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Strategies to overcome workforce shortages

New Zealand
Partner Institute: 
The University of Auckland
Survey no: 
(15) 2010
Toni Ashton
Health Policy Issues: 
HR Training/Capacities
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no no yes no no


The New Zealand health workforce is under pressure from a number of sources. In 2009, the government released five reports, all of which agreed on the need for more coordinated and longer-term health workforce planning. Three new initiatives have now been introduced: a voluntary bonding scheme for graduates who work in under-serviced areas, an increase in the number of medical training places, and the establishment of a new agency to coordinate education and training.

Purpose of health policy or idea

The New Zealand health workforce faces two key problems. First, the demand for health workers exceeds supply and this gap is widening. The problem is especially acute in rural areas. Second, there is a lack of overall planning of the education and training of health workers. The following three initiatives have recently been introduced in an effort to address these problems.

1. In February 2009, a voluntary bonding scheme was announced whereby graduate doctors, nurses and midwives would be eligible for student loan debt write-offs and cash incentives in return for working from three to five years in communities which have high vacancy rates and where positions take a long time to fill.

2. In the government budget of May 2009, funding was allocated for a gradual increase in the number of new medical training places over the next 5 years up to 200 additional places per annum, plus 50 new training places for general practitioners (GPs) over the coming year.

3. In August 2009, the government announced the establishment of the Health Workforce New Zealand Board to coordinate the education and training of doctors, nurses and other health professionals. The Board's role will be to rationalise the planning and funding of health workforce training, the overall objective being to provide a single, coordinated response to improving training, recruitment and retention of the health workforce.

Main points

Main objectives

To improve education, training, recruitment and retention of the health workforce.

Groups affected

Health professionals, especially doctors and nurses.

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Characteristics of this policy

Degree of Innovation traditional traditional innovative
Degree of Controversy consensual consensual highly controversial
Structural or Systemic Impact marginal marginal fundamental
Public Visibility very low very low very high
Transferability strongly system-dependent rather system-neutral system-neutral

Voluntary bonding as a means of retaining new graduates and increasing medical school placements have both been implemented at times in the past. However this is the first time that a single agency has been responsible for addressing workforce issues across the sector.

The basic ideas behind all three of these policies could quite readily be transferred to other health systems, especially increasing the number of medical students. However the details around the voluntary bonding scheme and the roles and responsibilities of the Health Workforce New Zealand Board have been tailored to match the specific needs of the workforce in New Zealand.


Political and economic background

The New Zealand health workforce is under pressure from a number of sources. In addition to those problems that are shared by other countries - such as an increase in the proportion of part-time workers due to the feminisation of the workforce, increased demand for health services, and the aging of the health workforce - New Zealand faces major challenges from the internationalisation of health workers. It has the highest percentage of migrant doctors among OECD countries (52 percent compared with an OECD average of 36 percent) and one of the highest for nurses (OECD, 2008). It also has one of the highest rates of outward migration of health workers. Four years after graduating, around 25 percent of NZ trained doctors are no longer registered in New Zealand and the loss increases to around one third after 9 years.

The number of practising doctors per 1000 population is lower in New Zealand than the OECD average (2.2 compared with an average of 3.1). The problem is particularly acute for specialists with New Zealand having only 0.8 specialists per 1000 population compared with an OECD average of 1.8. Although the reverse is currently true for nurses (9.5 per 1000 people compared with an OECD average of 8.7), the average age of nurses in New Zealand is now 47 years and the annual exit rate is considerably higher than the annual recruitment rate. There are also problems of maldistribution of the health workforce across rural and urban areas.

An additional concern is a lack of overall planning and integration of health education and training. Currently the numbers and mix of health workers in training at the undergraduate level are determined by the Tertiary Education Commission which manages funding for all tertiary education on behalf of the government. Because it resides within the education sector, this agency is largely divorced from the health system. 

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no no yes no no

Origins of health policy idea

In 2001, the government set up a Health Workforce Advisory Commission to advise the Minister of Health on workforce issues. This committee published numerous reports and guidelines over the next few years and a number of initiatives were introduced based upon their advice. (See for example previous surveys on the Development of the Primary Care Workforce, ( 12/2008), a Health Workforce Career Framework, ( 11/2008) and the Competence Assurance Bill, (1/2003)).

In 2008, a new centre-right coalition government once again focussed its attention on the problems of the health workforce. It called for a series of five reports on the medical and nursing workforces. All five reports agreed that there is a need to:

  • enable greater leadership for improvements in national and regional co-ordination to reduce the current duplication in workforce activities across the health and disability sector
  • strengthen health and disability workforce planning that is aligned to service delivery, and
  • balance long-term responses to workforce supply issues with the pragmatic tactics used by district health boards to meet their unique short-term workforce needs.

All of the reports recommended the establishment of a separate national entity to respond to the complexities of health and disability workforce training issues.


Initiators of idea/main actors

  • Government
  • Providers

Approach of idea

The approach of the idea is described as:

Stakeholder positions

All of these three initiatives have generally won support from interested parties throughout the sector. However some professional groups have reservations about the success of the initiatives in addressing some of the more fundamental problems with the workforce. For example, the NZ College of General Practitioners has pointed out that the financial disadvantages faced by GPs compared with hospital-based doctors will continue to act as a barrier to potential applicants for the additional GP training places. Similarly, the Association of Medical Specialists has expressed concern that increased training of doctors is likely to be a waste of public money unless the poorer working conditions and lower salaries for specialists in New Zealand compared with countries like Australia can be addressed.

Actors and positions

Description of actors and their positions
Minister of Healthvery supportivevery supportive strongly opposed
General practitionersvery supportivesupportive strongly opposed
Professional associationsvery supportivesupportive strongly opposed

Actors and influence

Description of actors and their influence

Minister of Healthvery strongvery strong none
General practitionersvery strongweak none
Professional associationsvery strongneutral none
Minister of HealthGeneral practitionersProfessional associations

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

Implementation of all three initiatives is already underway. The Ministry of Health is administering the voluntary bonding scheme with graduates from 2005 onwards being eligible to apply. Sixty new medical school placements were funded in 2010, and the country's two medical schools are now expanding infrastructure and staffing to cope with the predicted increase in student numbers in future years. The Clinical Training Agency Board (subsequently called Health Workforce New Zealand) was appointed in August 2009. It is now developing plans for further initiatives including new models of care and new approaches to professional development.

Expected outcome

Demand in the first year of the voluntary bonding scheme far exceeded expectations. While the government had estimated that around 350 doctors, nurses and midwives might apply, more than 890 recent graduates were admittted to the scheme. The scheme was also extended in February 2010 to incorporate additional regions and specialties. However the effectiveness of the policy in terms of retaining new graduates will not be known for at least 3 years when the first participants complete the minimum duration of employment required to be eligible for payment under the scheme.

Inreasing the number of available places for medical training is unlikely to be successful in addressing the shortage of doctors unless real efforts are made to retain the new graduates.

Having a single agency to address the issues facing the health sector workforce should overcome some of the complexities and conflicts that have occurred in the past and encourage greater collaboration from interest groups across the sector.




Impact of this policy

Quality of Health Care Services marginal rather fundamental fundamental
Level of Equity system less equitable four system more equitable
Cost Efficiency very low neutral very high

If these, and other initiatives, are successful in improving the education, training, recruitment and retention of the health sector workforce, this in turn could have a very fundamental impact on the quality of services. Equity should also be improved if the voluntary bonding scheme improves access to services in rural areas. However, the impact on cost efficiency is judged to be neutral because, while this policy may improve the efficiency of some aspects of health workforce training, it is likely to increase total expenditure at the national level.  


Sources of Information

Author/s and/or contributors to this survey

Toni Ashton

Suggested citation for this online article

Toni Ashton. "Strategies to overcome workforce shortages". Health Policy Monitor, April 2010. Available at