Educational and labor wastage of doctors in Mexico: towards the construction of a common methodology

Background This paper addresses the problem of wastage of the qualified labor force, which takes place both during the education process and when trained personnel try to find jobs in the local market. Methods Secondary sources were used, mainly the Statistical yearbooks of the National Association of Universities and Higher Education Institutions (ANUIES in Spanish). Also, the 2000 Population Census was used to estimate the different sources of labor market wastage. The formulas were modified to estimate educational and labor wastage rates. Results Out of every 1000 students who started a medical training in 1996, over 20% were not able to finish the training by 2000. Furthermore, out of every 1000 graduates, 31% were not able to find a remunerated position in the labor market that would enable them to put into practice the abilities and capacities obtained at school. Important differences can be observed between generalists and specialists, as well as between men and women. In the case of specialists and men, lower wastage rates can be observed as compared to the wastage rates of generalists and women. A large percentage of women dedicate themselves exclusively to household duties, which in labor terms represents a wastage of their capacity to participate in the production of formal health services. Conclusion Women are becoming a majority in most medical schools, yet their participation in the labor market does not reflect the same trend. Among men, policies should be formulated to incorporate doctors in the specific health field for which they were trained. Regarding women, specific policies should target those who are dedicated full-time to household activities in order to create the possibility of having them occupy a remunerated job if they are willing to do so. Reducing wastage at both the educational and labor levels should improve the capacity of social investment, thereby increasing the capacity of the health system as a whole to provide services, particularly to those populations who are most in need.


Introduction
The medical workforce has been studied from diverse points of view by means of a wide variety of methodolo-gies and at varying levels of depth. Some studies approach the subject from the formal education standpoint, examining the problems encountered in the updating of knowledge, the number of human resources available and the distribution and proportion of resources according to the population. Other studies look into working conditions, prevailing ethical codes and productivity, among other topics. In a first review of the available specialized literature, very few studies were found to deal systematically with the difficulty for trained individuals in the health field to put into practice their acquired knowledge to deliver services [1].
In many countries the supply of doctors is being generated without planning and, very frequently, with no regulation at all. Doctors are being educated in schools that provide them with a professional degree; in spite of this, they will eventually face difficulties in finding a job. This problem is related to the qualified labor force wastage, as well as to the specific market configuration. On the other hand, there is another source of wastage that takes place during the education process and is reflected in the demand for medical education, the number of dropouts, the final efficiency rates at a national level and the organization and location of medical schools [2].
Besides these problems, the wastage of scholars has various facets that are not easy to identify, study or solve. One of these, perhaps the most important, is the enormous economic burden for a society represented by an inconclusive education process in which many students drop out before finishing their studies, making it impossible for them to put into practice the knowledge they acquire. This represents a fruitless investment and a wastage of economic resources that no nation can afford, particularly in the developing world.
Social investment in medical training should produce a benefit for societies, their institutions and citizens. The role of medical practice is highly valued in most societies, but it is up to governments to establish regulations that enable education to produce well-trained doctors practising under high ethical and professional standards. Government intervention is crucial to guaranteeing that this social investment provides the highest possible outcome. Health care reforms are taking place in many countries and are creating new conditions for medical practice, but not many of them regard HRH as a strategic planning issue [3].
It is also necessary to consider that wastage and geographical distribution are very much related. Indeed, doctors in Mexico have been concentrated for many years in urban areas, yet these areas also show high underemployment and unemployment rates. On the other hand, the lack of interest of doctors to practice in remote regions paradoxically results in a very reduced wastage in suburban and rural areas [4]. Therefore, the dynamics between human resources supply and the actual requirements of institutions lead to breakdowns that are expressed as labor wastage -that is to say, time and capabilities that graduate doctors do not put into practice either directly or indirectly for the production of health services.
The paper is not limited to the estimation of wastage rates but, based on the information obtained, widens its scope to discuss the implications for HRH -among them, the need to solve wastage in urban areas while encouraging the flow of doctors to remote areas. It also suggests the need to protect social investment in medical education. A further issue emphasized is the participation of women, as it has been made evident that their enrolment to medical schools has grown significantly in the last 15 years, yet their engagement in the labor market still occurs under different conditions as compared to those of men [5].

Objectives
The paper pursues the following objectives: • to characterize the problem of wastage of doctors during their education process and in the labor market; • to begin to construct a methodology that allows for the study of the problem in Mexico and, at the same time, could be replicated in other countries; • to contribute to the discussion of the wastage of human resources in the health sector at the national and international levels; • following the initial diagnosis about the wastage found in medical personnel, to use the sex variable to explore a relevant dimension of the problem.

Conceptual framework
The purpose of this section is to establish definitions that will set out the foundations for the presentation of results based on the information gathered. Due to the particularities of each field and for the sake of the exposition, the educational and labor market subjects will be addressed separately.

Wastage during education
Many studies in Mexico have dealt with the problems of school dropouts, final efficiency, repetition, exclusion and effectiveness and efficiency of the training institutions, among others. However, both at national and international levels little has been done to study the problem of specific professions (such as medicine) comprehensively so as to fully understand the causes and effects of the wastage of human and economic resources during the educational process [6].
The data presented in the following sections were obtained mainly from the National Association of Universities and Higher Education Institutions (ANUIES in Spanish), a nongovernmental agency that for more than 35 years has been responsible for compiling and systematizing information provided by 138 public and private institutions [7]. The stability and duration of this process of data collection renders the information obtained from this source highly reliable.
The following concepts have been taken from the existing studies:

Global attrition
This is a condition experienced by someone who does not comply with the timelines and does not complete the corresponding stages of the study plan of an institution in a specific year [8]. The student voluntarily or involuntarily interrupts his/her studies without having completed the studies required for his or her career. Such an interruption is not a spontaneous act, as there are family, social and institutional factors behind it [9]. Among the main causes of an interruption of studies are family attitude, economic conditions, study habits, inadequate selection of career, motivation, age, civil status and employment [10].

Graduates
Students who have completed the total number of credits required and/or have fully complied with the established procedures (such as writing a thesis) included in the plan of studies, receive a degree from a university or other institution of higher education.

Wastage in the labor market
There are factors affecting the labor market that are difficult to identify and much more difficult to quantify. The issue of unemployment and its varied manifestations in shape and time make it a somewhat polemical topic when dealing with secular variations. Although parameters to measure unemployment have been established at the international level, this has not allowed to count on timely information that might be comparable among countries and even among regions and states within a country [11]. In the case of professional groups, quantifying unemployment is not enough to understand labor market unbalances.
In the case of Mexico, the National Institute of Statistics, Geography and Informatics -INEGI -carries out two important data collections reporting results on various aspects related to employment at the national level: the General Census on Population and Housing is carried out every ten years, and a National Survey of Urban Employment, every three months.
Periodically INEGI reports a series of statistics about the employment situation across the country; one of these is the rate of open unemployment at the national level. However, this rate alone is not the most adequate indicator to establish the dimension of labor wastage, among other reasons because it is a macro indicator that shadows other levels of participation in the labor market that could be considered inadequate for an individual with professional training.
As part of the conceptual and methodological definitions of the present work we propose to estimate the rate of wastage among doctors, which would incorporate all those conditions in which a graduate from a medical school does not put into practice the knowledge gained from the school for the production of health services. Some situations, such as unemployment, are easy to identify as part of this wastage, but others (e.g., that of individuals who work less than 20 hours a week) are more difficult. We quantify wastage through the number of individuals who fall into categories in which their training does not match their labor activity. (Table 1) For the purpose of this study, the following concepts would need to be taken into account [12].

Employment
This is the situation in which graduates work as general practitioners or, as students for a medical specialization degree, in a full-time clinical practice at a hospital. It also includes specialist doctors with a labor position in health institutions according to the degree obtained. The category also comprises those doctors who are dedicated to research and/or teaching activities and those in managerial positions in health institutions.

Unemployment
This refers to individuals without employment, including those awaiting a reply about a job application (and who are not looking for any other job), those who are too discouraged to continue looking for a job and those who are actively seeking one.

Underemployment
This refers to individuals who have finished their studies and carry out activities different from their training; such activities may take place outside the health sector and/or in areas not directly related to the delivery of health services. To estimate underemployment in the general population, labor specialists normally consider working time and income criteria. In this case, since we are dealing with a professional group, a dimension that has proved to be appropriate for this measurement is the match between training and labor activities. This type of underemployment is known as qualitative underemployment and it is useful to understand the participation of highly trained groups of the population.

Household activities
These refer to individuals who do not have remunerated work because they are dedicated to household activities on a full-time basis.

Inactive, not available
This refers to groups of individuals who are retired, pensioned or suffer a permanent disability.

Labor wastage
This refers to qualified human resources who do not practice activities related to their formal education because they are not employed (including those dedicated to household activities) or because they carry out activities that do not correspond to their training.

Methods
With respect to wastage that takes place during the years of study, the Anuario Estadístico (Annual Statistical Book) published by ANUIES between 1976 and 2001 was used as the main source of information. It was necessary to carry out our own calculations to estimate enrolment, incoming students, graduates and abandonment per group pertaining to a common period of study, with a cohort of five years each.
Since there is no information on the incoming students disaggregated by sex, drop-outs and graduates for the years before 1996, it was possible to calculate rates of abandonment and final efficiency for only two graduating classes.
To calculate the wastage in the education of the medical students, the following formulas were established: As to the wastage in the labor market, the database of the XII Censo General de Población y Vivienda, 2000 [13] (XII General Census on Population and Housing, 2000) was examined for information about the following variables: sex, age, education and individuals who had studied for the career of medicine. The information about specialists available in the Census database was very limited. Thus, we decided to focus our exercise on generalists (in Mexico, generalists are those graduated from medical schools who have not obtained a specialist degree).
As to the latter, census codes were compared to find out their activity status (their own or activities not related to their education), occupation (making it explicit if they were dedicated to household activities), and whether they were unemployed, retired, pensioned or permanently disabled.
Codes used to classify the activity area were taken from the North American Industry Classification System (NAICS) used by the 2000 National Census of Population and Housing. Category 6 corresponds to health services. Codes used to classify the educational level correspond to a classification developed by the National Institute of Statistics, Geography and Informatics.
Once this information was processed, the following formulas were built. To calculate the rate of employment among individuals who studied medicine: For the rate of unemployment, the formula used was: And for the rate of wastage it was established that:

Results and discussion
Based on the definitions set forth in the framework provided for this work and the formulas set out in the methodology section, the following results for the total medical personnel were obtained.

Wastage during education
In general, enrolment in the career of medicine in Mexico has shown non-linear behavior during the last 25 years. At the beginning of the 1990s it showed a tendency to drop,  (Table 2).
Throughout this period, the proportional participation of women maintained constant growth. According to the annual statistical book from ANUIES, the percentage of women enrolled in medicine jumped from 43.9% in 1990 to 50.4% in the year 2001. It was in the year 1999 when the women enrolled outnumbered men for the first time, by 1038 students (Figure 1).
An indicator that clearly illustrates wastage during education is the rate of final efficiency in the career of medicine at a national level. In the same manner, the series of graduating classes with the same cohort was constructed, ena-bling us to observe that the highest final efficiency was achieved in the graduating class of 1985 and that of 1995, with a rate of 834.9 and 804.3, respectively. After ten years the second-highest rate was reached, during the period 1995-1999 (Figures 2 and 3).
Although it is true that the final efficiency varies from one medical school to another (which also would be important to further investigate), there is no doubt that at the national level the registered rates are worrisome, given the number of medical students who do not complete their studies.
On the other hand, the proportion of incoming students in relation to the total enrolment for medical training in Mexico during the period 1977-2001 was calculated. The result for the first year (1977) was 21.9, and for the second Year 1 9 7 7 1 9 8 0 1 9 8 3 1 9 8 6 1 9 9 0 1 9 9 3 1 9 9 6 1 9 9 9 2 0 0 1  The notoriously high rate of attrition in 1990-1994 may well be related to the economic crisis Mexico was facing by the end of the period, which made it very difficult for students and their families to afford medical education. The rate of efficiency shown in Figure 2 mirrors the capacity of schools, students and families to reduce the volume of drop-outs [14]. As can been seen in Table 3, the information about dropouts, graduates and final efficiency does not show any significant difference whenever the sex variable is included. However, given that it was possible to obtain information by sex for only two classes pertaining to the same period of study, it would be difficult to reach any solid conclusion in this respect.

Total
Upon constructing series of data by year, it was found that women have moved from representing 19% of the graduates in 1970 to almost half the graduates in the year 2001 (49.3%). Since 1996, the number of female medical graduates has been very similar to that of men. Something similar occurs when comparing the information about incoming students and dropouts ( Table 4). The number of graduates who received their degree has not shown significant changes in the recent years: in 1996, 45.9% were women, a figure that went up to 49.3% in the year 2001.

Wastage in the labor market
Out of the total number of general physicians and specialists in 2000, 70% were working in medical care and 5% were studying. From a sex perspective, 13% of the men were not working and 2% of the women were inactive, while the percentage of men and women working in medicine was 75% and 59%, respectively; that is to say, there was a difference of 16 points favoring the number of men employed.
Out of the population with education in general medicine that was dedicated to household activities, only 0.5%    1977-1981 1978-1982 1979-1983 1980-1984 1981-1985 1982-1986 1983-1987 1984-1988     were men while 11% were women. Another item of information that stands out regards inactive and unavailable personnel: in fact, there are more men than women as such, which may indicate that there are fewer women retired and pensioned [15] (Table 5).
Results after repeating the same operations, but taking into account the variable sex, are presented in Tables 6, 7 and 8.

Discussion
The methodology proposed in the present document can be reproduced in other countries if a population census database is available. WHO should encourage countries to estimate medical and other occupational groups' wastage rates in order to find out ways to reduce this phenomenon and to make the most of social and private investments [16,17].
In Mexico, an Inter-institutional Commission for the Training of Human Resources for Health, an entity created by high educational and health authorities to plan the supply, demand and distribution of human resources for health in the country, has been working for almost 30 years. It is suggested that the Mexican case be revised, since this might contribute to encouraging linkage and interaction between training and health services institutions with the aim of achieving a better planning process according to country-specific characteristics. Figure 4 shows that doctors enrolled at medical schools can follow one of two patterns: the first refers to students obtaining their diploma, and the second, to students dropping out or not fulfilling the established requirements to graduate. Once in the labor market, graduates can be divided into two subgroups: those who are ready to be immediately employed and those who are not. In turn, those who are ready can be employed, unemployed, underemployed or fully dedicated to household activities. Those who are not ready to be immediately employed are divided into students that go on for a specialization degree and those who are inactive.
The wastage of resources during the education of medical students is significant, as was shown in the results. This problem should be studied in further detail to enable us to arrive at an estimation of the economic cost that this represents at the individual, family and social levels. This economic cost cannot be estimated from the available information regarding wastage in medical training and in the labor market. Before moving ahead to the next step, it would be important to conceptualize the factors that intervene in the wastage process in order to attain an objective assessment of it. Questions such as how to determine and estimate indirect costs and how to assign a money value to the time lost when people abandon the market temporarily seem to be of utmost importance.
The inequalities between men and women in the labor market are reflected not only as higher wastage rates, as has been shown in this document. In this respect, there is an increasing trend toward a decline in working conditions imposed in many developing countries by employers, both private and public. This process of decline includes the stagnation of salaries, the lack of guarantee of labor rights and benefits, and the use of temporary contracts instead of permanent positions. In Latin America it is possible to identify countries where declining working conditions have spread, such as Argentina, Brazil, Ecuador, Mexico and Peru. Contracts reflecting these conditions are offered mostly to women [18].
In Mexico previous studies have shown a relation between geographical distribution and wastage. The highest levels of medical unemployment and labor wastage in Mexico are found in urban areas [19]. This fact can be appreciated when comparing states with large rural populations to states with more urbanized populations [20]. Within the first group the estimated availability of doctors per population tends to be lower than in the second group. For example, in the southern state of Chiapas, with 54% of its population being rural, the number of available doctors per 1000 inhabitants is 0.79, while in the Federal District (Mexico City), with 99.8% of its population being urban, the number of doctors per 1000 inhabitants is 3.03, 3.8 times higher than in Chiapas.
Possible outcomes for individuals, from medical schools to the labor market Figure 4 Possible outcomes for individuals, from medical schools to the labor market. The diagram shows that doctors enrolled at medical schools can follow one of two patterns: the first refers to students obtaining their diploma, and the second, to students dropping out or not fulfilling the established requirements to graduate. Once in the labor market, graduates can be divided into two subgroups: those who are ready to be immediately employed and those who are not. In turn, those who are ready can be employed, unemployed, underemployed or fully dedicated to household activities. Those who are not ready to be immediately employed are divided into students that go on for a specialization degree and those who are inactive. A proportion of those initially enrolled will later be represented by the rate of attrition. It would be a sound idea to sensitize medical students about the problem and the need to move on to unsaturated areas. On the other hand, health policies should enhance incentives for doctors to move to underserved areas, including higher salaries and the possibility of further training for those doctors who show willingness to take that option.
The top decision-making levels of the health system should be supporting the design and development of studies aiming at understanding in detail the issues concerning labor wastage; this would contribute to producing policy recommendations that stress the need for a comprehensive and coordinated institutional participation [21].
The methodology followed to calculate the wastage during the educational process as well as in the labor market was demonstrated to be adequate to support these kinds of studies. Hence, based on the information derived from a population census and on the management of similar variables, it would be possible to replicate this method in other countries. Additionally, this would make it possible to carry out comparative and complementary studies that would set forth the problem in more detail and would assist in the formulation of alternative policies within the health sector.
Such a methodology can be applied without further implications for the exploration of the development and labor conditions that prevail in other occupational categories, such as nursing and dentistry.

Conclusion
Although assessment of the wastage phenomenon could be more accurate if a wider set of data were available, it can in any case be said that in Mexico the wastage of human resources in the health sector is a major problem.
In the year 2000, 310 of every 1000 enrolled students did not finish their training. This represents an important source of wastage of human resources.
There is no doubt that the wastage of a highly qualified workforce has a negative impact on the economy of any country. Governments and families invest huge amounts of material and financial resources to train professionals; ultimately these professionals may not find a position within the labor market in which the functions they perform accord with the long training they have received [22]. By the end of the 1990s, 720 of every 1000 enrolled medical students finished their training, and of 1000 doctors available in the labor market, only 58% found paid employment that enabled them to practise the skills obtained during their training.
As part of the problem, the experience individuals have accumulated to fully integrate into the labor market as well as the barriers and opportunities they face to get a job must be taken into account. Finally, health systems, including their educational components, must look for ways to reduce the wastage of human resources in order to increase the efficiency of the system as a whole; this should be considered a social imperative.
Unemployment and the rate of wastage among women are much higher than for men [23]. This reflects an inequitable labor situation that adds up to a series of disadvantages related to the male-centered social structure prevalent in Mexico. For example, men generally receive a higher income for carrying out the same tasks as women; they also are usually accorded administrative positions [24].
It is clear that the issue explored in the present article represents one of the faces of a long-standing paradox. The number of doctors in urban areas has surpassed the demand from the population to the point of producing unemployment, underemployment and, ultimately, wastage. In rural areas, in contrast, doctors are still absent in many communities, so people become ill and die of communicable and preventable diseases for want of competent medical care [25]. Understanding this phenomenon is the first step towards solving the problem. But to proceed with the second step, it will be necessary to develop new policies, based on sound information, aiming at attaining a more equitable and efficient distribution of resources, including health personnel.