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Health care professionals
Health care has long beena concern for Canadians.Since the introduction of health insurance in 1972, numerous commissions have examined health care and proposed ways to improve it. These various reports focused largely on access to health care, its funding (public or private), and its quality. In 2001, Canada ranked fourth among the OECD countries in terms of share of GDP allotted to health—9.7%. Along with the U.S. and Finland, health care costs in Canada increased dramatically in 2000 and 2001 (OECD 2003).
Human resources are also an important concern for the health care system. Whenever nurses and physicians are mentioned, the words 'shortage' and 'waiting list' leap to mind. In the early 1990s, efforts were made to control the growth in the number of physicians to avoid a surplus. Now, however, more students are being admitted into medical schools and more foreign physicians are being sought in order to avoid a shortage. The aging population poses a double challenge as caseloads increase and health workers in the baby boom generation begin retiring. Because women usually work fewer hours than men, their increased entry into general practice and specialized medicine has intensified the pressures on these occupations (Chan 2002). This, combined with massive retirements in some occupations in the 1990s, has served to reinforce the impression of a labour shortage in health care.
Health workers, especially professionals, have undergone many changes in recent years, from both a demographic and work standpoint. Using census data from 1991 and 2001, these changes are highlighted for all health care workers and then examined in more detail for nurses and doctors.
The health work force
Health workers can be divided into three major categories: professionals, technical personnel, and support personnel (see Definitions). Professionals made up 57% of all workers in health occupations in 2001. The majority of professionals (63%) were nurses, with physicians—general practitioners and specialists—far behind at 14% (Table 1).
In 2001, almost 824,600 persons worked in the health field, an increase of 15% since 1991. In comparison, the labour force as a whole increased by 11%, as did the population of Canada. Health workers accounted for 5% of the labour force in 2001 (Chart A). 1 Provincially, Manitoba posted the highest proportion (6.4%) and Ontario the lowest (4.8%). The Territories also had a low proportion (3.6%).
Characteristics of health workers
Women have always accounted for a large proportion of health workers (Table 1). In 2001, nearly four health workers in five were women (79%) compared with less than one in two in other sectors. They were particularly evident in support occupations requiring few skills (87%).
From 1991 to 2001, the average age of workers in the labour force increased by 1.8 years. In comparison, the increase for health workers was relatively large (2.8 years), especially for professionals (3.3 years).
The increase varied by occupation. In 1991, health professionals were only slightly older than their counterparts in other fields (39.5 compared with 39.1), but by 2001, the gap had widened to two years. Among professionals, registered nurses and licensed practical nurses saw the largest increase—4.1 and 4.4 years respectively. Because nurses make up such a large proportion of professionals, they are mainly responsible for the significant increase in this group's average age. In 2001, specialists had the highest average age (45.7) followed closely by head nurses and supervisors (45.4) and general practitioners (45.2).
The prospect of a labour shortage in some health occupations is causing government officials to advocate policies of greater openness toward foreign workers. However, in 2001, the proportion of recent immigrants (those who arrived in Canada during the previous 10 years) was little changed from 1991 among health professionals (remaining below 4%), whereas the proportion rose by just over one-third (from 4.5% to 6.1%) among non-health workers (Table 2). The difference may be the result of the difficulty many professionals face in getting their credentials recognized. However, the proportion of immigrants in the technical and support categories rose slightly.
Work intensity generally increased for health workers from 1991 to 2001. The proportion employed full year, full time increased more than for other workers, rising 4.3 percentage points over the decade, compared with 2.4 points for other workers. Health professionals and support personnel led the way with 5 points.
By contrast, the proportion of health workers who worked mostly part time decreased by 2 points. Compared with other workers, those in health occupations, whether professional, technical or support, more often work part time. The greater prevalence of part-time may be related to the difficulty nurses experience in obtaining full-time positions as well as to the large proportion of women in health occupations (Chart B). 2
Coupled with high work intensity is a low unemployment rate. The unemployment rate for health workers in 2001 was considerably lower than for other workers (1.9% compared with 5.6%). Professionals were the least likely to be unemployed, at only 1.2%. Technical and support personnel also had relatively low rates (2.4% and 3.1% respectively).
In 2001, health workers averaged the same number of hours per week as the rest of the workforce (32.8). Professionals posted a slightly higher average (34.2). By comparison, in the non-health area, senior managers worked 42.7 hours and other professionals 34.7 hours.
Income from employment
Overall, average annual employment income grew 7.2% in real terms between 1990 and 2000 (Table 3). 3 For health workers, the increase was 8.9%, compared with 7.0% for non-health workers. Professionals experienced the greatest increase (13.8%), followed by support personnel (8.6%), with technical personnel trailing behind at 0.6%.
Median employment income increased more modestly (3.3% overall) because of large increases registered in the upper income groups. Health workers again stood out. Professionals posted the largest gain (15.1%), support personnel showed a modest gain of 7.9%, and technical personnel a drop of 0.2%.
Health professionals also compared favourably with similar groups outside health. Average employment income during the same period rose 4.9% for other professionals and 13.9% for senior managers. The median dropped 2.5% for the former and rose 0.2% for the latter.
Among those working full year, full time, health workers again came out on top with median earnings increases greater than in the rest of the workforce. This coincided with an increase in their average age and in hours worked. Technical and support personnel showed a modest increase in median earnings and a larger increase than professionals in hours worked. 4
Among professionals, the increase seems to reflect in part their increased work intensity and the rise in their average age. However, these general observations conceal differences that appear when health occupations are examined separately, the two most important in numerical terms being nurses and doctors.
'Nurse' refers to both registered nurses and licensed practical nurses. However, the two are examined separately, even though their duties are similar and both are regulated. Licensed practical nurses often work under the supervision of registered nurses or physicians. In most cases, they have one year of postsecondary training, while registered nurses have at least a college education, with a bachelor's degree becoming increasingly common.
While the number of registered nurses increased substantially in the 1980s, a slowdown in hiring and staff cuts through attrition in the 1990s transformed a perceived surplus into a perceived shortage. Between 1991 and 2001, the number of registered nurses grew a modest 2% (Table 1), while the number of head nurses and supervisors fell by 48% because of the elimination of line-manager positions. The ranks of registered nurses have grown more slowly than the total population with the result that the per capita ratio has shrunk, dropping from 93.3 nurses per 10,000 population in 1991 to 82.5 in 2002 (Table 4). 5 The ratio declined across Canada, with Alberta and British Columbia having the lowest in 2001. 6
Exacerbating the situation, the number of licensed practical nurses decreased by 11% between 1991 and 2001. The decline affected just about every part of Canada, with British Columbia, Ontario and Alberta having the lowest overall ratio in 2001.
The nursing profession is still overwhelmingly female—93.8% in 2001, compared with 94.6% in 1991. Quebec had the highest proportion of male nurses, at 9.1%, compared with 3.7% in Prince Edward Island (Chart C). Registered nurses and licensed practical nurses are among the health professionals whose average age increased most between 1991 and 2001—4.1 and 4.4 years respectively (Table 1). This is primarily because of the small number of people joining the profession—a consequence of both the low hiring rates in the early 1990s and falling enrolment in nursing programs (Chart D).
The profession's difficult working conditions—long hours, shift work, understaffing, and low availability of full-time positions—may be a factor in the declining enrolments in college and university nursing programs. These conditions may also be responsible for the tendency among nurses to retire relatively early.
It has been estimated that the profession would lose more than 64,000 registered nurses between 2001 and 2006 because of retirement or premature death (CIHI 2003a). 7 This number represented 28% of the ranks in 2001. British Columbia would be most affected with 32% likely to retire between 2001 and 2006; the Atlantic region would lose the least with 22%.
No comparable forecasts have been done for licensed practical nurses. According to the Licensed Practical Nurses Database (LPNDB), however, more than half of those currently working as licensed practical nurses will be 55 or over by 2012, and a large proportion will be eligible for retirement between now and then—60% in British Columbia and about 42% in Nova Scotia (CIHI 2003b).
Because of the shortage of doctors, governments are now considering expanding the role of nurses by allowing them to take on duties normally carried out by physicians. With increased responsibilities, the growing complexity of their jobs, as well as technological advances, more and more registered nurses now have bachelor's degrees. In fact, several provinces announced in the late 1990s that a bachelor's degree in nursing would become a prerequisite (CIHI 2003c). The proportion of registered nurses with at least a bachelor's degree quintupled during the period, from about 5% in 1991 to nearly 25% in 2001.
Work intensity and annual employment income
The low availability of full-time positions for nursing staff has been making headlines for years. However, in 2001, nurses were among the health professionals whose average hours per week increased the most (nearly 8%) relative to 1991 (Table 5).
In addition, the proportion of nurses working full year, full time increased—registered nurses from 50% to 58%, licensed practical nurses from 50% to 56%. 8 Whether the work is full- or part-time has numerous effects in the area of employment benefits. According to the Registered Nurses Database, the number of full-time positions has actually increased since 1998 (CIHI 2003c), growing faster than the number of part-time positions. These gains were made at the expense of casual positions.
The median annual employment income of registered nurses rose over 17% in real terms during the 1990s—the second largest increase after therapy and assessment professionals (21%). 9 Licensed practical nurses also saw significant growth in their earnings (11%).
Full-year, full-time registered nurses had the largest gain in median earnings among professionals (8.0%). Because of their large proportion, this increase was a major factor in the 8.4% rise for all health professionals between 1990 and 2000. Licensed practical nurses had a modest 2.7% increase. The gains are attributable in part to increases in hours worked per week (2.1%) and average age, but they may also reflect the growing scarcity of professionals of this type.
General practitioners and specialists
Professionals in the health sector increased by just under 9% between 1991 and 2001, while professionals in other sectors went up by 36%. General practitioners increased by just under 12%, while specialists rose 34% as a result of the growing preference of physicians for specialized medicine over family practice (Chan 2002). 10
Canada had 2.2 physicians per 1,000 population in 2001, well below the 2.9 average for OECD countries (OECD 2003). 11 Most provinces had comparable ratios (ranging between 2.2 and 2.4) except New Brunswick, Saskatchewan, Prince Edward Island and the Territories, where the ratio varied from 1.7 to less than 1 (Chart E). These regional disparities can be ascribed to a number of factors. For example, some remote regions may have difficulty attracting physicians and may be served by neighbouring regions with higher ratios. The number of general practitioners and specialists includes interns, and since some provinces have greater enrolment capacity than others, their ratios may be artificially inflated.
The number of specialists per capita also varied by province and territory. However, the pattern was much the same as for the overall ratio—the same provinces and regions had high and low ratios. Whether the specialist ratio is high or low may be related to whether the area is urban or rural. Specialists are found more often in large urban areas. In rural areas, general practitioners are more likely to attend births and provide palliative and urgent care—functions carried out in urban areas by specialists (CIHI and Statistics Canada 2003).
The ratio of physicians per 1,000 population does not reflect hours worked, productivity, nor heavier demand for their services within certain population groups. These factors have been taken into account in the adjusted ratio (Chan 2002). This ratio accords physicians a weight, based on the number of medical procedures they carry out, by age and sex. A weight is also given to the population based on different health needs, by age and sex. While the unadjusted ratio points to a slight increase in the per capita number of physicians over the past few years, the adjusted ratio indicates a steady decline after a peak in 1993 (Chart F).
General practitioners and specialists have the highest average age among professionals—for several reasons (Table 1). In general, physicians retire relatively late, as confirmed by the high proportion who are 55 or older. In addition, enrolment in faculties of medicine has been falling and years of postdoctoral study has been rising, as family medicine loses ground to specialized medicine. 12
In 2001, about 48% of professionals outside health were women, compared with 78% in the health sector. While this proportion remained stable between 1991 and 2001, the proportion in some traditionally male occupations increased—from 27% to 34% among general practitioners, and from 23% to 32% among specialists. The rise reflects incoming medical graduates, the majority of whom since 1996 have been women (CIHI 2002). The relatively recent influx of women into these professions is reflected in their being, on average, younger than their male counterparts (40.6 versus 47.8).
The proportion of self-employed workers in the labour force grew between 1991 and 2001. While rates varied widely by sex and occupation, health professionals seemed much more inclined to be self-employed—17% in 2001, compared with 13% in other sectors (Table 6). However, this appears to be a male tendency—50% versus 8% of women. The low percentage is partly the result of women being concentrated in occupations where self-employment is uncommon such as nursing. On the other hand, women are in the minority among specialists, general practitioners, dentists, veterinarians, optometrists and chiropractors, most of whom are self-employed. And even in occupations where self-employment is high, proportionally fewer women than men are self-employed.
Work intensity and annual earnings
Average hours worked by specialists and general practitioners declined appreciably between 1991 and 2001 (-6% and -3% respectively) (Table 5). In addition, fewer worked full year, full time—specialists went from about 68% in 1991 to 61% in 2001, general practitioners from 67% to 65%.
The decline may be due to the higher proportion of women in these occupations. Between 1991 and 2001, women accounted for most (73%) of the increase in the physician workforce—particularly among general practitioners where they accounted for virtually all of it (98%). Despite the major influx of women into these occupations, those working full year, full time accounted for the majority of the increase among these professionals. However, full-year, full-time women physicians averaged just under 50 hours a week, while their male counterparts worked 56 hours. The gap varies with age, increasing in the age range where women usually have children and declining thereafter (Chart G). Nevertheless, in 2001, there was a significant difference in most age groups.
The decline in the proportion of full-year, full-time specialists and general practitioners may also be because they are among the oldest of all health professionals, and hours worked tend to decrease after age 55 (Chart H). The number of health professionals 55 and over rose by 35% between 1991 and 2001.
The high average age of physicians, combined with the influx of women into these occupations, accentuates the perception of a shortage, since women and older physicians work fewer hours than male physicians under age 55. Other factors, such as rules designed to reduce the number of medical procedures and some hospitals' need to cut the number of available beds, also lengthen waiting lists and reinforce the perception of a doctor shortage.
Full-year, full-time specialists and general practitioners are working fewer hours—2.7% and 2.2% less respectively. Yet administrative data indicate that hours worked by physicians vary from year to year. Since most are paid by the procedure, another way of measuring their work intensity is to look at the number of medical procedures performed per unit of time. This measure, obtained from administrative data, indicates that full-year, full-time physicians of both sexes performed more medical procedures in 1998-1999 than in 1989-1990 (CIHI 2002). In both periods, male doctors performed more procedures. In addition, despite a decline in average weekly hours worked, specialists and general practitioners combined still worked more hours per week in 2001 than other health professionals (54.5 and 53.5 respectively).
Median annual earnings rose 3.3% in real terms for full-year, full-time specialists and fell 4.9% for general practitioners. These variations contrast with the 8.4% growth for all health professionals. By way of comparison, median annual earnings declined by 1.9% for all workers and by 2.1% for other professionals.
The earnings changes affecting general practitioners and specialists may be linked to several factors. While on one hand the rise in average age should cause the employment income of physicians to rise, the increase in women entering the profession and fewer self-employed would help explain the opposite trend. 13 Increased operating expenses 14 as well as a tendency to underbill may also account for the lack of growth in physicians' incomes. There are various reasons for underbilling. Some physicians may simply be unaware that certain procedures can be billed. Others who are uncomfortable with billing for some procedures or who want to simplify administrative processes do not bill their patients for some services not covered by health insurance (blood or urine samples). Underbilling could amount to as much as 15% of a physician's annual income (Clarke 2001).
Annual earnings by province
The annual employment income of physicians (specialists and general practitioners) varies considerably by province (Table 7). Even if the analysis is confined to the income of full-year, full-time workers, there may be proportional differences in number of hours worked between provinces due to such factors as the age-sex distribution of professionals, the scarcity of professionals, and the composition of the population they serve. In addition, the specialties of physicians in certain provinces, the types of clinics operated by general practitioners, and the proportion who are self-employed may affect their average earnings.
Median average employment income differs by $45,000 between specialists in the Atlantic provinces and the Prairies. A gap of 35,000 exists between Ontario and British Columbia for general practitioners.
Because the nursing profession is unionized, income disparities may reflect the intensity of salary negotiations by various unions, the age composition of the workforce, greater needs in certain regions, a shortage of nurses, the usual number of hours worked, and the proportion of overtime. Because earnings data for registered nurses include head nurses and supervisors, the gaps may also reflect the higher pay given to supervisory staff in some provinces. For example, a $8,000 difference exists between the earnings of full-year, full-time nurses in British Columbia and their counterparts in the Atlantic provinces.
Income gap between men and women
In 2000, the income of women health professionals working full year, full time fell 36% short of the income of their male counterparts (Table 8). But the gap varied by occupational group, ranging from 53% for specialists to 7% for audiologists, speech-language pathologists, physiotherapists, and occupational therapists. But because women work fewer hours than men, the gap must be adjusted to reflect the difference in hours worked—reducing it for most occupations.
However, a substantial gap remains for specialists and general practitioners. For example, the average annual earnings of women specialists working full year, full time were 44% less than those of their male counterparts. While the gap was somewhat smaller for general practitioners, women still earned 20% less than men.
Part of the gap is probably caused by age, province, locality, and salaried or self-employment status. The effect of these variables was tested with a Oaxaca decomposition model. About a third of the gap is due to women being younger and less likely to be self-employed. The remaining two-thirds can be attributed to the field of specialization, physicians being paid by the procedure, women performing fewer medical procedures than men, and other unobservable sex differences.
In health occupations, women are in the majority—nearly four out of five in 2001. In addition, health workers are somewhat older on average than other workers, 41.1 compared with 38.7. And their average age has risen more rapidly than in other occupations since 1991.
Health workers generally increased their work intensity—many increased their work hours, and the proportion working full year, full time was up sharply. Nevertheless, part-time work remained common, probably because of the large proportion of women in the health sector, as well as the difficulty of obtaining full-time nursing positions. Health occupations also had a relatively low unemployment rate in 2001.
During the 1990s, health workers in general saw their median annual earnings rise twice as much as that of other workers: 6.4% compared with 3.1%. Professionals stood out with the strongest increase (15.1%), with much smaller gains for support personnel (7.9%). In part, these increases reflected an increase in both work intensity and average age.
The ranks of nurses (registered and licensed practical nurses) grew more slowly than the total population with the result that the per capita ratio shrank, dropping from 113.2 per 10,000 in 1991 to 98.4 in 2001.
The profession's difficult working conditions—long hours, shift work, understaffing, and low availability of full-time positions—may be a factor in the declining enrolments in college and university nursing programs. These conditions may also be responsible for the tendency among nurses to retire relatively early. However, the number of full-time positions has actually increased since 1998, more rapidly than the number of part-time positions. These gains were made at the expense of casual positions. The increase in full-time positions probably explains in part why nurses were among the health professionals whose average hours per week increased the most from 1991 to 2001.
Full-year, full-time registered nurses had the largest gain in median earnings among professionals (8.0%). Licensed practical nurses had a modest 2.7% increase. The gains are attributable in part to increases in hours worked per week (2.1%) and average age, but they may also reflect the growing scarcity of professionals of this type.
Canada had 2.2 physicians per 1,000 population in 2001, well below the 2.9 average for OECD countries. The provinces had comparable ratios (ranging between 2.2 and 2.4) except New Brunswick, Saskatchewan, Prince Edward Island and the Territories, where the ratio varied from 1.7 to less than 1.
General practitioners and specialists are among the oldest professionals. This is due in part to the low number of entrants, a consequence of a decline of enrolment in faculties of medicine and an increase in the number of years of postdoctoral study as family medicine loses ground to specialized medicine. Also, physicians retire relatively late.
The median annual earnings of full-year, full-time specialists were up 3.3% in 2000 compared with 1990, while general practitioners saw their earnings fall by 4.9%. These small variations differ dramatically from the 8.4% increase observed for health professionals and occurred despite a significant increase in average age. The variations also coincided with an increase in the influx of women, a decline in hours worked relative to 1991, and a decrease in the proportion of self-employed.
Women health professionals who worked full year, full time earned 64% as much as their male counterparts in 2001. The size of the gap depended on the occupation, ranging from 53% for specialists to 7% for audiologists, speech-language pathologists, physiotherapists, and occupational therapists. After the fewer hours worked by women was taken into account, a substantial gap remained for some occupations. Among specialists and general practitioners, a third of the gap was the result of women being younger and less likely to be self-employed. The remaining two-thirds could be attributed to factors such as field of specialization, fewer medical procedures performed by women, and unobservable differences.
Diane Galarneau is with the Labour and Household Surveys Analysis Division. She can be reached at (613) 951-4626 or firstname.lastname@example.org.