4.2 Human resources
4.2.1 Health workforce trends
The number of health workers in Switzerland has seen a strong increasing tendency over the past two decades, in particular, for physicians and nurses, while it has remained more or less stable for dentists, pharmacists and midwives (see Table4.5). The number of practising physicians increased by almost 40% between 1990 and 2013, i.e. from about 3 per 1000 population to about 4 per 1000 population. The proportion of physicians practising in hospitals remained more or less stable and was at about 45% in 2012. There are a number of data problems, which complicate comparisons over time (see note to Table4.5). However, it is clear that the specialties of paediatrics, and psychiatry and psychology saw the strongest increases. The number of nurses increased by almost 35% between 2000 and 2013. Yet, it should be kept in mind that these numbers reflect physical persons (PP) and do not take into account shifts in part-time employment. The development of full-time equivalents (FTE) may have been different as there has been a trend towards more part-time work.
In 2013, the number of physicians and nurses per 1000 population was amongst the highest in Europe (see Fig4.7). With 4.1 physicians and 17.7 nurses (including midwives) per 1000 inhabitants, Switzerland had the second highest combined number of physicians and nurses after Monaco in the entire European Region (see Fig4.7). In fact, the number of nurses was the highest amongst all countries in the European Region, although there might be some inconsistencies concerning the classification of nurses and nursing assistants in international databases. The number of physicians is likely to be even higher than shown in the figure because data on physicians working and specializing in hospitals is thought to be incomplete.
Fig4.7 shows that Monaco, Norway, Greece, San Marino, Austria and Portugal are the only countries in western Europe that have higher numbers of physicians for their populations. The number of practising physicians increased by 26.3% between 2000 and 2012 (from 25 216 to 31 858), corresponding to an increase of 13.5% per 1000 population (from 3.50 to 3.97) (FMH, 2014). This increase can be compared to international figures, where the number of physicians (measured in physical persons, PP, and not in FTE) has also increased in most countries (see Fig4.8).
According to FMH statistics for 2013, the distribution of physicians across cantons shows huge variations, with cantonal density ranging from 1.58 per 1000 population in Appenzell Innerhoden (AI) to 9.71 in Basel-Stadt (BS) (see Fig4.9). There has been an increase in the number of physicians in almost all cantons since the year 2000. However, the strongest increase has taken place in Basel-Stadt, where the number of physicians was already highest in 2000. The distribution of GPs across cantons is much more equal, although density still ranges from 0.48 per 1000 population in Fribourg to 1.12 in Basel-Stadt (see section 5.3).
Looking at the physician workforce in more detail shows that it is undergoing an important transformation from a male-dominated towards a female-dominated profession. Growth in the physician workforce is occurring more rapidly among female physicians (+7.1% when compared with 2012) than male physicians (+2.7%) (Hostettler & Kraft, 2014). In 2013, more than 60% of total physicians (at all ages) were male but more than 60% of physicians under 35 were female (see Fig4.10). Interestingly, a considerable number of active physicians are above age 65, indicating that physicians remain professionally active even beyond retirement age. In general, slightly more than half (52.8%) of all physicians work predominantly in ambulatory care, while slightly less than half (45.5%) work in hospitals (Hostettler & Kraft, 2014).
In 2011, the Federal Council published a strategy against physician shortage and for the promotion of family medicine (Federal Council, 2011). Based on a review of Obsan projections concerning the availability of primary care services in 2030 (Jaccard Ruedin et al., 2009) and considering some other studies, it was concluded that there was currently no shortage of physicians in general. However, Switzerland was able to ensure availability of physicians only by attracting a high number of foreign-trained physicians. In fact, the proportion of foreign-trained physicians has continued to increase (see section 4.2.2). In addition, the number of primary care physicians was declining in some areas and available physicians were responding to this by increasing their activity levels. The most important recommendation of the strategy was to increase the number of medical training places in Switzerland in order to overcome the heavy reliance on foreign-trained physicians.
In political discussions around a popular initiative to promote primary care (see section 5.3.1), the unfavourable demography of GPs was seen as a reason for concern. Almost half of practising GPs in 2013 were above age 55 and therefore likely to retire within one or two decades (see Fig4.11). However, the number of specialization diplomas awarded in the area of primary care (general internal medicine or practical physician) has increased considerably in recent years, i.e. from 359 in 2006 to 755 in 2012 (Obsan, 2013), reversing a prior trend towards lower numbers of trained primary care physicians.
Nurse density in Switzerland in 2013 (17.7 per 1000 population) was the highest within the WHO European Region and almost twice as high as the average of the region, followed closely by Norway (17.2) and Denmark (16.6, dates from 2012) (see Fig4.7 and Fig4.12). Despite its high level, nurse density continues to increase. In contrast to the high level of nurses, Switzerland has a relatively low ratio of 0.31 midwives per 1000 population, which is similar to the average of the EU15 (0.30) but far below the average of the United Kingdom (0.49).
Table4.6 shows the distribution of nurses across different care settings in Switzerland. Across all settings, nurses are the largest group of care professionals, accounting for about 55% of FTE, and hospitals employ about half of all care professionals. About 64% of all nurses work (and almost 70% of FTE are delivered) in hospitals, and nurses constitute the vast majority (about 72%) of all care personnel in hospitals. By contrast, just about half of all nursing assistants work in long-term care institutions, where they constitute the largest group of care professionals.
Despite the – by international standards – very high number of nurses, it was estimated in 2009 that Switzerland needs an additional 4500 nurses and nursing assistants trained annually in order to meet its demand (GDK/CDS, 2009b). Therefore, as part of a “Masterplan” for the training of care professionals (SERI, 2010), training capacities for nurses and nursing assistants are being expanded (see section 4.2.3).
In 2011, there were a total of 4123 ambulatory dentists or 0.54 dentists per 1000 inhabitants (FSO, 2013a). This is an increase in ambulatory dentists of about 10% since 2005 (FSO, 2013a). Fig4.13 shows that the density of dentists is low in Switzerland compared to the EU average (67 per 100 000 population in 2011). As for most other health professionals, geographical distribution differs considerably between rural and urban areas.
Switzerland has a relatively low number of 0.54 pharmacists per 1000 population (see Fig4.14), considerably below neighbouring countries and the EU average (0.82 per 1000). However, this does not take into account self-dispensing doctors and is thus only an imprecise indicator of access to pharmaceuticals in the Swiss context (see section 5.6.2).
4.2.2 Professional mobility of health workers
Switzerland relies heavily on foreign-trained health professionals (Jaccard Ruedin & Widmer, 2010). In 2013, 29.4% of all active physicians in Switzerland held a diploma from a foreign medical university (Hostettler & Kraft, 2014) and 37% of all specialization diplomas were awarded to foreign-trained physicians. In ambulatory care, the proportion of foreign-trained physicians is smaller than in hospitals: in 2013, 36.3% of physicians working in hospitals had a foreign diploma, while this proportion was 23.1% in the ambulatory sector (FMH, 2014). Every year since 2008, net migration to Switzerland exceeded 1000 physicians (immigration minus emigration of foreign physicians) per year (Obsan, 2012), which is more than the annual number of physicians trained in Switzerland (see section 4.2.3).
The most important country from which physicians migrate to Switzerland is Germany. Physicians trained in Germany account for 57% of foreign physicians practising in Switzerland (see Fig4.15). Physicians trained in France account for about 5% of foreign-trained physicians (FMH, 2014). When looking at the origin of migrating physicians whose diplomas were accredited in Switzerland in 2013, about 42% came from Germany, 18% from Italy, 16% from France and 5% from Austria (FOPH, 2014j). Immigration from Germany, Austria, France and Italy is facilitated by common languages.
Emigration of physicians trained in Switzerland is much less common and reliable data are unavailable. However, the FOPH estimated in 2011 – based on requests for English translations of Swiss diplomas and issued Certificates of Conformity with EU regulations – that every year between 200 and 250 physicians trained by Swiss medical schools might leave the country (at least temporarily) (Federal Council, 2011). Despite the relatively small number, this constitutes almost a third of annually trained physicians in Switzerland.
Immigration of other health professionals is also considerable. Between 2007 and 2012, net migration of nurses was always above 1400 but showed considerable upward variation, exceeding 3000 persons in 2008 (after full free movement of persons was granted to EU15 countries plus Malta and Cyprus in June 2007) (Burla, Vilpert & Widmer, 2014). These numbers are very high when compared to the number of annually trained nurses (see section 4.2.3). Immigrating nurses work mostly in hospitals or long-term care institutions and only rarely in ambulatory care. In addition, a considerable number of migrant workers from EU countries are assumed to provide informal home care to Swiss elderly, but reliable data on this are unavailable (van Holten, Jähnke & Bischofberge, 2013).
The heavy reliance on foreign health professionals is due to a mix of factors, including the inadequate supply of national training places, a comparatively old workforce (see section 4.2.1), and increasing demand for health care services. However, high immigration rates of highly trained professionals are characteristic also for other sectors of the Swiss economy and migrating health professionals constitute only a small part of the overall migration flow to Switzerland (Jaccard Ruedin & Widmer, 2010).
4.2.3 Training of health workers
Increasing national capacity for the training of health workers is a high priority in Switzerland, as documented by the inclusion of the objective “more and well qualified healthcare workers” in the Health2020 strategy (FDHA, 2013). In 2010, a Masterplan for training of health care professionals, focusing on non-university based health professionals, was agreed upon by – among others – the FOPH, GDK/CDS and OdASanté (SERI, 2010). The aim of the plan is to increase training capacity for nurses and other care professionals in order to overcome the estimated lack of about 4500 nationally trained professionals and to reduce dependency on migrants. In addition, in 2011, the government passed a strategy against physician shortage, calling for the number of physicians trained each year to be increased from 800 to around 1300 (Federal Council, 2011). More recently, the aim has been set to at least 1100 by 2016/2017 (FOPH, 2014f).
Training of physicians
There are five medical faculties in Switzerland, located in Zurich, Basel, Bern, Geneva and Lausanne. In addition, students can study for at least parts of their Bachelor of Medicine in Fribourg (all three years) and Neuchâtel (the first year only). Basic training as a physician lasts at least six years. After successful completion of three years of studies, students are granted a Bachelor of Medicine. After three further years (two at university and one in practical training), they obtain a Master of Medicine. Master graduates can then take a final state exam after which they are awarded the Swiss confederate medical diploma. Graduates who hold this diploma are qualified to work under supervision in a hospital or ambulatory care setting.
The Joint Commission of the Swiss Medical Schools (SMIFK/CIMS) defines learning objectives for medical training at universities. Regulations for state exams of physicians and dentists are issued at the federal level with the inclusion of different stakeholders such as medical faculties, the Commission for Medicinal Professions and the SERI (see section 2.8.3 and FOPH, 2013f).
In order to be allowed to work independently, physicians have to undertake further training. Training as a “practical physician” takes at least three years after completion of medical studies and is the minimum requirement in order to be allowed to work independently in primary care. Practical physicians have the option to continue their training and to specialize in general internal medicine after another two years of training, with the alternative options of qualifying either as a GP or as a hospital generalist.
Other specialist training programmes usually take between six and seven years of practice in different hospital departments related to the field of study (Obsan, 2013). Subsequently, doctors are allowed to work independently in hospitals or ambulatory care. There are currently 44 official specializations in Switzerland (Obsan, 2013). After successful specialization, doctors are legally bound to participate in continuous professional education according to a point system (Hänggeli & Bauer, 2010).
All specialization programmes have to be accredited by the SIWF/ISFM (see also section 2.8.3). Certain requirements exist for each specialization (e.g. length of training, rotations, number of procedures performed, etc.) but there is no structured progression as such.
Fig4.16 provides an overview of the development of medical training capacities between 2000 and 2013. It shows that the number of new medical students accepted at universities has increased considerably since 2004 and reached almost 1650 in 2014. The number of applicants for studies has seen a similarly strong increase over the past decade and remains about twice as high as the number of accepted students. The number of specialization certificates awarded (1645 in 2013) is much higher than the number of medical university graduates (836 in 2013). This is mostly because a large number of physicians move to Switzerland after having completed their basic medical education (see section 4.2.2). In addition, physicians can obtain more than one specialist degree, which means that physicians can be counted twice.
Training of nurses, midwives and other “non-university based health professionals”
Training paths and qualifications for nursing and other health care professions have been substantially restructured since the early 2000s (Schäfer, Scherrer & Burla, 2013). Today, a wide range of different paths exist for obtaining different nursing degrees and other health care-related qualifications (see Fig4.17 and Obsan, 2013). Depending on their secondary education, candidates may choose vocational (professional) education and training or education at a university or a University of Applied Sciences, leading to different degrees in nursing or care assistance. The Swiss education system distinguishes between different qualifications obtainable at the secondary II level and those obtainable at the tertiary level (see Fig4.17). Since 2008, PhD programmes in nursing exist at the University of Basel and the University of Lausanne.
Responsibility for the regulation of non-university based education of health professionals is with SERI (see section 2.8.3). A “Masterplan” for the training of care professionals (SERI, 2010) was developed jointly by SERI, FOPH, GDK/CDS, OdASanté and others in 2010, with the aim of increasing the number of trained nursing professionals in the country. As part of this plan, the number of training places is being increased, nursing qualifications are being integrated into the general system of secondary and tertiary education, and recognition of foreign qualified nurses is being improved (SERI, 2014b).
In the French parts of Switzerland, nurses train at Universities of Applied Sciences and qualify after three years of study with a Bachelor’s degree in nursing. Subsequently, they can continue training for 18 months and obtain a Master in Nursing. In the German-speaking part of Switzerland, most nurses train at Colleges of Professional Education and Training (Höhere Fachschule/École Supérieure). Training also takes three years and graduates obtain a professional diploma in nursing. However, training at Universities of Applied Sciences is also becoming more important in the German-speaking parts. In Italian-speaking parts, about 50% graduate from Universities of Applied Sciences and 50% from Colleges of Professional Education and Training.
Nursing assistants (Fachmann Gesundheit/assistant en soins et santé communautaire) are trained during an apprenticeship of three years and obtain a federal Vocational Education and Training (VET) diploma. They carry out practical nursing tasks in hospitals, long-term care institutions or ambulatory settings. As shown in Fig4.17, they may obtain further training to become fully qualified nurses. In addition, a category of health and social care assistants exists who have to complete a two-year apprenticeship before obtaining a VET certificate (see Fig4.17).
Fig4.18 shows that the number of new entrants to the different nursing and nursing assistance programmes of the various institutions increased considerably between 2011 and 2014 for all categories of nursing professionals. In 2013, almost 3100 students started nursing studies, with about two thirds enrolling at a College of Professional Education and Training and the remainder enrolling at a University of Applied Sciences. Long-term trends are difficult to evaluate because of the restructuring of training programmes since the early 2000s. However, the number of nurses trained at Universities of Applied Sciences has seen a strong increasing trend since 2006.
The number of nursing assistants enrolled in apprenticeship programmes increased considerably between 2011 and 2014. The number of nursing assistants newly enrolled in 2014 was above 4100 and that of health and social care assistants was at 880.
Midwives in Switzerland qualify with a three-year Bachelor in Midwifery at Universities of Applied Sciences (Schäfer, Scherrer & Burla, 2013).
Pharmacists and pharmaceutical assistants
Pharmaceutical studies last for five years including an internship year. Successful completion of both Bachelor (three years) and Master (18 months to two years) qualifies graduates to work in a pharmacy. Pharmacists may decide to train for a specialization in one of three programmes. Both non-specialized and specialized pharmacists are obliged to take part in continuous professional education. Pharmaceutical assistants undergo vocational training for three years (pharmaSuisse, 2013).
Dentists and dental assistants
Dentists study for five years at university and may further specialize afterwards. After having passed the Swiss confederate exam, dentists can choose from four specialization programmes before eventually continuing with one of four further subspecializations. A variety of assistant professions exist, which are trained for mainly in vocational settings. Examples of such job roles are dental hygienists or prophylaxis assistants (SSO, 2015).
For chiropractors, a six-year training programme has been offered at the University of Zurich since 2008 (FOPH, 2014i). After completion of studies, chiropractors have to specialize for 2.5 years before being allowed to work independently.
Training in CAM
For physicians, training programmes recognized by the SIWF/ISFM exist for five different CAM methods: anthroposophical medicine, homeopathy, neural therapy, phytotherapy and traditional Chinese medicine (SIWF/ISFM, 2014). Holding one of these certificates is a requirement in order for these methods to be reimbursed by MHI (see section 5.13).
For other health care professionals or nonmedical personnel, there are plans to introduce confederate diplomas for CAM methods at the level of Colleges of Vocational Education and Training (Ausbildung-Weiterbildung.ch, 2014; FOPH, 2013d). Currently, there are a large number of institutions offering certain qualifications. The online portal ausbildung-weiterbildung.ch counts 256 institutions offering courses in CAM (Ausbildung-Weiterbildung.ch, 2014).
4.2.4 Career paths
Doctors’ career paths
After graduation from medical studies, doctors in Switzerland usually start working in a hospital as an assistant doctor (Assistenzarzt), while training for their chosen specialization. After having been awarded a specialty degree, doctors can either pursue a hospital career or work in an ambulatory setting.
In hospitals, most specialist doctors work as Oberarzt/chef de clinique, which means that they are responsible for supervising assistant doctors. In addition, specialist doctors can be promoted to become consultants or lead physicians (Leitender Arzt/médecin dirigeant), which means that they will have to coordinate the activities of several wards or services. Finally, the chief physician (Chefarzt/médecin chef) is the head of the medical hierarchy in a hospital and is responsible for the education path of the assistant doctors. In university hospitals, doctors may combine clinical duties with research activities and chief physicians are often also university professors. In addition, doctors can progress to assistant medical director and medical director of a hospital. Promotions and career progressions are dependent either on superiors or on the institutional board. Medical directors of public and university hospitals are appointed by the respective governing boards, usually based on a proposition by peers, i.e. the chief physicians of the hospital.
In ambulatory care, doctors can found a practice alone (single practice) or with partners (group practice) or can choose to be employed in an HMO or group practice. Physicians working in practices are often affiliated with a hospital, where they may perform surgeries a few days per week and may attend to their patients during inpatient stays.
Other health workers’ career paths
Possibilities within the different health care professions are manifold and vary considerably. In general, career progression in all fields very much depends on personal capabilities, choices and desires. For example, pharmacists may decide to pursue a career in a competitive industry environment or choose to run a private pharmacy. Nurses can work in a hospital and progress to different levels of responsibility for patients as well as for staff, or they may decide to pursue an academic career in nursing sciences. For many health care professions, a career in public health or in public administration can also be an option, again depending on personal goals and ambitions.
Collaborative care models in primary care practices have recently started to involve APNs (Advanced Practice Nurse) in Switzerland. Two rural cantons (Uri and Glarus) adapted health law in 2016 and 2019 to promote financial support of primary care models with APNs. These pilot projects showcase that APN involvement is a promising response to projected GP shortages, especially in rural areas.
The national health strategy “Health 2020” promotes collaboration between various healthcare professions, including adjustments of training, research and working conditions. Since 2016, the Act on Health Professions (GesBg) regulates seven health professions on bachelor’s level. However it lacks regulation of professional profiles and scope of practice of nurses on master level (e.g. APNs) although trainings are available in Swiss universities (e.g. Lausanne, Basel). In June 2019, the Swiss Nursing Association’s working group proposed a definition of scope of practice and requirements of APNs to accelerate regulation.
A lack of skilled employees is a general problem in the Swiss economy. However, the lack of nurses in in the domain of long-term care is a particularly urgent issue. In a recent survey, more than 90 percent of elderly and nursing homes indicated that they face problems in recruiting new health professionals (SSERI 2016). The aging population in Switzerland will further increase the demand for long-term care and, therefore, will continuously reinforce the problem. In fact, it is estimated that approximately 100 000 newly trained nurses will be needed between 2014 and 2030: 28’000 additional nurses for elderly and nursing homes, 19’000 additional nurses for home care, 18'000 additional nurses for hospitals and clinics, and 40’000 to replace retiring nurses (Mercay et al. 2016).
Impetus of the initiative
In 2011, the federal council launched a skilled employees initiative (“Fachkräfteinitiative”) in order to address the general shortage of skilled employees in the economy. This is an ongoing initiative and consists of several programmes that aim at increasing the capacity of skilled employees.
Content of the initiative
At least nine programs of the skilled employees initiative focus on the health sector. Among them are several initiatives directly or indirectly targeting the shortage of nurses in long-term care. In the following, two of these programs are briefly described.
One of the first initiatives was the Masterplan Education in Nursing Professions (“Masterplan Bildung Pflegeberufe”). It aimed at increasing the number of graduates in nursing professions. Thanks to this initiative, the number of graduates for nursing professions at the secondary education level has increased steadily between 2010 and 2015. Currently, the annual number of secondary level graduates sums up to approximately 84% of the yearly demand in order to reach the additional nurses needed until 2030. At the tertiary educational level, the number of nursing graduates has remained relatively stable over the past five years and covers only approximately 55% of the estimated demand. Efforts to increase the number of graduates will continue in the future.
The most recent action plan, which was launched at the beginning of 2017, indirectly targets the nursing shortage. It aims at reducing the need for professional nurses by increasing the ability of persons who informally care for relatives (“Entlastungsangebote für pflegende Angehörige”). In a first step, the program aims at describing the situation of individuals that care for relatives in Switzerland. Based on the available evidence, actions will be taken to improve assistance for informal caretakers and aid programs that are already in place. The program is planned to run until 2020.
Fachkräfteinitiative – Massnahmen des Bundes.[Initiative for skilled workers – Federal measures] https://www.wbf.admin.ch/wbf/de/home/themen/fachkraefte.html, last accessed: 1 May 2017
Mercay C, Burla L, Widmer M. (2016). Gesundheitspersonal in der Schweiz – Bestandesaufnahme und Prognosen bis 2030. [Healthcare personnel in Switzerland – Inventory and Prognosis until 2013] Obsan Bericht 71, Neuenburg.
Swiss Conference of Cantonal Health Directors and OdASanté (2016). Nationaler Versorgungsbericht für die Gesundheitsberufe 2016 – Nachwuchsbedarf und Massnahmen zur Personalsicherung auf nationaler Ebene. [National report for health care professions 2016 - Needs and measures for personnel retention at national level]
Seco, Ressort Arbeitsmarktanalyse und Sozialpolitik (2014). Fachkräftemangel in der Schweiz – Indikatorensystem zur Beurteilung der Fachkräftenachfrage. [Shortage of skilled workers in Switzerland - Indicator system to assess the demand for skilled labor.]
State Secretariat for Education, Research, and Innovation SSERI. Masterplan Bildung Pflegeberufe. [Masterplan on Education in Nursing Professions] https://www.sbfi.admin.ch/sbfi/de/home/themen/berufsbildung/gesundheitsausbildungen/masterplan-bildung-pflegeberufe.html, last accessed: 1 May 2016
State Secretariat for Education, Research and Innovation SSERI (2016). Der Bundesrat ergreift Massnahmen gegen Fachkräftemangel in der Pflege. [Federal Council takes measures against the lack of skilled employees in nursing] https://www.admin.ch/gov/de/start/dokumentation/medienmitteilungen.msg-id-64883.html, last accessed: 23 May 2017.