Critical Issue: The Implicit Assumption of Labor Market Closure and Systemic Endogeneity in Health Workforce Models
A central (and problematic) assumption that underlies nearly all the health workforce projection models reviewed in this study is the treatment of the national health labor market as a largely closed and structurally self-contained system. While the paper thoroughly categorizes demand-side and supply-side modeling frameworks, it fails to address the fundamental issue of external labor market interdependence, particularly international health worker mobility and policy-induced migration flows.
Why this matters:
In many health systems—especially in high-income countries—the equilibrium of health labor supply is increasingly shaped by cross-border dynamics, including:
– Active international recruitment,
– Bilateral migration agreements,
– Shifting global wage differentials and credential recognition frameworks,
– Crisis-driven mobility (e.g., COVID-19, geopolitical instability).
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Yet the modeling approaches summarized in the paper:
– Treat immigration as an exogenous or fixed parameter (if included at all),
– Rarely model elastic supply in response to changing national training capacity or demand signals,
– Do not capture policy feedback loops where national shortages accelerate foreign recruitment, which in turn distorts global labor markets and ethics of workforce sustainability (e.g., WHO Global Code of Practice violations).
Thus, these models, by design, risk creating a false sense of national self-sufficiency—when in reality, many countries maintain health service delivery through structurally dependent foreign labor flows. Ignoring this embedded global dimension severely limits the validity and transferability of such models for long-term strategic planning.
Raised Issue:
The paper’s otherwise robust reporting guideline framework does not explicitly include the need for modeling global labor market interdependence or testing model sensitivity to international migration scenarios. This is a significant omission, as it implicitly assumes that labor supply gaps will be resolved domestically—through training, retention, or productivity shifts—without acknowledging that the prevailing solution in practice is often international recruitment.
In doing so, the models may produce optimistic projections about national system solvency that are structurally decoupled from geopolitical and ethical realities of global health workforce flow—particularly from LMICs to HICs.
Why this is a high-impact concern:
– It touches both on technical modeling limitations and ethical/policy misalignments.
– It undermines sustainability narratives in HIC workforce planning.
– It challenges the current practice of evaluating national workforce resilience in isolation, which contradicts real-world interdependence.