How many doctors in 20 years' time?

6 World Health • 47th Year, No. 5, September-{)ctober 1994 How many doctors in 20 years' time? Bui Dang Ha Doan Within 15 to 20 years in many countries there will be an abrupt reduction in the numbers of practising physicians and a major increase in the total of elderly people -precisely those who require more medical care. At the end of the 1950s, thanks to economic expansion, the world entered an era of high expectation. People everywhere aspired to more education, more medical care, more culture, more comfort- in short, better well-being in every domain. In the health sector, governments sought to promote equal access for all to health care and, at the same time, to make health care more abundant. In particular, To what extent should recruitment of medica/students be stepped up? It is a decision that will require a great deal of courage. from the mid-1960s, the number of faculties of medicine rose nearly everywhere and the recruitment of medical students was stepped up. A decade later, the total of newly grad- uated doctors had doubled or even tripled. This whole process was particularly striking in most of the industrialized countries, but many of the developing countries witnessed it A doctor examines a young patient in Nepal. Can the ideal number of doctors per population ever be reached? too. The number of medical faculties in India rosefrom 44 in 1955 to 106 in 1980, while in Mexico they rose from 18 to 52 during the same period. The result was not slow to appear. From 1975, in a great many coun- tries, the total force of active doctors increased considerably. At the start of the 1980s a medical surplus was becoming apparent everywhere. Of course, this plethora of physicians in no way meant that people's medical needs were being met. Most often, it implied rather an overloading of the economic capacity of the nation, whose limited resources could not afford to finance the treatments dispensed by too many doctors. The public authorities in several countries then began to think seriously about reducing the number of admissions to the faculties of medicine. However, a significant reduction in university recruitment today only results in a drop in the annual total of new medical graduates about seven to ten years later, and that is exactly what is happening. In many coun- tries, the annual output of newly World Health • 47th Year, No.5, September-october 1994 trained doctors only started to fall noticeably from the end of the 1980s or even at the start of the 1990s. Moreover, any reduction in each year's addition of newly graduated physicians does not lead to an imme- diate fall in the total effective stock of the medical profession. There is a built-in delay. What is more, when a professional medical corps is very young, as is the case today, the num- bers of doctors taking retirement are very small. Even if there is a reduc- tion in the new arrivals, they are still more numerous than those who are quitting the profession. As a result, the medical profession is continuing to expand and the total numbers are still rising, although at a slower and slower pace. Stabilization point will be reached, in most countries, be- tween the year 2005 and the year 2015 . Unfortunately- and this is an important point- it will only last for a short period. In fact, towards 2010 to 2025, we shall see all those excess graduates who were encouraged during the period 1975-90 reaching retirement age. Each year, there will be a dizzy spiral in the numbers of doctors taking retirement. From 2015 in France, for instance, according to our calculations, those quitting professional work will each year exceed the level of 8100 - more than three times the annual total today of around 2400. France will not be alone in this; many countries, both In many countries, decreasing numbers of doctors will coincide with an abrupt increase in the elderly people in need of care. industrialized and developing, will equally see this unusual kind of boom in two decades' time. So the total number of practising physicians will drop sharply. Yet it is precisely around that period of 2010-25 that many coun- tries will see a drastic rise in the total of elderly persons. The demographic projections of the United Nations show that people aged 65 and over, Today, there is an oversupply of young doctors who will not retire before well into the next century. 7 who in 1980 constituted about 9% of the population of Canada, for exam- ple, will see their proportion rise to 18% in the year 2025. In developing countries too, there will be an up- surge in demographic aging. The proportion of elderly in Brazil will rise from 4% in 1980 to more than 9% in 2025. For the Republic of Singapore the change will be from less than 5% in 1980 to more than 18% in 2025. In other words, in a great many nations within 15 to 20 years there will simultaneously be an abrupt reduction in the total of active doc- tors and a major increase in the numbers and proportion of elderly people. Yet the elderly are precisely those who require more medical care. At the same time, the expected eco- nomic growth will no doubt set in train a still more intense quest for well-being and will further step up the demand for medical treatment. So in about two decades, we risk seeing a reversal of the situation. From an excess of doctors that many countries are experiencing today, whether industrialized or developing, we shall enter an era when the need for treat- ment may no longer be fully met because of the lack of medical staff in sufficient numbers. Measures to mitigate the negative effects of this situation do exist and take various forms. But they need to be taken immediately. The problem is that, today, we are still in the middle of a period of medical over- supply. Those measures are conse- quently very difficult to take, whether from a psychological or from a political point of view. As always, we are going to need a great deal of courage to face up to the future. • Dr Bui Dang Ha Doan is Director of the Centre for Sociology and Medical Demography, 60 Boulevard de Latour-Maubourg, 75007 Paris, France.