulties the LTC sector is facing in meeting demands for care (OECD, 2023[25]). Many countries in South and Southeast Asian countries are experiencing a shortage of health and care workers trained in geriatric care, coupled with inadequate healthcare infrastructure, particularly in rural areas. For instance, in India, medical students receive only one to two weeks of geriatric training, which constitutes less than 1% of their total medical education (NITI Aayog, 2024[37]). Social isolation and economic insecurity among older adults, especially those lacking access to pensions or adequate health insurance, further exacerbate the situation (ADB, 2024[38]).

Training of LTC workers helps to increase access to formal job opportunities in the healthcare sector. Although LTC jobs can be more complex than often portrayed, educational and training requirements for personal care workers are low. In fact, many countries do not require that personal care workers hold a minimum education level, and this despite the fact that mismatches in training and skills – such as specific geriatric training, health monitoring and care co‑ordination – can have a negative impact on the quality of care provided. Among countries that do, the requirement varies from vocational training (Hungary, Latvia, Luxembourg, the Netherlands) to a high school certificate (Belgium and Sweden) or a technical qualification after high school (Malta and Estonia). Very few countries (Canada, Denmark, Germany and Korea) have developed a career structure for LTC workers. This situation is aggravated by the fact that the LTC workforce in the OECD is often foreign-born (22% of employment) and working informally (OECD, 2020[39]). Flexible career pathways in healthcare can help address this issue by facilitating the rapid upskilling of health and care workers to meet the increasing demand for elder care services. By providing specialised training in geriatrics, chronic disease management and home‑based care, flexible pathways can assist countries in ensuring a stable supply of health and care professionals equipped to serve ageing populations, particularly in long-term care. Targeted training and innovative programmes can expand the health and care workforce and enhance care for the elderly. Further, after years of practice, many LTC workers in both the informal and formal sectors gain valuable skills. Recognising prior learning, along with additional training, can open up better career opportunities for formal workers and help informal workers transition into formal LTC jobs.

In the United Kingdom, the Skills for Care workforce planning body has launched the Care Workforce Pathway for Adult Social Care, which seeks to develop the first pathway for staff working in care roles (Skills for Care, 2024[40]). The initiative maps role categories in the care sector with definitions of behaviour, knowledge and skills expected for each role category. This sets the blueprint for identifying the skills and knowledges needed for the many different care roles. Flexible learning opportunities are key in addressing the skill shortages in the care sector, as many adults working in this sector face a multitude of barriers to participating in training.

In Australia, all continuous training programmes for LTC workers are sponsored by government’s funding. In addition, following the Aged Care Workforce Strategy, the Aged Services Industry Reference Committee started an examination process to reform the national training package qualifications and skill sets needed for LTC, as well as new approaches to career structuring and progression in the sector. In 2023, the My Aged Care Learning Strategy 2023 was released. This strategy outlines the required capabilities and minimum training to access to the aged care system and adopts a blended approach to learning, including on-line training, on-the‑job learning and evaluation by experienced workplace trainers and managers (Department of Health and Aged Care, 2023[41]).

In Austria, where a technical degree after high school is required for personal care workers and a Bachelor’s degree is required for nurses working in LTC, training for LTC workers is fully covered by governments and employers. Training can be provided during working time, and the ten weeks of education required to participate in the LTC workforce can be provided on-site, in schools or in universities (OECD, 2020[39]).

Germany has provided funds for education and redesign of degrees. School fees have been abolished in nursing education and a new legislation merged specialised nursing systems (general, geriatric and paediatric) allowing for more flexibility (Federal Ministry of Health, 2023[42]). Regarding specific measures for geriatric care, the education and training initiative for elderly care implemented between 2012 and 2015 extended options for shortening training when applicants have relevant knowledge and contributed to an increase in the number of trainees in geriatric care.

In Iceland, where no statutory minimum requirements exist for personal care workers, they can receive education or training specific to LTC. Courses take 2‑3 months, part time alongside work. Short training is mostly covered by unions or employers, and workers are often allowed to take part of it within working time. For social care workers, formal LTC education usually takes 2 years; for nurse aides (for which a Bachelor’s degree is required), it usually takes 3‑4 years (OECD, 2020[39]).

In the Philippines, the Technical Education and Skills Development Authority (TESDA) has developed the Caregiving (Elderly) NC II programme which is designed to meet the growing demand for skilled caregivers, addressing the challenges posed by an ageing population.6 The programme offers a structured and flexible pathway for individuals aspiring to enter the caregiving profession. The programme is part of TESDA’s broader strategy to enhance the workforce by providing nationally recognised certifications and skills training aligned with global standards. The Caregiving (Elderly) NC II programme equips students with the competencies necessary to provide care and support for the elderly in a variety of contexts, including private care, hospitals, clinics and other healthcare facilities. The programme encompasses both theoretical instruction and hands-on training, ensuring that graduates can effectively apply their skills in real-world settings.

The Caregiving (Elderly) NC II programme, delivered through TESDA’s accredited training centres across the Philippines, combines classroom-based instruction with supervised practical training to prepare individuals for professional caregiving roles. For those with prior caregiving experience, TESDA offers Recognition of Prior Learning (RPL), enabling candidates to have their skills assessed through practical demonstrations and interviews. This process allows them to gain certification without redundant training, saving time and resources. For individuals requiring additional training, TESDA provides modular learning options, ensuring they complete only the components necessary to complement their existing knowledge. Graduates of the programme receive the Caregiving (Elderly) NC II certificate, recognised both domestically and internationally, opening doors to employment in various settings, including private caregiving, hospitals, clinics, and residential care facilities. Beyond immediate employment, TESDA facilitates pathways for career progression, allowing certified caregivers to transition to related careers in healthcare or pursue advanced qualifications. In 2023, the programme recorded a total of 1 788 enrolments and 1 273 graduates, underscoring its critical role in addressing the growing demand for eldercare services amidst the country’s rapidly ageing population.7

In response to its rapidly ageing population, Thailand has developed a Community-Based Long-Term Care (LTC) Programme, aimed at providing comprehensive care for elderly individuals who are homebound or bedridden (ADB, 2020[43]). Launched in 2016, the programme seeks to improve the quality of life for older adults by offering co‑ordinated health and social services. Managed by local administrative organisations from the health and social services sectors, with support from the Ministry of Public Health, the programme establishes a framework for integrating care within the community. Central to the LTC programme are CHWs, who undergo 70 hours of training in areas such as chronic disease management, health promotion and mental health care to become community caregivers. Some CHWs are paid professionals, while others serve as volunteers. They visit elderly individuals in their homes, providing support for daily living activities, medical care and rehabilitation services. Depending on the individual’s needs, in-home care may range from two to eight hours per week.

In addition, the programme has established a new role for care managers, typically nurses or social workers, who play a key role in the initiative by assessing the health and social needs of elderly beneficiaries and co‑ordinating care plans. These managers undergo 70 hours of training focussed on ageing, the rights of older people, the role of a care manager and basic care management practices. They work with both the families of the elderly and health and care professionals to ensure that care is personalised, effectively monitored. Care managers are also responsible to manage and monitor the performance of five to ten caregivers.

Funded through the Universal Coverage Scheme (UCS), Thailand’s LTC programme represents a significant step in addressing the healthcare needs of its ageing population. By emphasising community-driven care and providing formalised training for caregivers, the programme not only supports elderly individuals in ageing at home but also offers a structured career path for those aspiring to enter the caregiving profession. By 2018, the programme had expanded to cover 5 639 out of 7 776 subdistricts, aiming to serve 193 000 people. As Thailand continues to expand and refine the programme, it may serve as a model for other Southeast Asian countries facing similar demographic shifts.

Similarly to long-term care, community health workers often face large levels of informality in the labour market yet could play an important role in addressing workforce shortages. Zimbabwe faces a persistent human resource for health (HRH) crisis marked by shortages, maldistribution, and attrition of health professionals. The challenges are driven by migration of doctors and nurses, poor remuneration, inadequate supervision, and disparities between rural and urban postings, which collectively undermine the country’s ability to deliver equitable services (ReBUILD Consortium, 2015[44]). Despite the launch of the Health Workforce Strategy 2023‑2030, which aims to scale up annual training outputs to 7 000, create 32 000 new positions, and integrate community health workers (CHWs) into the system, Zimbabwe continues to grapple with significant gaps (WHO Africa, 2024[45]). Within this constrained context, informal providers such as Village Health Workers (VHWs) or CHWs play an indispensable role in sustaining primary healthcare delivery. Established in the 1980s, the VHW programme provided community-level services in health promotion, prevention, minor treatment, and surveillance, particularly in underserved rural areas (CHW Central, 2018[46]). However, these workers often lack consistent remuneration, standardised training, and adequate supervision, leaving their contributions under-recognised and vulnerable to systemic neglect (Munyai, Mudau and Mashau, 2025[47]).

The reliance on informal providers reflects broader structural weaknesses, where up to 60% of Zimbabwe’s workforce operates informally, acquiring skills outside regulated systems (Medina, Jonelis and Cangul, 2017[48]). In health, this results in large numbers of providers working without clear credentialing, regulated scopes of practice, or pathways for professional advancement, and potentially without the competence to do the job. While VHWs and CHWs are integral to bridging service gaps, they remain outside the authority of professional councils that license and regulate doctors, nurses, and allied professionals (ReBUILD Consortium, 2015[44]). Recently, the government signalled a shift by announcing the absorption of 22 000 CHWs into the civil service by the end of 2025, with a longer-term goal of doubling their numbers to 40 000 by 2030 (Frontline Media, 2025[49]). This represents a move toward formal recognition, yet the absence of flexible credentialing mechanisms limits opportunities for informal providers to transition into more advanced roles, such as health assistants or technicians.

Creating flexible pathways for informal providers could significantly strengthen Zimbabwe’s health workforce. Modular training and bridging courses that acknowledge prior informal experience would allow VHWs to acquire credentials and progress into semi-formal or formal cadres. Standardised curricula, supervision, and regulation would improve the quality and safety of care, while official recognition and remuneration would enhance motivation and retention. Such pathways would also deliver cost-efficient expansion of service coverage, particularly in rural areas where physician shortages are acute. However, these reforms require regulatory innovation, investment in training infrastructure, and integration into broader HRH planning to avoid perpetuating a two‑tier system. Zimbabwe could move closer to achieving universal health coverage while simultaneously addressing its HRH crisis by formalising and professionalising the role of VHWs and other informal providers.

The formalisation of previously informal healthcare provision is enabling workers in Tanzania to enter formal health professions. The Accredited Drug Dispensing Outlets (ADDOs) represent an innovative yet hybrid approach to strengthening Tanzania’s pharmaceutical workforce. Although considered informal, ADDOs operate under a semi-formal framework, as dispensers receive structured training and certification before being licensed to operate. They were first introduced to expand access to essential medicines through community pharmacies known as Duka la Dawa Muhimu (DLDM), with a particular focus on underserved rural and peri‑urban populations (Rutta et al., 2009[50]; Pharmacy Council, 2015[51]).

Over time, ADDOs have evolved into a flexible pathway into formal health professions, enabling thousands of individuals – many of whom would not otherwise enter the health sector – to contribute to service delivery. To date, Tanzania has established more than 9 000 accredited medicine outlets staffed by over 19 000 trained dispensers, significantly increasing coverage of pharmaceutical services across the country (Pharmacy Council, 2015[51]). Their contribution has been notable in areas such as antimicrobial stewardship, where ADDOs have played a role in guiding appropriate medicine use and expanding health literacy (Rutta et al., 2009[50]). However, sustainability challenges remain. Ensuring consistent quality assurance, regulatory oversight, and professional standards has proven difficult given the scale and diversity of ADDOs. Variations in adherence to dispensing guidelines, limited supervision, and the commercial pressures faced by operators can compromise service quality. Long-term sustainability therefore depends on stronger regulatory mechanisms, ongoing professional development for dispensers, and better integration of ADDOs into the formal health system (Pharmacy Council, 2015[51]) and institutionalisation through existing training frameworks including the Technical and Vocational Education and Training Institutions.

In summary, while ADDOs have demonstrated how non-traditional pathways can expand healthcare access and serve as stepping-stones into formal professions, their sustainability hinges on balancing access, quality, and regulation within Tanzania’s broader health system.

Recognition of prior learning

In the context of adult learning, recognition of prior learning (RPL) has emerged as a vital policy tool in enabling better skill matching between workers and jobs, and facilitating upskilling and reskilling. RPL is a process by which candidates have their prior learning and experiences identified, assessed, documented and certified as education and training credentials. RPL can be used to validate both practical and theoretical skills, and it is the bridge that enables non-formal and informal learning to be formalised. This validation of acquired skills and competencies opens up work and training opportunities to those that possess the skills without having undergone formal education. As such, RPL is a policy tool that increases the employability of citizens, often faster and (potentially) at a lower cost than formal education. It can also help address labour and skill shortages by reducing training time.

RPL systems are diverse, and this section describes examples from different countries. Each system is unique to some extent in the way it assesses candidates, what type of support is offered and what are the final outcomes of the process. However, all RPL programmes must be built on RPL standards, which are reference points for skills and knowledges for which a candidate is assessed against. As a minimum, RPL standards need to identify the qualification, occupation, block of competencies or individual competency that is required for a job. The competencies and knowledge need to be linked to related learning outcomes or tasks, which are practical descriptions incorporated in the assessment method. Ideally, the standards will be linked to the national qualification framework or occupation standard, so that employers easily able to understand the certificate issued through the RPL process. Assessment methods can either be the same for all candidates or adjusted to the candidate’s needs and experiences.8

RPL has the potential to provides an entry pathway to formal employment in the healthcare sector for LTC workers employed informally and for community health workers who provide personal care and administer medication or perform medical acts in households. Numerous informal care workers possess the necessary skills to carry out healthcare tasks, yet do not have the formal qualifications required to carry out the same tasks under a formal work contract. Community health workers play a vital role in primary healthcare, often acting as frontline providers for underserved, marginalised, and hard-to-reach populations. Despite their contributions to delivering accessible, affordable, and people‑centred care, their roles are often loosely defined, inconsistently compensated, and poorly integrated into formal health systems (Mignote et al., 2023[52]). Recognition of prior learning becomes a central component in making visible the skills and competencies and enabling formalisation and work mobility of LTC carers and community health workers.

Still, the use of RPL in the healthcare sector has its limitations. Many health and care professions are highly regulated and remain subject to strict licensing standards with rigorous academic assessments a necessary pre‑requisite to enter the occupation. Such is often the case of physicians and nurses, who must undergo substantial education programmes to obtain the necessary licence to practice within their field. For these occupations, recognition of prior learning could only play a very minor role in validating smaller training modules and slightly shortening the duration of the education programme.

For lower-level entry jobs within the health and care sector such as community health workers and healthcare assistants, RPL can be a deciding factor in motivating an adult to take‑up a formal job. Embarking on a comprehensive qualification can be a daunting task for adults who have not undertaken any formal training in a long time, and lack of time is cited as the biggest barrier to training among adults (OECD, 2020[53]). RPL has often an individual-centric starting point, where the process focusses on what the individual needs to enter the occupation, rather than what a one‑size‑fits all training programme. By focussing on the individual’s prior experience, the length of an education programme can be reduced through the certification of training modules or the qualification itself.

In the Philippines, the NCII programmes for both for the Barangay Health Services (community healthcare workers) and Caregivers (long-term care workers) include RPL processes, so that candidates who have gained competencies through means other than formal training programmes, such as through education, informal training, previous work, or life experiences, may apply for recognition for a particular qualification. RPL includes a competency assessment process that confirms whether the individual can perform to the standards expected at the workplace as expressed in the relevant competency standards.

Similarly, in Japan, the Career Level Classification System for Long-term Care Professionals aims to make care professions more attractive by increasing he transparency of career paths and enable RPL in the workplace (Elderly Service Providers Association, 2025[54]). Developed by a private organisation, the Elderly Service Providers Association, under the initiative of the Cabinet Office of the Japanese Government, the system was introduced in 2012 to address high turnover rates in the care sector, as many workers felt their skills were not adequately recognised or reflected in their wages. The system maps the skill requirements in care occupations from Level 1 (entry level) to Level 7 (mastery) for both theoretical knowledge and practical skills. The knowledge components of the assessment system employ the official certification system for long-term care workers, meaning candidates have to pass existing examinations. However, the practical skill assessment is the core feature of this system. Assessors – coworkers trained and qualified by the Elderly Service Providers Association – observe applicants’ daily work and evaluate their skills on a scale from Level 1 to Level 4, with Level 4 indicating leadership capabilities in the workplace. The grading system consists of evaluation criteria for practical skills have the structure of three large units, subdivided by 13 medium units, 41 small items and 148 individual points to be assessed totally. The units and points to be assessed vary on which level is being graded (Study team, 2021[55]). This enables workers to be hired as support staff and gain qualifications as they acquire skills on the job and through training, and obtain qualification with the support of their employer.

Some countries, such as South Africa, are attempting to implement RPL for a range of roles in the healthcare sector, not only for low-skill occupations (Box 2.2). Implementing a sector-wide RPL system requires comprehensive policy design to address both the range of skills acquired informally or non-formally, as well as the different skills and training requirements of different health and care occupations.

Box 2.2. Recognition of prior learning in South Africa

South Africa’s RPL system is anchored in the National Qualifications Framework (NQF) Act No. 67 of 2008, together with associated legislation including the National Policy for Implementation of the Recognition of Prior Learning, created by the South African Qualifications Authority (SAQA, 2014[56]). In South Africa, RPL allows recognition of learning (formal, informal, non-formal) gained outside conventional academic settings (through work experience, community service, mentorship, etc.), measured against learning outcomes required for qualifications, professional registration, or licensure (SAQA, 2002[57]; 2014[56]).

There are three avenues through which South Africa’s RPL framework facilitates flexible career pathways for healthcare professionals. First, access to health profession education. For health professions such as nursing, RPL has been integrated into the South African Nursing Council (SANC) policy to enable people who have relevant work experience or informal training to enter formal nursing qualifications or receive credits towards specialised training (South African Nursing Council, 2009[58]). This lowers barriers for candidates who may not meet traditional academic entry requirements but have amassed relevant competence through experience. Second, accelerated registration or licensing. The RPL process can allow practitioners to have parts of their skills, knowledge, and experience formally acknowledged so that they may bypass some formal training modules or fulfil registration requirements more quickly, assuming their competencies meet required standards. While detailed published examples for medical doctors (through the Health Professions Council of South Africa, HPCSA) are less immediately visible, the policy environment under SAQA mandates that professional bodies must have RPL policies if they seek recognition of professional designation (South African Career Development Association, 2022[59]). Third and final, formalisation of previously informal work. Many health and care workers who have acquired skills through service, mentorship, or informal settings may not have formal credentials. With RPL, such workers can gain recognition for these skills, receive credits, or undergo competency assessment, thereby becoming formally recognised and eligible for licensure, better employment opportunities, and progression. Nursing is a concrete example: work experience and informal learning are accepted by SANC under RPL to allow for credentialing and specialised training (South African Nursing Council, 2009[58]).

The benefits of South Africa’s RPL framework is twofold. First, redress & equity. RPL is explicitly used to correct past inequities – racial, educational, socio-economic – that excluded people from formal education and professions. It allows learners from disadvantaged backgrounds to formalise their competence (SAQA, 2014[56]). Second, improves mobility & progression. RPL enhances the ability of professionals to move across roles, elevate higher qualifications, or enter into specialised fields without repeating redundant education by allowing credits for prior learning (SAQA, 2014[60]). Nursing applicants who have non-formal or informal experience can use RPL to access nursing training programmes, or to gain credit toward certain modules, enhancing professionalisation of nurses with experiential learning backgrounds (South African Nursing Council, 2009[58]). Likewise, RPL is embedded in national frameworks like the NQF, which ensures that all Quality Councils (including those that cover health professions) are required to accept and implement RPL (SAQA, 2014[56]).

Despite the benefits, the RPL framework faces several challenges and limitations. First, there are varied implementations across professions. While bodies like SANC have clear RPL guidelines for nursing, other professional boards do not always have as explicit procedures, especially for professions such as medicine, where regulatory, safety, and quality considerations are more tightly controlled. Despite pilot initiatives aimed at community health workers, these remain with a provincial scope and do not yet make part of a national RPL system for all CHWs and informal caregivers. Second, there are notable challenges with quality assurance and assessment. Assessing prior learning rigorously, ensuring fairness, consistency, and alignment with national qualification standards requires well-trained assessors, appropriate instruments, and moderation. Some institutions struggle with capacity, funding, and administrative complexity. Third and final, there are challenges with recognition in licensing and scope of practice. Even when formal learning is recognised, there may still be restrictions from regulatory councils about what practice candidates can perform without full formal qualification or supervised practice.

The South African experience with RPL highlights several lessons that can inform other African contexts. First, a nationally legislated framework, such as the SAQA Act and the NQF, is critical to ensure legitimacy, consistency, and co‑ordination across professions. Second, professional councils must develop clear guidelines – as seen with the SANC – to translate national policy into practical pathways for licensing and registration. Third, robust quality assurance systems are needed, including standardised assessment tools, well-trained assessors, and effective credit-transfer mechanisms, to maintain credibility and fairness. Finally, transparency in recognising prior experiences, whether from formal work, informal practice, or mentorship, helps applicants prepare adequately and builds trust in the system. Collectively, these elements enable RPL to expand access, formalise skills, and strengthen professional mobility within the health sector.

Across the OECD, seven countries have taken initiatives in recognising previous work experience in long-term care by awarding course credits in education programmes (OECD, 2023[61]). In Denmark, an assessment of individual competences is available to all participants in the training programme, where they can get certification for an entire AMU training programme or individual modules. The assessment comprises a conversation with a VET teacher and a written and/or practical assessment. The validation process can take between half and five days and is free for employed adults and through unemployment programmes by the public employment service. The assessment of individual competencies plays an important role in the flexibility of the training programmes, as the RPL certificate can be used to not only validate entire modules within the training programmes, but it can also be used to shorten the training duration of certain modules if the candidate is found to have prior experience in some of the learning outcomes. The AMU RPL certificates are recognised both in the wider education system and by employers, and the RPL certificate can be used to shorten training durations of further education, such as higher VET qualifications not in the AMU system, as well as a certificate of skills when applying for jobs in the healthcare sector.9

Although RPL can be used to validate candidates’ practical skills and theoretical knowledge, in the specific case of healthcare programmes, validation of practical skills tends to be more common. For example, in Norway, any adult that has minimum five years of working experience in the healthcare sector without a healthcare‑related qualification can get certified as a healthcare professional (helsefagarbeider) if they pass a five‑hour theoretical exam. The years of working experience can be validated as the practical component of the training programme through documentation of work experience, tasks and responsibilities. Requirements for length of work experience can be reduced if the candidate has undertaken relevant modules on a secondary school level. If needed, the candidate can attend classes at an adult education institution to prepare for the written exam, and the classes range from one semester to two years depending on the desired intensity of training. The classes are often offered both in-person and online to make it more accessible for adults who have time constraints due to work or family responsibilities. Upon passing the exam, the worker gets access to higher-paying jobs in the healthcare sector. Though the RPL pathway is available for all occupations that require a vocational certificate in Norway, participation in the programme is highest in the health and youth development sector, with 38% of all RPL candidates in 2018 achieving a vocational certificate in this sector (NOU, 2018[62]).

Quality engagement with low- or medium-skilled worker entering the healthcare sector for the first time is important for the success of the validation process and further training. For this reason, RPL systems are more effective and efficient when combined with training programmes and quality career guidance, and when there is a clear career pathway for the candidate after they obtain the certificate (OECD, 2023[63]). To facilitate such an experience, RPL systems need to feature different actors that interact with the candidate to instil in them a confidence in their own abilities, and the belief in the positive labour-market outcomes post-assessment. Experts can be actors such as career guidance advisors, labour-market/occupational experts, and employers. In New Zealand, Careerforce is a multi-dimensional programme that features a wide array of services in the field of training and recognition of skills to enable formalisation and upskilling pathways to those already working in the health and care sectors. Through the Careerforce programme employers get access to support and material to carry out on-the‑job assessments, while trainees have available guidance advisors and workplace mentors to help them showcase the skills they already possess through the RPL process. Careerforce targets both the formalisation and certification of uncertified/generalist workers in the health and care sector, and the upskilling of workers that already possess entry-level qualification but want to progress in their careers (Box 2.3).

Box 2.3. Supporting those employed in the healthcare sector in obtaining recognised healthcare qualifications

The case of Careerforce in New Zealand

Careerforce New Zealand is an industry training organisation (ITO)1 that supports employers in implementing industry training in the sectors of aged care, disability support, healthcare, home and community support, and mental health and addiction support.

Careerforce offers a range of services for both employers and trainees to enable the assessment of existing skills and upskilling opportunities. For employers, the programme can be used as a tool to upskill staff, increase the quality of service and invest in staff retention. Careerforce help employers set up and run efficient and effective skill assessments and training programmes with the support of a Careerforce Workplace Advisor and occupation-specific learning and assessment resources (which can be paper-based or online depending on the trainee’s preferences).

Trainees enrol in an assessment and training programme to achieve a nationally recognised qualification while working. The trainee carries out existing and new work tasks under the guidance of Observers who know the correct standard of performance expected in the workplace. Observers are people working alongside trainees, who are able to capture and attest to their skills and competencies. The final assessment is carried out by an Assessor who observes the trainee in the workplace in a practical assessment (and a short-written examination) and are able to capture and attest to the trainee’s skills and competences, as well as provide mentoring.

Qualifications are available on a secondary school level (New Zealand Qualifications Framework Level 2‑4) and sub-degree vocational certificates and diplomas (New Zealand Qualifications Framework Level 5‑6).

1. Industry training, also known as on-the‑job training, workplace training or earn and learn pathways, is available for people already in employment who are looking to keep their knowledge and skills up-to-date and advance their careers.

Source: Careerforce programme website, https://www.careerforce.org.nz/, (accessed 17 June 2024).

The recognition of previous learning and experience is not limited to individual-level assessments. It can also be used as a more structural tool to strengthen training programmes and enable career transitions between certain complementary but distinct occupational groups (see Box 2.4, which presents two examples of transitions between the armed forces and the healthcare sector). Applying such structural approaches to mapping acquired skills and experiences of distinct population groups against the learning outcomes of healthcare qualifications is one of the most effective tools in enabling mid-career transitions to the health and care workforce. It creates a pipeline of people with similar backgrounds and experiences to transition to the health and care workforce and share the story of their success with their peers – an important motivating factor in career transitions.

Box 2.4. Facilitating career transitions between complementary occupational groups through the recognition of prior learning

Armed Forces into Allied Health programme in the United Kingdom

In the United Kingdom, “Armed Forces Personnel” has been identified as an occupational group that share key skills and competencies with “Allied Health Professionals”, but where the educational and career pathways are not as straightforward due to an insufficient system for recognition of prior learning between these two sectors. The Armed Forces into Allied Health Report, funded by NHS England, identifies obstacles in the RPL system that hinder career transitions from the Armed Forces to a career in the NHS.

The study finds that RPL practices do not adequately recognise the skills and competencies of Armed Force Personnel for entry into health-related higher education programmes. Despite possessing most, if not all, the necessary skills to enter a medical-related higher education programme, many former Armed Forces Personnel have had to undertake year-long preparatory courses in order to enrol in health-related qualification programmes due to insufficient recognition of the training undertaken during their time in the Armed Forces. The study recommends including two 15‑credit modules in the Armed Forces curriculum – Anatomy & Physiology and Working in the NHS – which are tailored training courses to bridge the gaps identified by shortcoming in the RPL system.

Emergency Medical Technician partnership between U.S. Army and Midlands Technical College

In the United States, the army-to-healthcare pathway has also been recognised. The Unites States Army has partnered up with the Midlands Technical College (located close to the Fort Jackson military base) to recognise the skills of soldiers that are appropriate for careers in the healthcare sector. After an extensive mapping of the skills soldiers learn through military training with the learning outcomes of certain healthcare training programmes, colleges are now able to offer short training programmes for entry to the healthcare workforce. Midlands Technical College now offers a five‑week intensive course for soldiers on topics such as airway respiration and ventilation, cardiology, and resuscitation, Emergency Medical Services operations and trauma. Once the soldiers have completed this voluntary course, as well as certain mandatory courses that are part of the military training, they are qualified to take the National Registry EMT exam, which opens doors to multiple job opportunities in the healthcare sector, including emergency dispatcher, medic, emergency room technician, and registered emergency medical technician worker. Similar programmes are available for veterans in other U.S. states.

Source: NHS Health Education England (2023), Armed Forces into Allied Health (AFIAH) Report: https://www.hee.nhs.uk/our-work/allied-health-professions/helping-ensure-essential-supply-ahps/making-step-health-case-studies; U.S. ARMY (2022) Soldiers attend special EMT training, https://www.army.mil/article/257213/soldiers_attend_special_emt_training.

Career guidance

Career guidance can help to reduce shortages in the healthcare sector in two ways: by enabling career transitions into the healthcare sector (jobseekers or those previously employed in other sectors); and by increasing the retention of workers already engaged in the healthcare sector by supporting career progression. Career guidance encompasses a range of services designed to support individuals in making well-informed decisions about their education, training and career paths. It fulfils several functions:

• Provide essential information about education programmes, training options and employment opportunities, and ensure this information is easy to access and understand.

• Help individuals assess their skills, offering personalised advice to make strategic decisions about their career development and lifelong learning.

• Support jobseekers in the development of job-search and networking skills, orient them towards job opportunities tailored to their skills and interests and to job placement programmes.

• Dispel misinformation and false assumptions about the structure of the health and care workforce, such as hierarchy of importance.

As healthcare continues to evolve with new technologies, specialities, and training pathways, career guidance ensures that individuals can navigate these complexities and identify opportunities aligned with their skills and aspirations. By offering personalised advice, career guidance helps bridge the gap between the available workforce and the needs of the healthcare sector, ensuring that individuals understand the qualifications required, the potential for upskilling, and the roles they can pursue within the field. It can help jobseekers understand the landscape of entry-level occupations and their training requirements, help those working informally to validate their experience and move into formal work, or assist workers already in the health and care workforce to keep their skills up to date or advance professionally. Ultimately, not only does career guidance support the professional development of individuals but also contributes to the sustainability of the healthcare sector.

In Canada, the Career Transition Program is a government and provincially-backed initiative designed to assist mid-career transitions to enter high-demand sectors such as healthcare. The programme offers career counselling, training support, and financial assistance to help people transition into new roles. One example of this is the British Columbia Health Career Access Program which offers a pathway for individuals to start as healthcare support workers while receiving on-the‑job training and later transitioning into full healthcare assistant roles.10 Candidates can apply to become a Healthcare Support Worker or a Healthcare Assistant. Candidates apply to the Healthcare Access Program by applying/expressing their interest to one of the two positions. If the candidate receives and accepts an offer of employment, the work and training can begin. The candidate completes an orientation and onboarding programme and can begin working in the healthcare support/assistant position and will receive employer-provided training throughout the placement. Once the work placement is completed, the candidate begins a full-time education programme at a post-secondary institution, lasting approximately one year. The candidate receives their post-secondary qualification upon successful completion and can register as a healthcare assistant. Career and training guidance, and financial support, is provided throughout the process.

Connecting people with the right services is crucial and career guidance programmes play a role in this process. For those who have already some labour-market experiences in the healthcare sector, career guidance can be a good tool to map their experience, skills and competences, as well as their career aspirations. Through this process, candidates are put in contact with training providers and other career services (for example, adults who might already be working in a health or care capacity but without a formal qualification are encouraged to partake in up-skilling opportunities and formalise their skills by obtaining a labour-market relevant certificate). Individuals with low education qualifications are less willing to pursue learning opportunities because they lack awareness of the direct and indirect benefits of learning: as a result many fail to recognise their own learning needs and hence do not seek training opportunities (OECD, 2021[64]). Without appropriate intervention, less-educated health and care workers are at risk of getting caught in a “low skill trap”, being employed in low-quality jobs with weak career prospects and few opportunities and incentives to engage in learning. In the New Zealand Careerforce programme (Box 2.3), guidance and mentoring are important to help candidates complete the assessment and training, and mentors are chosen so that they match the candidate well in experience (e.g. working for the same healthcare provider) and can help them increase their confidence throughout the process. Career guidance advisors are specialised in the sector and can help the candidate browse the wealth of information and opportunities of different career pathways.

In the healthcare sector, career pathways can be difficult to understand, as healthcare involves many different specialities and professions working together, with (very) different training requirements. Individuals who want to enter the health and care workforce might be overwhelmed with information, trying to understand the difference in training requirements (for example, between an entry-level position as an assistant in an elderly care facility and a similarly named position in a dental hygiene clinic), or figuring out the difference in tasks and responsibilities (for example, between a rehabilitation specialist and nurse in post-op rehabilitation care). Making available comprehensive and user-friendly information about career pathways is extremely useful for workers and jobseekers. Guidance and information about career pathways can be delivered under the form of face‑to-face interviews or can be distributed and managed through online interfaces.

Before, or instead of, seeking advice from a career guidance advisor, 69% of adults look independently online for information on employment, education and training opportunities (OECD, 2021[65]). Although this form of career guidance and advice requires autonomy and initiative for the users, it is generally based on sound and up-to-date information on labour market needs. Oftentimes, national healthcare providers and government bodies are best equipped to identify their labour and skills needs and map out career and training pathways within the public system. For instance, in the United Kingdom, the NHS has developed an extensive online platform (the NHS Health careers portal) to manage healthcare careers and find opportunities, training, pathways and support to transition to a job in health.11 The site features up-to-date occupational profiles, training requirements, information about both comprehensive training programmes and modular courses, and opportunities for recognition of prior learning. Individuals can create profiles on the website and manage their own career pathway, which includes both new entries into the health and care workforce and career mobility within the sector. If needed, they can get in touch with the service for digital one‑on-one guidance with a guidance advisor.

In the United Kingdom, Skills for Health (a sector skills council) provides career guidance through its “Careers Information, Advice, and Guidance” service. This service offers information on health and care roles, entry requirements, and career progression pathways. The guidance is specifically designed to help individuals understand the different entry-level roles, such as healthcare assistants or nursing associates, and the qualifications required to move into these positions. Skills England’s occupational map (previously the Skills for Health’s Healthcare Apprenticeship Pathways Tool) lets users view different career routes.12 Career pathways are grouped by sub-sectors (e.g. Allied Health Professionals) and healthcare topics (e.g. Prosthetist and Orthotist) and pathways are mapped from entry-level occupations (e.g. Healthcare Support Worker (level 2)) to the highest-level occupation within that sub-sector/topic (e.g. Advanced Clinical Practitioner (level 7)). Each occupation on the career pathway has information about training, assessments and standards, and users can search for training providers and apprenticeship opportunities for all occupations in the pathway.

To tackle workforce shortages in the healthcare sector, providers will need to recruit from a diverse pool of workers. Attracting non-traditional applicants to the healthcare sector is a strategy that can help fill critical labour gaps, especially by engaging individuals from underrepresented groups, career changers, veterans, and those returning to the workforce. This approach not only diversifies the workforce but also ensures that a broad range of skills, experiences and perspectives are brought into healthcare, improving the quality of care and meeting growing patient demands.

Career guidance plays a pivotal role in encouraging underrepresented groups to enter the healthcare sector. Many low- and medium-skill occupations in the healthcare sector are dominated by women, particularly in areas such as nursing, primary care, long-term care and mental health. In most countries, these occupations also face significant workforce shortages. Encouraging more men to take‑up entry-level health and care jobs can help fill these gaps. In addition to filling shortages in the health and care workforce, a more gender-balanced workforce would have other advantages: promoting diverse perspectives, addressing gender-specific health needs, and challenging gender stereotypes. To attract men, targeted career guidance strategies can be implemented to reshape perceptions, provide clear pathways, and highlight the diverse opportunities in healthcare.

However, breaking stigma and informational barriers to men’s entry in female‑dominated jobs is not easy. In addition to general policies such as quotas, gender-based scholarships and financial incentives, guidance and awareness policies that actively encourage men to take up jobs in the healthcare sector should be developed. Programmes such as Step into Health (United Kingdom) are contributing to the diversification of the healthcare sector by offering guidance and support to workers transitioning from a male‑dominated industry (the Armed Forces) to the healthcare sector, including nursing and allied health professionals (see Box 2.4). The Norwegian Government has actively been pursuing this goal with the Men in Health (Menn i Helse), a programme which utilises career guidance, recognition of prior learning and work-based learning to transition unemployed men into entry-level health and care roles (Box 2.5).

Box 2.5. Men in Health programme in Norway

The Men in Health (Menn i Helse) programme is a public programme for men to obtain experience and certificates to work in the healthcare sector. The programme is available for all unemployed men aged 25‑55+ who are registered with the public employment services. Relevant candidates can contact the programme independently or be referred by the public employment service. Once enrolled in the programme, the candidate meets a career guidance advisor that will follow them through the entire programme, assisting with various challenges or issues the candidate might have.

The programme is initiated with a session with a career guidance advisor to map out the candidate’s experience and interest to best match them with a sub-sector within the healthcare sector. Then the candidate undertakes a practical 3‑month work placement to see if they are interested in pursuing a training programme and career within that sub-field. The career guidance advisor and a workplace mentor are in charge of mapping out the candidate’s skillsets and interests. Once the work placement is completed and the existing skills and experience are identified and validated, the candidate can start their (shortened) training programme to a vocational certificate as a health worker (can be shortened to a one‑year training programme and one year work placement). The training programme combines on-the‑job learning and theory-based classroom teaching conducted at secondary schools of adult education institutions. The vocational certificate is issued upon the successful completion of a final exam.

The candidate receives financial support from both the public employment service and a salary from the employer (municipality). Upon successful completion of the programme more than 9 out of 10 candidates are employed within their first year. Programme evaluations show that the close guidance the candidates receive is an important part in building their self-confidence to complete the training programme and final examination, as many candidates had never considered health and care jobs in female‑dominated occupations, particularly home care, rehabilitation and treatment centres, and with children with special needs.

The Norwegian Government considers the Men in Health programme to be one of the most successful initiatives for the recruitment of men into the care sector (Ministry of Health and Care Services, 2023[66]).

Source: Confederation of Municipalities in Norway (2024), Men in Health project website, https://mennihelse.no/ (accessed 27 September 2024).

Regional initiatives to address shortages

Regional and local initiatives to address shortages are emerging in many countries, as rural areas face significant problems in attracting health and care professionals. This situation causes high inequalities in the access to healthcare between individuals living in urban areas and those who live in areas with a low population density. Of great concern is the difficulty of primary care centres in rural areas in recruiting and retaining general practitioners as well as the lack of nurses and dentists, ophthalmologists and other specialists in these rural areas. The concentration of medical and nursing schools in urban areas further widens this disparity, leaving rural communities underserved and worsening health inequalities, particularly in South-East Asia (Rao and Schmidt, 2023[67]).

This is a global phenomenon with multiple (global and local) causes. In 2010, with the aim of providing evidence‑based global recommendations to address the rural workforce crisis, the World Health Organization recommended a global policy to “increase access to health workers in remote and rural areas by improving retention”. The recommendation included educational approaches, regulation, financial incentives and personal and professional support (WHO, 2010[68]). Studies about the social determinants of workforce retention in rural areas identify several factors that determine retention: rural familiarity and/or interest of workers, social connection and place integration, community participation and satisfaction, and fulfilment of life aspirations (Cosgrave, Malatzky and Gillespie, 2019[69]).

Many countries have implemented educational interventions for recruiting and retaining health professionals in medical deserts. This varies from opening new (rural) medical schools to offering rural programmes, rotations or internships to medical students (Bes et al., 2023[70]; Noya et al., 2021[71]). Although most of these interventions were targeted on generalist doctors (and not in low skilled staff), it is interesting to mention a pilot project entitled AGnES (Arztentlastende gemeindenahe E‑Health-gestützte Systemische Intervention, i.e. a community-based, e‑health-assisted, systemic intervention to reduce physicians’ workloads), conducted in three regions of the German state of Western-Pomerania. The intervention consisted in delegating some medical tasks to physicians’ assistants. A survey was conducted to assess the attitude of Primary Care Physicians (PCP) toward the delegation of home visit tasks, and to determine what they would prefer as the job description and type of employment contract for a health assistant who would be hired to assist them. Results showed that rural and individual PCP were 1.6‑1.9 times more likely to delegate tasks to their assistants compared to urban and group PCP. As a result, the delegating PCP spent significantly less of their time on running their general practice. Interestingly most PCP were in favour of delegating home visits to qualified assistants (77%) highlighting the need of well-trained non-specialised staff.

Many countries leverage volunteer work and NGOs to address healthcare coverage gaps in rural areas. For example, in Bangladesh the Urban Primary Healthcare Project contracts NGOs to provide primary care services in disadvantaged areas and in Sri Lanka, the Anti-Malaria Campaign leverages NGO capacity for diagnostic and surveillance support. However, it is important for governments to maintain leadership to ensure that NGO efforts align with public health objectives, address potential conflicts of interest, protect workers’ rights, ensure quality health service provision and foster trust for long-term partnerships. Another approach to palliate health workforce shortages in rural and remote areas is task sharing. In the area of mental health, Hoeft et al. (2017[72]) conducted a systematic review on task sharing of mental health care in rural areas of high-income countries. The review identified approaches to task sharing that focussed mainly on community health workers (CHW) and primary care providers. Technology was also identified as a way of using mental health professionals to support care across settings, both within primary care and in the community. The review also highlighted how provider training, supervision and partnerships with local communities can support task sharing. Interesting examples include:

• Home visitation from a nurse and CHW for pregnant women on Medicaid in the United States to address stress and mental health (in this example the nurse shares part of her/his responsibilities with the CHW, CHW were trained). The CHWs add to the nurse home visit programme by offering peer support to address chronic stressors, increase access to resources, improve health behaviours, and help engage women in services. Reported outcomes show an increase in the total number of pregnant women receiving service and care and an increase in the number of pregnant women at risk reached by the intervention (Roman et al., 2007[73]).

• Waitzkin et al. (2010[74]) assessed the role of “promotoras” (trained CHW) in depression care at community health centres. After a structured training program, primary care practitioners and promotoras collaboratively followed a clinical algorithm in which primary care practitioners prescribed medications and/or arranged consultations by mental health professionals and promotoras addressed the contextual sources of depression. The study found no difference (negative or positive) in patient’s health outcomes, however the intervention was positively received by healthcare staff and contributed to freeing resources among primary care practitioners.

Notes

← 1.  For example, the Norwegian programme Men in Health, is a broad initiative to attract men to healthcare jobs, but also includes specific initiatives to recruit men in the area of long-term care.

← 2.  AMU course catalogue for the healthcare sector can be found here: https://www.ug.dk/voksen-og-efteruddannelser/arbejdsmarkedsuddannelser.

← 3.  “Barangay” is the smallest political-administrative unit of the Philippines, corresponding to a village size settlement.

← 4.  More information about the Eixample Clinic Vocational Training Institute can be found here: https://eixampleclinic.es/es/.

← 5.  More information about the NHS Apprenticeship programme can be found here: https://www.healthcareers.nhs.uk/career-planning/study-and-training/nhs-apprenticeships.

← 6.  ILO consultation with the Learning Development Division (LDD-NITESD) at TESA on 20 November 2024.

← 7.  Learning Development Division (LDD-NITESD), TESDA, “Enrolment and Graduate Data of TVET WTR Programs in Health Sector”, provided on 29 November 2024.

← 8.  For more detail on how to set up a recognition of prior learning system, see: https://www.oecd.org/content/dam/oecd/en/topics/policy-sub-issues/adult-learning/booklet-rpl-2023.pdf.

← 9.  More information on individual assessments of skills within the AMU system can be found here: https://www.uvm.dk/arbejdsmarkedsuddannelser/hvad-og-hvor/individuel-kompetencevurdering--ikv-.

← 10.  More information on the BC Health Career Access Program can be found here: https://www2.gov.bc.ca/gov/content/employment-business/job-seekers-employees/find-a-job/health-care.

← 11.  NHS Health Careers portal can be found here: https://www.healthcareers.nhs.uk/.

← 12.  Skills England’s occupational map can be found here: https://occupational-maps.skillsengland.education.gov.uk/.