This study reports on a particular point in the cycle of HRH planning: the transition from training to employment in the national health system, in a country where this sector provides care for 60% of the population. Results from this analysis of primary data show that at 2013 training rates, Peru has the number of physicians, nurses, and midwives it needs to meet the estimated HRH gap in the national MOH system during the next decade. This is explained by the number of HRH graduates, which has been increasing from 2007 to 2011 due to the additional offer of training provided by private universities . Yet, our analyses show that not only is availability of new graduates important but that current entry rates of HRH into employment by the MOH system may hinder meeting such targets. The proportion of HRH graduates entering the MOH system 2 years later ranges from 8 to 45% during the period of this study, showing that a significant number of qualified professionals do not enrol in the MOH system workforce in the immediate year after completing their SERUMS. Scenario analyses indicate that if 2013 absorption rates are held, the gap for physicians and nurses will not be met until 2027 and 2024, respectively, while the gap for midwives will likely be met by 2017. Furthermore, less than one in five newly trained MOH-priority medical specialists enrol in the MOH system workforce, suggesting that there are some major barriers to entry immediately after SERUMS and after completion of postgraduate clinical training.
Shortages in HRH have been reported in Peru indicating substantial deficiencies in the total number of available healthcare professionals and medical specialists [8, 13]. Using a labour market framework, the shortage of healthcare professionals in Peru may be explained by the low proportions of healthcare professionals entering the MOH system from SERUMS or from postgraduate clinical training shown in this study, high rates of out-migration , and low rates of retention rather than merely a limited supply in training of professionals .
The differences in the proportion of graduates who enter SERUMS (nearly 100% of physicians vs. 62% of nurses and 85% of midwives over the time period) in the immediate year after graduation could indicate that nurses and midwives may have other options of immediate employment in the private sector or the social security system that do not require being posted in a remote and rural area and may even offer longer-term opportunities than the MOH.
The average proportion of SERUMS healthcare professionals entering the MOH system has been consistently low, 28% of physicians, 38% of nurses, and 33% of midwives. To increase the number of healthcare professionals in the MOH system, strategies to raise the proportion of SERUMS-completed healthcare professionals and graduated medical specialists entering the MOH system need to be explored. In 2009, the Peruvian government instituted a strategy to increase the number of SERUMS positions at rural and remote outposts available to physicians , and while this indeed increased the number of SERUMS physicians, as seen in Fig. 2, these results show that it did not ultimately translate into more healthcare professionals remaining within the MOH system immediately after completing their SERUMS.
Entering employment in the MOH system from SERUMS is clearly not linear, but further investigation is needed to understand the specific barriers such as those on the supply side (e.g. lack of MOH system positions, mismatch between skills ) or the demand side (e.g. salary, work hours, prestige, professional development opportunities). Miranda et al.  and Huicho et al.  found that in Ayacucho, Peru, physicians were five times more likely, and nurses and midwives 14 times, to choose an urban-based job over a rural one. Incentives that professionals preferred included salary increases and bonus points to gain entry into postgraduate training programmes. For example, Mayta-Tristán et al.  proposed that SERUMS should be voluntary and not time-limited, offer academic incentives for further training after 3 years of service, and ensure basic workplace protection for the HRH. These proposals are modelled on the successful Rural Practitioner Program in Chile, a programme with a near 100% retention rate . Nevertheless, recent reviews of recruitment and retention strategies for primary care physicians have found weak evidence [19, 20] except for some limited effectiveness of undergraduate and postgraduate placements in underserved areas and selective recruitment of medical students (i.e. those from rural areas) . Similarly, the low proportions of medical specialists entering the MOH system after postgraduate clinical training not only further exacerbate the workforce shortage but indicate a significant loss of training investment. Although some of these losses can be explained by migration , further research is needed to evaluate the proportion of medical specialists who enter the MOH system in future years and explore possible barriers of entry, including availability of employment offers and their geographical distribution.
In addition to the low proportions of SERUMS-completed healthcare professionals and medical specialists entering the MOH system, the workforce shortage is compounded by mismatched training competency. Peru has been able to meet its demand for training in healthcare professions, with 70% of graduates attending private universities, yet a massive disconnect remains between the primary care-level competencies developed in universities and those desired by the MOH . This mismatch continues for medical specialists in primary care with only one joining the MOH system in 2013 and low demand for postgraduate training positions within the MOH system (251 available in 2013 and only 143 taken up) .
These findings can be relevant to health systems in other countries, where quantity of HRH may not be critical but other constraints and barriers, fiscal or otherwise, exist . For example, Peru has sufficient number of medical schools, 33 vs. 20 in Australia and 25 in England [9, 22, 23], and students to meet the physician gap. Yet, these results indicate that there are several points postgraduation (nurses and midwives) and post-SERUMS (all professionals) in which the system fails to attract and/or retain the professionals required to counteract HRH shortages. Countries that are investing in the development of their HRH should consider also investing in understanding health labour market trends , such as the rates of entry to employment at different points in a healthcare professional’s trajectory and determining the barriers to entering the public national health system. Building adequate incentive structures to improve the entry and retention of HRH into the public sector will require an evaluation of the value provided by already committed resources, including their cost-effectiveness  to ensure the best use of limited resources.
This study provides an assessment of the transition of healthcare professionals from university training, through SERUMS, and entry into the MOH system. It moves beyond merely quantifying HRH and signalling gaps in density to explore what happens to HRH within the local labour market and incorporates the complexity of various transition points. The main strength of this study included the ability to track individuals over time to assess if they ultimately become employed by the MOH system in the immediate year after completing their SERUMS, providing a robust exploration of trends over the time period. It makes use of primary data, rather than models or theoretical assumptions, and as such could be considered innovative. The focus of the study has international significance in relation to the market for physicians, nurses, and midwives in Peru, particularly in attracting new graduates into employment in the Ministry of Health’s (MOH) system. Nevertheless, this study has limitations. Data on HRH in this study accounts for those working for the MOH system, excluding those working for other sectors, such as ESSALUD and the private sector. Yet, because the MOH system covers the majority of the population, these findings still show evidence of matters causing the gap in healthcare professionals. Furthermore, the MOH’s databases shared with the authors did not include information on salaries, and no primary data sources on levels of HRH unemployment and migration existed to the knowledge of the authors. Projections were based on average rates for a period of 5 years. The analysis looked at the transition of HRH from graduation, to SERUMS, and then employment in the MOH system in the immediate years after but did not consider that professionals may join further on. However, it can be assumed that those employed by the MOH system are not employed by ESSALUD at the same time (as this is not allowed by the Government), although they might have a dual practice in the private sector. In spite of its limitations, the scenario projections included in this study may prove useful to policymakers in Peru and other countries in the same stage of development, to persuade them to use concurrent and synergic strategies to address gaps in HRH.