Experts propose 70% hike in medicine study places

A governmental expert committee in Norway has proposed increasing study places in medicine for doctors by 70% to tackle the problem that too many medical students are being trained abroad for a different health system.

One major consequence of the proposal would be that the number of study places in medicine for approximately 3,000 Norwegian students abroad, paid for by loans and grants from the Norwegian State Educational Loan Fund, would have to be significantly reduced.

The six-person governmental expert committee appointed by the Ministry of Education and Research in June 2018 was mandated to analyse how the capacity at Norwegian universities graduating medical doctors can be increased.

The committee was set up in the context of almost half of medical doctors (47%) who are taking up a career in Norway today having graduated from universities outside Norway.

“Norwegian medical students are getting a good higher education abroad,” the press release from the ministry stated, “but they are educated for a different health system than Norway.”

The committee was chaired by Professor Hilde Grimstad of the Faculty of Medicine and Health Sciences at the Norwegian University of Science and Technology (NTNU) and was served by a secretariat placed at the University of Bergen.

The expert committee has produced a 120-page document with several appendices, notably with a cost benefit analysis of the different models discussed by the committee.

The report, Study Places in Norway in Medicine. Needs. Models. Possibilities, was delivered by committee chair Grimstad – hence labelled ‘the Grimstad report’ – to Minister of Research and Higher Education Iselin Nybø on 25 September. The report contains 19 recommendations on five central tasks mandated by the government.

As a special analysis, the consultancy Oslo Economics has provided Appendix Seven in the report, an analysis of “Cost effects of the increase in study places in medicine in Norway”.

The most extensive proposal is that Norway should target the World Health Organization (WHO) recommendation of graduating at least 80% of the health personnel needed by 2027. This means expanding the number of medical students in Norway from 636 today to 1,076 in 2027 or by 69%.

The expert committee is proposing that the intake at Norwegian universities be upscaled immediately to reach the target of 440 additional study places by the autumn term of 2027 at the latest.

The majority of the committee proposes that the student intake at the four universities currently educating doctors be increased – these are the University of Oslo, University of Bergen, NTNU in Trondheim and the University of Tromsø, the Arctic University of Norway.

A special recommendation is given to a collaboration between the University of Bergen and the University of Stavanger on the West Coast of Norway. A minority of the committee is seeking alternative study places, notably in the Eastern region of Norway, which has the largest university hospitals, and to break up the predominant six-year professional degree programme into a bachelor-masters model.

Highest proportion of doctors

Norway has among the highest proportion of medical doctors among the OECD countries, with 4.8 doctors per 1,000 population, surpassed only by Austria. In 2018, 14.7% of the 25,604 Norwegian doctors under 70 years of age were foreign citizens, but a significantly higher proportion – more than 40% – were educated abroad.

Also, the number of medical doctors who are Norwegian citizens educated abroad grew from 4,569 in 2012 to 6,878 in 2018 or by 50.5%. Foreign citizens educated abroad and working as doctors in Norway in the same period increased from 2,859 to 3,389, or by 18%.

Oslo Economics, which analysed the trends in medical doctors educated in Norway compared with those educated abroad, states that there are currently approximately 3,700 medical students in Norway, with around 520 graduating each year.

In comparison, there are approximately 3,200 Norwegian medical students abroad.

Furthermore, the proportion of applicants to beginner positions at Norwegian hospitals with an education from Norway is in steep decline, from 44% of those applying in the spring of 2013 to 30% in the spring of 2018, while over the same period the number of applicants for beginner positions who had undertaken a medical degree in a country within the European Economic Area grew by 37%.

Medical students abroad 2008-18

The number of Norwegian students in medicine in other countries grew from 2,380 in 2008 to 3,166 in 2018, or by 33%. The majority (88%) of Norwegian students abroad in 2018 studied in these five countries: Poland, Hungary, Slovakia, Denmark and the Czech Republic.

Some 2,781 students out of a total of 3,166 students received a Norwegian study loan for their medical studies abroad.

The universities abroad receiving most Norwegian medical students in 2017-18 were: Comenius University in Slovakia (373), Jagiellonian University in Poland (345), Semmelweis University in Hungary (262), the University of Southern Denmark (233) and the University of Pécs including Janus Pannonius University in Hungary (226).

The report from Oslo Economics said that if this development continues, there will be more Norwegian students undertaking a medical degree outside Norway than those graduating in Norway in less than 10 years.

Students today are finding their way to medical studies abroad with great counselling support from the Association of Norwegian Students Abroad (ANSA).

Also, three private Norwegian university colleges – Bjørknes University College, Atlantis Medical College and Kristiania University College – have established collaborative agreements with universities in Hungary, Poland, Slovakia and Cyprus, with studies undertaken partly in Norway and partly at the collaborating institution abroad and where the degree is conferred by the collaborating partner university abroad.

Due to increasing costs, the expert committee is proposing that another committee should be appointed by the ministry with a mandate to reduce the funding of Norwegians in study places in medicine outside Norway to 5-10% of the need. This means reducing the Norwegian State Educational Loan Fund eligibility for studies in medicine abroad in parallel with the expansion of the capacity in Norway.

Positive reaction

The four Norwegian universities that educate medical graduates are all positive about the committee’s proposals, not least because the majority of committee members are recommending that all additional study places should be at these four universities.

Marit Hermansen, president of the Norwegian Medical Association, said they are glad the Grimstad report concludes that the number of study places in medicine in Norway must be increased. She thinks that 85% of the doctors needed should graduate in Norway.

“Norway ought to be self-supportive with regard to medical doctors, and the recommendations are hence a step in the right direction,” she said.

Øystein Ohr, leader of Norwegian Medical Students’ Association, said they are very satisfied with the proposals. A significant increase in study places in medicine will send an important signal that Norway is taking the WHO code seriously.

However, ANSA President Hanna Flood said Grimstad’s recommendations are “heinous towards Norwegian medical students abroad”.

“This proposal is based on the idea that Norway has quality in its medical education that no other country can match,” she said. “Today thousands of Norwegian students are educated abroad. The proposals are also breaking with academic freedom,” Flood said.

Professor Ole Petter Ottersen, rector of the Karolinska Institute in Stockholm in Sweden, who himself is a trained medical doctor and was rector at the University of Oslo from 2009 to 2017, said the success of the committee’s proposal is dependent on how it is going to be funded.

“Without a solid financing plan, this is a high-risk venture. And you have to be realistic: My experience is that it is difficult to absorb so many new students over a short time period,” he told University World News.

“And we have to remember that this is not a black and white question: I see it as positive that some of our doctors are educated abroad, given the richness of perspective this gives.”

When receiving the report, Minister Nybø said that the required funding of approximately NOK1.2 billion (US$132 million) per year would not be easy to find. She also said she is sceptical about reducing financial support for students who are undertaking their medical education abroad.

But she added that the report will be sent to all relevant stakeholders for comment, “and then in the end it will be a political decision if and how and at which institutions these study places will be allocated.”

On the day the report was published, Professor Grimstad wrote an op ed article in the major newspaper Aftenposten: “Yes, it is expensive. But can we afford not to do it?” she asked.