Flexible Learning Pathways into Healthcare Occupations

3. Evaluating the impact of flexible training pathways on healthcare provision

Beyond the evaluation of single initiatives implementing flexible pathways to boost the health and care workforce supply, it is important to assess whether new, modular, flexible pathways initiatives targeting entry level jobs have the potential to address health and care workforce shortages.

As mentioned above, flexible training policies for low-skilled workers in the health sector aim to address workforce shortages in entry-level health and care professions. In addition, they can alleviate shortages in higher-skilled health and care jobs indirectly by freeing up their time and allowing them to concentrate on higher level tasks. On the one hand, this approach, also known as task sharing (Fulton et al., 2011[75]), can potentially improve healthcare delivery efficiency, as well as and worker’s employability. On the other hand, allowing individuals who have not acquired qualifications through traditional pathways to enter the healthcare system may raise concerns about potential negative impacts on the quality of care.

The impact of facilitated entry pathways on the overall healthcare system can be analysed according to several criteria:

• improvement of healthcare delivery;

• potential quality or safety concerns for patients, resistance among health and care professionals; and

• from a more global perspective, reduction of health and care workforce shortages.

This section provides examples of direct and indirect assessment of training on health outcomes and the reduction of health and care workforce shortages. However, evaluations of impact of flexible entry pathways remain limited.

Task-shifting has positive impact on healthcare quality when lower-skilled professionals are adequately trained

In the area of health prevention, frequent skills-mix changes have been introduced among nurses, community health workers and pharmacists. Several studies (California Health Workforce Alliance, 2013[76]; Hartzler et al., 2018[77]; Maier, Aiken and Busse, 2017[78]), show that in many countries, nurses and community health workers have expanded their role in prevention. Often, the reasons for implementing skills-mix changes are triggered by provision shortages, by the increasing incidence of chronic diseases and by the need for tailored services in hard-to-reach populations.

In this context, Maier et al. (2023[79]) conduct a study to evaluate the impact of task shifting on health promotion and prevention. Results show that community health workers can help increase the take‑up of cancer screenings; and, for skin cancer screenings, adequately trained Nurse Practitioners demonstrated sensitivity levels equal to dermatologists with skin cancer expertise and higher than general dermatologists in identifying malignant lesions.

Leong et al. (2021[80]) provide a comprehensive overview of task shifting from physicians to allied health and care workers in primary care and its impact on clinical outcomes. Although not limited to entry-level positions, authors identify key elements for successful implementation of task shifting, including training, supportive organisation systems, collaboration among all parties, a system for co‑ordinated care, and adequate financing. Several reviewed studies suggest that shifting responsibilities improve or do not decrease the quality of care provided lower-skilled or less specialised professionals are adequately trained. Finally, Anthony et al. (2019[81]) show that role substitution by community health practitioners in remote communities was feasible with equivalent care delivered to that provided by general practitioners and was cost-saving.

Little evidence exists about the overall impact of flexible training pathways on reducing health and care workforce shortages

Addressing workforce shortages in the healthcare sector is a critical challenge globally. Various strategies, including vocational training, task shifting, and innovative educational partnerships, have been explored to mitigate these shortages and improve healthcare delivery. However, evaluations of the overall impact of these kind of policies are rare. In fact, it is complex to disentangle their effects from other factors that can also have a strong impact on the health provision (economic, demographic, public health policies, etc.); and because, often, sources of information on the final outcomes of programmes are scarce, incomplete and hardly comparable, which makes these evaluations (technically) difficult to implement.

Theoretical impact evaluations shed light about the potential positive impact of health workforce task shifting on addressing shortages and on correcting inefficiencies in task distribution (Scheffler and Arnold, 2018[82]).1 However, simulations do not provide evidence about the real outcomes of flexible training policies.

Brazil’s Family Health Strategy, launched in 1994, is a cornerstone of the Unified Health System, providing universal health coverage to the population. The programme targets primary care access for low-income and vulnerable groups through community-based clinics and multidisciplinary teams of doctors, nurses, and community health workers. Community health workers are recruited from local community members who are familiar with the area’s geography and culture and have community endorsement. They undergo up to eight weeks of initial residential training, followed by continuous training and supervision led by teacher-trained professionals (Sripathy et al., 2017[83]). The training curriculum, developed by the Ministry of Health and approved by the Ministry of Education, is then adapted by municipalities to meet local needs. The successful expansion of Brazil’s Family Health Strategy, centred on community health workers, has facilitated the transformation of healthcare delivery from a hospital-centred model to a community-based, preventive approach. This shift has improved access to comprehensive primary care, reducing hospitalisations for chronic conditions manageable with outpatient care (Macinko et al., 2010[84]). As a result, the demand on secondary and tertiary providers has eased, leading to cost savings and alleviating workforce shortages across the Brazilian healthcare system.

Some evidence exists about the positive effects of training programmes on nurse and long-term care workers retention (and thus on the reduction of workforce shortages).

• Long-term care is a labour-intensive activity, and many countries face relatively high levels of staff turnover and job vacancy rates. A study examines the association between workforce retention and related staffing measures and the quality of English long-term care homes using a national database of social care providers’ staffing. The analysis finds significant correlations between quality and the levels of staffing vacancies and retention of both residential and nursing homes. The findings suggest that quality could change for the average care home with a relatively small alteration in staffing circumstance (Allan and Vadean, 2021[85]).

• In 2009, Leese et al. published a study aimed at investigating the impact on care provision of employment policies in England to encourage retention of primary and community nurses over the age of 50 years. Results show that when older nurses left, there was concern about the loss of skills, experience and intelligence about local communities. Also, concern about pensions was a key influence on nurses’ decisions to stay or leave nursing. In areas with a high number of older nurses, opportunities were being taken to promote flexible working by means of workshops to raise awareness of the possibilities available to continue in nursing for longer (Leese, Storey and Cheater, 2009[86]).

In a much broader context, some examples exist on the evaluation of the impact of general active labour market policies (ALMP) by sector. In Ireland, evidence shows that in the Community Employment programme, labour market outcomes post participation tend to be better for participants in Health and Social Care Schemes (see Fig 6.5 of the source). One of the reasons may lie in the higher degree of specialisation of these specific schemes, which may make it easier for participants to identify job vacancies in need of the job skills they acquired during their participation in Community Employment (OECD/Department of Social Protection, Ireland/EC-JRC, 2024[87]).

To summarise, few studies evaluate the impact of flexible training of low-skilled workers on the reduction of health and care workforce shortages. However, abundant evidence suggests a positive effect of task shifting strategies on health outcomes, which indirectly free resources of high-skilled professionals. Moreover, many of these studies identify the lack of adequate training as a barrier for effective implementation of these strategies, advocating for more and more flexible training pathways.

Conclusions

The evidence presented in this report demonstrates that flexible pathways into entry-level health and care positions represent a critical yet underutilised strategy for addressing persistent workforce challenges in the health sector. By implementing flexible and modularised training programmes, strengthening partnerships, leveraging digital and hybrid learning, and implementing quality career guidance and recognition of prior learning, barriers to entry for adult learners can be lowered, addressing critical skill shortages. These approaches are particularly valuable for attracting non-traditional candidates and facilitating the transition of informal caregivers into formal health and care roles.

Moving forward, governments and health systems should prioritise the development of comprehensive policy frameworks that integrate flexible learning pathways that address the current rigidity of health and care career structures while ensuring the quality of training and its relevance to meet the growing complexity of care needs, particularly in long-term care settings. Systematic evaluation mechanisms to assess the impact of flexible pathways on both individual employment outcomes and broader health system performance is also necessary, including measuring improvements in care quality, workforce stability, and the effectiveness of task reallocation in alleviating shortages among higher-skilled health and care workers. However, while creating flexible pathways into entry-level positions is a good strategy to address shortages, it must be balanced with sustained investment in the education and training of regulated health professions. The healthcare sector requires a diverse interprofessional structure that contributes in their unique ways to a larger need, with a variety education, training and experience. Without an investment in both flexible and traditional pathways, there is a risk that health systems might favour quicker, cheaper workforce solutions and underinvest in progressional education for highly regulated professions (i.e. doctors, nurses, dentists etc.). Without solid long-term planning and financing of professional education, the quality and sustainability of care may suffer. To address this and ensure a sustainable and skilled workforce, policies in flexible pathways must be part of broader health workforce planning that is grounded in labour market analysis and aligned with the population’s health needs.

Note

← 1.  For example, Scheffler et al. use a forecasting model to estimate the need for, supply of, and shortage of doctors, nurses, and midwives in 39 African countries for 2015. The forecast indicated that 31 countries will experience needs-based shortages of doctors, nurses, and midwives, totalling approximately 800 000 health professionals. Authors models estimate the additional annual wage bill required to eliminate the shortage at about USD 2.6 billion (2007 USD) – more than 2.5 times wage‑bill projections for 2015. Further simulations illustrate and discuss how changes in workforce mix can reduce this cost, as well as the policy implications (workforce skill-mix changes, worker incentives, and training capacity) that would allow countries to realise these savings (Scheffler et al., 2009[89]).