Abstract
Finding the “right-size” physical therapy workforce is an increasingly important issue, but it has had limited study, particularly across nations. This perspective article provides a comprehensive examination of physical therapy workforce issues across 4 countries (United States, Singapore, Portugal, and Bangladesh), which were deliberately selected to allow consideration of key contextual factors. This investigation provides a theoretical model uniquely adapted to focus on variables most likely to affect physical therapy workforce needs. This theoretical model was used to guide acquisition of public domain data across the respective countries. The data then were used to provide a contextualized interpretation about the physical therapy workforce supply (ie, physical therapists per capita) across the 4 countries in light of the following factors: indicators of physical therapy need, financial and administrative barriers affecting physical therapy access and demand, the proportion of physical therapy graduates (with varying trends over time across the countries), and the role of emigration/immigration in supply inequalities among countries of lower and higher income. In addition, both the physical therapy workforce supply and scope of practice were analyzed in the context of other related professions across the 4 countries. This international comparison indicated that there may not be a “one-size-fits-all” recommendation for physical therapy workforce supply across countries or an ideal formula for its determination. The optimal, country-specific physical therapy workforce supply appears to be affected by discipline-specific health care and contextual factors that may vary across countries, and even within the same country. This article provides a conceptual framework and basis for such contextualized evaluations of the physical therapy workforce.
The demand for rehabilitation is rising in tandem with the growing burden of disability related to chronic conditions, driven largely by improvements in management of acute medical conditions and the aging of the population.1–5 Therefore, finding the right-size supply of physical therapists is an increasingly important issue. Even though the need for research-led physical therapy workforce planning has been recognized for decades,6,7 the pace of research has been slow. Prior work examined the issue within and across nations.
Within nations, 3 studies are germane. In 2007, Landry and colleagues8 studied the population-adjusted ratios of physical therapists registered in Canada and found comparative shortages in the physical therapist supply across Canadian regions. In 2010, Zimbelman and colleagues9 developed a forecasting model for the United States, estimating the shortages and surpluses of physical therapists until 2030 relative to estimated demand. They showed relative shortages nationwide, particularly in the south and west regions.9 Similarly, recent forecasting models by the American Physical Therapy Association (APTA) have projected national shortages of physical therapists until 2020.10,11
Across nations, several studies are relevant. In 2009, Landry and colleagues12 performed a cross-border comparison of Canada and the United States showing that relative and absolute growth in the physical therapist supply had been higher for the United States than for Canada. In 2011, the World Report on Disability13 presented population-adjusted ratios on the international supply of physical therapists and occupational therapists, showing large disparities across countries. Also in 2011, Gupta and colleagues14 provided data showing higher unmet needs for rehabilitation practitioners in low-income countries and substantial variation among high-income countries. Finally, data collected by the World Confederation for Physical Therapy in 2012 reveal that physical therapist supply varied from 0.002 to 2.82 per 1,000 people among 69 countries.15
Although these studies provide important insights;14,16 they have several limitations. First, lack of uniform data collection is a key obstacle, and data may not available at all (ie, in many low-income countries).14,15 Second, there is limited attention to potentially important contextual variables (eg, socioeconomic, demographic, the health care system) that might influence physical therapist supply and demand.17,18 Third, physical therapist characteristics (eg, education, direct access, practice roles) are seldom considered, despite variation between countries.18–20 Finally, physical therapist supply and practices might be intertwined with related professions (eg, occupational therapists, nurses),21 but how this varies across countries is rarely considered.
In short, there is need for comprehensive, contextualized analyses of the physical therapist supply across countries to help inform physical therapy workforce policies. This perspective article examines the physical therapist supply across a convenience sample of 4 countries (ie, United States, Singapore, Portugal, and Bangladesh) selected per an a priori theoretical model to reflect contextual factors likely to affect physical therapy workforce supply needs (see Method section for details).
Method
Theoretical Model
Investigation of the right-size physical therapy workforce benefits from a priori theoretical elaboration on which variables and how their complex interplay might affect the physical therapy workforce needs. Therefore, a theoretical framework was selected and adapted to a contextualized determination of the right-size physical therapy workforce.
O'Brien-Pallas and colleagues17,22,23 presented a workforce planning framework, with roots in Anderson's service utilization model and Donabedian's health care quality framework, depicting how the health care workforce can meet population health needs. It considers the dynamic interaction of multiple variables, such as workforce development (ie, education/training), the skill mix of human resources, workforce deployment and utilization (eg, distribution across geographic regions and sectors), health care system variables (eg, access to care, services management), and how the national context (eg, socioeconomic factors) interacts with all of those variables.
These principles were adapted to the aims of this article (Fig. 1). We studied the size of the physical therapy workforce across nations in relationship to: (1) the current supply of the physical therapy workforce (ie, population-adjusted physical therapist ratios),12–14 (2) physical therapy need (ie, antecedent demographic and epidemiological indicators that physical therapy might be beneficial),14,24 (3) physical therapy access (eg, barriers to accessing physical therapy), (4) physical therapy demand across regions or service levels (ie, requests for physical therapist services),9–11,25–28 (5) physical therapist influx/efflux (eg, physical therapy education numbers, emigration/immigration patterns),10,11,29 and (6) the physical therapy scope of practice compared with related professions (eg, occupational therapists, physicians, nurses).19,21
How the “right” physical therapist supply can be affected by variables on the physical therapy, national, and international contexts.
Sampling Framework
We did not aspire to identify countries representing all of the potential national differences that might affect physical therapist supply, but rather to focus on fewer countries so as to investigate in depth the role of particular contextual factors. We selected a convenience sample of countries based on the following criteria: (1) representation of distinct national realities likely to affect the physical therapy workforce supply needs per our theoretical model (eg, sociodemographics, population health characteristics, geographic characteristics, prevailing health care systems) and (2) availability of at least one author with experience in rehabilitation health services research (T.S.J., G.K., M.L., H.H.) and at least one author with in vivo experience of physical therapy in each of the countries (M.L., P-H.O., P.L.G., A.M.F.L.). Potential authors, and respective countries, were identified through personal acquaintances and contacts. The sample of countries so selected were the United States, Singapore, Portugal, and Bangladesh.
Data Sources
Local and international public domain data were the main data sources, including institutional reports (eg, World Report on Disability13), the scientific literature (eg, relevant for each country), and local and international websites (eg, APTA, World Bank). Authors' qualitative accounts, based on their experiential knowledge of physical therapy in each country, were supplementary data sources when quantitative data were not applicable or available.
Results
Comparison of Countries and Their Health Care Systems
Table 1 depicts how the 4 countries vary on financial, geographical, and health care system variables.
Country Descriptors Related to Population and Territory, Financial Indicators, and Health Care Financing
Singapore is a very small, completely urban Asian country with the highest per-capita income of the sample. Access to health care is universal, with a balanced mix of public and private health care. For public health care, patients can utilize their personal compulsory medical savings, and there are applicable government subsidies. Private health care is funded out-of-pocket or through private insurance. Health care quality is generally good, and costs are controlled.30
The United States is a high-income country, but with lower per-capita earnings than Singapore. Situated in North America, the United States holds vast territory and population comprising both rural and urban areas. Administratively, the United States consists of many states with varying legal requirements (eg, in physical therapy licensure). Health care in the United States is largely market-based, reimbursed through private insurance or out-of-pocket expenses, with the exception of the elder population, the military, and veterans. Despite recent legislation,31 health care access is not universal (13.1% of the US population remained uninsured in 2014).32 Finally, US per-capita spending on health care is the highest in the sample.
Portugal is a middle-sized, middle-income western European country, with financial indicators above the world average. The Portuguese population is roughly double that of Singapore, albeit much smaller than that of the United States. Among our sample, Portugal has the most public-oriented health care system. Public providers deliver most of the care and generally are salaried employees. Patients have universal access to the national health system, with low co-payments. Private health care and insurance are voluntary and less representative, although there are some public-private agreements in place (eg, private physical and medicine rehabilitation clinics reimbursed by the government).33
Bangladesh is a low-income South Asian country. Its population size is above that of Singapore or Portugal but nearly half that of the United States. Although more rural than urban, the population is concentrated in much less territory than the United States. Among this sample, Bangladesh has the lowest per-capita spending on health care and the lowest percentage of public-funded care.
Physical Therapist Supply
Table 2 presents the current physical therapist supply across the countries. Portugal has the highest physical therapist supply (7.8 per 10,000 people). The United States is a close second (6.5), whereas Singapore has a lower number (1.5), and Bangladesh has the lowest supply (≥0.1 physical therapists per 10,000 people). Whether this supply is the right-size physical therapy workforce across countries requires consideration of the other elements in our theoretical framework (Fig. 1).
Supply of Current PTs, New PT Graduates, and Related Professions, All per 10,000 Peoplea
Physical Therapy Need
Physical therapy need is affected by demographics (eg, population aging) and chronic conditions or injuries. The Global Burden of Disease study1,2 includes aggregated, cross-national epidemiological data (stratified by cause-specific diseases, injuries, and risk factors). As proxy indicators of physical therapy need, we retrieved country-specific data on the metric “years lived with disability” (YLDs)1 (calculated by multiplying a disorder prevalence by the short- or long-term health loss associated with that disability), as many of the disorders included in the YLD metric are conditions that typically benefit from physical therapy. Table 3 provides such data for the participating countries and world averages.
Need Indicators for Physical Therapy and Rehabilitation
For most indicators, Portugal presents the highest apparent physical therapy needs of the sample, clearly above world averages. Musculoskeletal disorders, neurological disorders, and falls stand out as the highest inciting contributors to YLDs in Portugal compared with the other 3 countries. Overall, in Portugal, higher physical therapy need seems to be met by higher physical therapist supply.
The United States ranks second on proxy physical therapy need indicators, also above world averages in nearly all items. The exception is the YLDs due to injuries, where US values are lower than world averages. Cardiovascular and circulatory diseases as inciting causes of disability are higher in the United States than in any other participating country. Overall, physical therapist supply and need indicators in the United States are relatively aligned, although somewhat lower than those of Portugal.
Physical therapy need indicators for Singapore are generally lower than for Portugal and the United States, yet still above world averages. Some exceptions exist. Disabilities caused by injuries, neurologic conditions, and particularly chronic respiratory conditions are lower than world averages. Nevertheless, the overall physical therapy need in Singapore seems not low enough to justify the large discrepancy in its physical therapy workforce compared with Portugal and the United States (4.3 and 3.6 times lower, respectively).
Among our sample, Bangladesh presents the lowest per-capita apparent need for physical therapy on nearly all indicators. The exception is disability related to injuries. Nonetheless, in Bangladesh, the physical therapy need indicators do not diverge a lot from the world average. Thus, Bangladesh has the highest unmet need for physical therapy, given its extremely low physical therapist supply (eg, more than 18 times lower than that of Singapore).
Importantly, the proxy physical therapy need indicators increased from 1990 to 2010 on all indicators, all across the countries (Tab. 3). This increase may reflect what has been sometimes termed a “disability epidemic” and a “silver tsunami”34—both due to great successes in treatment of acute diseases, which have astronomically increased the burden of chronic conditions and age-related conditions, in turn, being reflected in increases in the indicators of physical therapy need.5 In higher-income countries, this is the greatest challenge for their health care systems.1–4 Bangladesh and other low-income countries have a 2-fold burden with escalating prevalence of chronic or disabling conditions against the backdrop of continued high rates of communicable, maternal, and nutritional health conditions,1,2,35,36 putting additional strain on their scarce health care and financial resources.37
Physical Therapy Access
Adequate physical therapist supply may exist, and the population may increasingly need it; however, health care access barriers may interfere with access to the needed physical therapist services.26,31,38 This scenario affects physical therapy demand and ultimately physical therapy utilization.
In the United States, access to physical therapist services can be highly variable across third-party payers, sectors of the health care industry, and regions. For example, although Medicare (public insurance for elderly people) pays for physical therapy in both postacute inpatient and home-based settings, coverage for outpatient physical therapy is comparatively limited (eg, US$1,900, which equates to approximately 14–16 visits, depending on the specific services provided).39 For private insurance, coverage varies even more. Hence, many uninsured and underinsured patients with chronic disabilities find it hard to afford the high out-of-pocket physical therapy expenses and may forgo the care.27,28,38,40 Direct access to physical therapy (ie, without physician prescription) is legal in most states in the United States41; however, that direct access is undermined by lack of third-party reimbursement in the absence of physician order and lack of stakeholders' awareness that direct access is available.28,42 Finally, in the United States, access disparities also arise from geographical imbalances in the physical therapist supply.9,26 Although telehealth can increase access to physical therapy in undersupplied regions, both financial (eg, limited third-party payment) and licensing barriers (eg, cross-state delivery) hamper its implementation.43
In Singapore, imbalance in the geographic distribution of physical therapists is not an issue. However, physical therapists in Singapore are concentrated in acute care hospitals, with lesser availability in postacute inpatient rehabilitation and community-based physical therapy settings. Additionally, patients in Singapore typically are discharged home after their inpatient stay,44 frequently with minimal rehabilitation follow-up. Compulsory medical savings can only be used to pay for very selected follow-up rehabilitation services, which, in turn, reduces patient access. Telerehabilitation is a cost- and supply-effective solution to extend physical therapy access at the community level in Singapore,45 but lack of third-party reimbursement limits its use.
In Portugal, most physical therapy care is publicly funded or delivered through public entities. Thus, physical therapy access barriers mostly are related to the timely availability of beds and appointments, which vary by region for postacute care in particular.33 In acute wards, physical therapy access may be constrained by hospital administrative procedures (eg, requiring rehabilitation specialist physician prescription of physical therapy in Portugal, in contrast to other countries where any physician can request physical therapy directly). Third-party funding at other service levels (eg, outpatient, home-based care) typically follows the same prescription requirements (ie, rehabilitation specialist physician approval), which hampers direct physical therapy access and entrepreneurship (eg, physical therapists owning their practice), although direct access is legal in Portugal.
In Bangladesh, the few existing physical therapists are centrally located in hospitals in urban centers, with most patients residing or obtaining day services there. Hence, people from other locations have limited to no access to physical therapy. In those areas, even when Bangladeshis were to seek physical therapist services (eg, after an acute stroke), availability is rather limited in terms of provider distribution.46 Moreover, there is limited public funding for physical therapy, so ability to pay and access to nongovernmental charitable organizations further constrain access. As demand exceeds supply, the few patients receiving hospital-based physical therapy typically are discharged shortly after admission. This gap in supply and demand places pressures on Bangladesh physical therapists to deliver aggressive therapy. Training of families and community health workers in rehabilitation (eg, by coaching or electronic means) offers potential to efficiently extend access to physical therapy in Bangladesh.47,48
Physical Therapist Influx/Efflux
Physical therapist supply across our sample of countries was shaped by diverse influx/efflux factors.
New physical therapy graduates.
Table 2 shows the aggregated number of physical therapy graduates for each country between 1995 and 2014, per 10,000 people. During that period, Portugal stands out with the most physical therapy graduates, having 1.8, 5.3, and nearly 90 times more population-adjusted graduates than those of the United States, Singapore, and Bangladesh, respectively. Figure 2 depicts the growth pattern over the years.
In Portugal, a massive increase in new physical therapy graduates occurred from 2000 to 2008, with a slight decrease more recently due to a saturated market and the country's economic downturn. Of note, both the massive increase and more recent decrease mainly occurred in the private education sector.49,50
In the United States, the number of population-adjusted physical therapy graduates has had smaller fluctuations. The growth in physical therapy graduates between 1995 and 2014 (44.3%, from 5,820 to 8,401 graduates per year) was partially neutralized by the growth of the US population over the same period (19.9%, from 266 to 319 million people).
In Singapore, between 1995 and 1999, the number of population-adjusted physical therapy graduates was close to that of Portugal. Thereafter, Portugal had a massive increase in number of graduates per year, whereas Singapore had anemic growth until 2010. All told, over the time period 1995 to 2014, physical therapy graduates per year in Singapore increased from 15 to 85 (466.7% increase), but the population also grew that period from roughly from 3.5 to 5.5 million people (57% increase), partially neutralizing the gains in the Singaporean physical therapy workforce. Singapore's government plans to increase the influx of nationally trained physical therapists, along with upgrading their educational requirements (Tab. 4).
Amount of Physical Therapy Education and Licensing and Emigration/Immigration Requirementsa
In Bangladesh, although there are no publicly available data stratified by year, the aggregated number of physical therapy graduates available for the last 19 years is extremely low (Fig. 2). In Bangladesh, physical therapy education was restarted in 1994 after a long period of no local physical therapy training.46 Currently, only 3 universities are training physical therapists for the whole country.
Influx of new national physical therapy graduates per year, per 10,000 people. Single point for Bangladesh for the aggregated value (1995–2014). For Portugal, there were no data for 2014. For all countries, the influx was adjusted for the respective countries' population of each year. (source for the adjustment: World Bank. Data. Available at: http://data.worldbank.org/indicator/SP.POP.TOTL. Accessed November 15, 2015.)
Overall, unsurprisingly, the number of new physical therapy graduates is lower in countries with lower physical therapist supply.
Compensatory emigration/immigration.
Shortages and surpluses in the physical therapist supply can be partly compensated by means of emigration/immigration.
In Singapore, relative shortages of physical therapists and graduates are being partly compensated for by immigration, but at the apparent expense of neighboring Asian countries with much lower income,51,52 possibly aggravating inequalities across countries.52–54
In Bangladesh, locally trained physical therapists are more likely (if they have the opportunity) to leave the country than otherwise, which exacerbates the extremely low physical therapist supply in Bangladesh. To counter this vicious cycle, a few programs have been implemented to facilitate physical therapists from higher-income countries to work or provide services (eg, periods of clinical training and practice) in low-income countries such as Bangladesh.55–57
In the United States, the proportion of foreign physical therapists is 3 times higher than the proportion of foreign occupational therapists (12% versus 4%).29 Although financially attractive, immigration to the United States can be a hard process due to demanding visa and licensing requirements (Tab. 4). For example, in 2010, only 535 foreign physical therapists passed the national examination for the entire United States.9 Additionally, migration within the United States (eg, from highly supplied to underserved regions9) is hindered by varying licensing requirements across states.
In Portugal, the process of emigration/immigration to and from other European Union (EU) countries requires no work permits, and nationally accredited physical therapy degrees are valid across the EU, provided that national licensing procedures are completed (Tab. 4). Although no concrete data were found, emigration to high-income European countries is reputed to be higher than immigration in Portugal (eg, due to Portugal's increasing physical therapist supply from expansion of local educational programs, the country's limited financial capacity to employ all new physical therapists, and financial attractiveness of higher-income European countries).58
Physical therapists leaving practice, practicing part-time, or not practicing at all.
When planning for the right-size physical therapy workforce, one must account for the physical therapists who leave practice (eg, due to death or retirement). Both are more likely when median age increases. In the United States, the mean age of physical therapists in 2013 was 44 years, and physical therapists older than 55 years of age constituted almost 25% of all US physical therapists.59 Attrition rates in the United States are estimated to vary from 1.5% to 3.5%,10 but we found no public data on attrition for the other countries. However, we did find data showing that physical therapists in the other countries are comparatively younger than those in the United States.49,51,59 In Portugal, although public domain data on attrition were not found, the total number of physical therapists registered in Portugal is lower than the number of nationally trained physical therapists over the last 19 years. Explanations for this difference include attrition (eg, due to practice as a nonskilled worker or nonregistered professional given the relative paucity of physical therapy jobs in Portugal) and emigration.
In addition to efflux, one must account for physical therapists who practice part-time. Public domain data on this factor were found only for the United States. In the United States, 85% of physical therapists work full-time, and part-time physical therapists work a mean of 24 hours a week.10
Physical therapist supply in relation to other professions.
When analyzing physical therapist supply in relation to other professions within our 4-country sample (Tab. 2), the concept of “plasticity” seems to apply (ie, multiple configurations of health care providers able to meet the population's need for related health care services).60 For example, the lower physical therapist supply of the United States, relative to Portugal, may be compensated by nearly 2 times more occupational therapists in the United States than Portugal, with the net result (ie, physical therapists and occupational therapists combined) being higher for the United States than Portugal (10.1 versus 9.7, per 10,000 people).
In Singapore, both physical therapists and occupational therapists appear to be in short supply compared with Portugal and the United States or even with other types of health workers within the country. For example, in contrast to the physical therapist supply, the number of nurses per 10,000 people in Singapore is similar to Portugal (Tab. 2).
In Bangladesh, not only are physical therapists and occupational therapists in very short supply, but the supply of physicians and nurses is nearly 4 and 17 times lower, respectively, than the world average. Thus, extremely low supply in Bangladesh is not exclusive to rehabilitation professionals.37 In Bangladesh, the extremely low supply of members of each health profession, along with the nonexistence of practice regulation,46 makes transverse assimilation of related rehabilitation practices a very needed and common practice.
In addition to role plasticity across professions, it is important to consider the role of physical therapist assistants. We found varying use of physical therapist assistants across the 4 countries along, with substantive differences in their training and licensure. Use of physical therapist assistants appears to be most common in the United States, with less frequent use and more limited training in Singapore, and even less so in Portugal. Physical therapist assistants are almost nonexistent in Bangladesh, with community health care workers, or the families themselves, sometimes functioning in a similar role.
Scope of physical therapist practice relative to other professions.
Plasticity in the health care workforce may be reflected in the scopes of practices.21,60,61 In the eTable, we depict typical physical therapist practices and activities across the countries and whether they are typically done by other professions as well. Core physical therapist practices across the 4 countries consist of evaluation, training or delivery of interventions related to exercise, gait, soft tissue treatments, modalities, assistive devices, transfers, or activities of daily living. Among these, gait-related interventions seem the most exclusive to physical therapists, with cross-disciplinary provision of other rehabilitation activities being the most common pattern.
For example, training in transfers and activities of daily living can be provided by physical therapists, occupational therapists, and nurses across the countries. Modalities and soft tissue interventions also are typical physical therapist practices, but across the countries, other practitioners (eg, chiropractors, massage therapists, physical therapist assistants) may perform them as well. These patterns may reflect role extension or transverse assimilation of practices61 to meet the increasing needs for rehabilitation.
In Singapore, physical therapists are typically autonomous when defining their own treatment plans, and performance of advanced practices also is an emerging trend. The ability for physical therapists to engage in advanced practices in Singapore sometimes varies among practice locations (eg, according to hospital regulations and existence of clinical pathways).
In the United States, physical therapists are allowed to be autonomous in defining their own treatment plan. However, many third-party payers require physician approval of the physical therapy treatment plan. Within the United States, in particular, physical therapists increasingly are taking on advanced practice roles, with added training and certification to support the extended roles. Examples of such roles in the United States include trigger point injections (eg, dry needling), iontophoresis of medication (eg, steroids), and making decisions to treat patients versus referral to other appropriate health care providers.42,62,63 However, there is considerable variation in advanced physical therapist practice roles across the United States (eg, physical therapists in the military are allowed to order selected medications, laboratory tests, and imaging studies).64
By contrast, in Portugal, physical therapists seldom are totally autonomous in defining their own treatment plan. Although not legally required, hospital regulations may dictate that not only physical therapist orders but also their specific activities are subject to rehabilitation specialist physicians' prescription. These administrative requirements lead Portuguese physical therapists to mainly perform high-volume, but less skilled, tasks. We found limited information on advanced practice roles for physical therapists in Bangladesh.
Performance of advanced care roles may both spur higher education requirements (eg, a 3-year doctorate in physical therapy is required across the United States) and simultaneously drive demand. Unmet patient care needs (ie, due to aging of the population and rapidly rising rates of chronic conditions) may stimulate education of physical therapists with advanced skills, but the higher educational costs, in turn, may motivate physical therapists to take on new, perhaps more lucrative, roles and avoid high-volume, but less advanced and less lucrative, care roles—which then may be partially shifted to other credentialed professionals (eg, physical therapist assistants, exercise trainers, massage therapists) who have lower educational requirements and costs. However, depending on how it is done, such role transference may be inefficient or ineffective.65
Discussion
There appears to be neither a uniform right-size physical therapist workforce supply nor an ideal formula for its determination. As was evident throughout this article, each country's scenario and unique context pose substantial variability, requiring tailored solutions.
Our findings support the idea that it is highly reductionist to look at international benchmarks with eyes only on physical therapy workforce ratios (ie, physical therapists per capita). Substantial variation was found across all 4 countries—and sometimes within countries—on indicators of physical therapy need, health care system issues (eg, access barriers affecting physical therapist demand), physical therapist influx/efflux (eg, physical therapy education, emigration/immigration patterns), physical therapist supply, and scope of practice in relation to other professions. Determinations of the right-size physical therapy workforce must account for these varying scenarios.
Accordingly, it appears that there is no “one-size-fits-all” answer, even for different regions of the same country.28,66 For example, some underserved rural US regions use models of care similar to those of other countries that also have a low physical therapy workforce.47,48 Supply and clinical care boundaries seem relatively “plastic” across related professions, with skill sharing and cross-assimilation common approaches to supply limitations across all of the countries, but with distinct applications within each country. In addition, care roles also seem plastic over time. For example, in the US physical therapists are taking on advanced care roles, while simultaneously delegating less skilled roles to qualified professionals of lower credentials, such as physical therapist assistants. We found some indications that drivers of plasticity in roles may not be limited to simple supply and demand issues. Whatever the causes, location-specific role plasticity must be accounted for when studying and planning for the right physical therapist supply.
Finally, a global perspective on physical therapy workforce planning seems necessary to avoid the “brain drain” of physical therapists from low-income, undersupplied countries to higher-income countries, albeit also with higher physical therapist supply.52,66,67 This perspective may include international policies for physical therapy workforce development and distribution,54,67,68 fair international recruitment procedures,53,69 and international exchange among physical therapists or physical therapist students.54–56,68,70 For instance, an international exchange program might bring much-needed help to those places with highest unmet needs and provide invaluable lessons to visiting physical therapists (eg, gaining expertise in treating patients with conditions seen less frequently in higher-income countries or novel care or service models, developed by necessity, that may translate well to other sites). By the same token, visiting physical therapists from countries of lower income and supply might upgrade their knowledge and skills to apply back home and train others. Thus, international exchange programs, facilitated by international recognition of physical therapist qualifications, could have broad, bilateral benefits.
Limitations
Four distinct countries were selected a priori to reflect theoretical considerations affecting the right-size physical therapy workforce. However, our analyses do not reflect all globe regions (eg, Oceana, Africa, Middle East, Central America, South America), nor all national scenarios among the regions addressed (eg, EU countries of higher income than Portugal; Spanish-speaking North American countries). Important particularities would be of interest for the nonaddressed locations and scenarios (eg, Australia is using telehealth technologies to address needs for physical therapy in rural areas71). We hope that this perspective article stimulates further study in regions and national contexts that were not represented and ignites a more global discussion and debate on the matter of physical therapist supply.
For several reasons, we do not present quantitative data on physical therapy demand, even though some relevant information was available for 2 of the countries analyzed (United States,10,11 Portugal49). From a practical standpoint, comparable data were not available across all 4 countries, and the 2 countries for which data were available differed in how the demand was calculated. Most importantly, physical therapy demand likely is affected by the differing health care systems across the 4 countries. Conversely, comparable data on proxy physical therapy need indicators were readily available across the countries. Moreover, from a theoretical standpoint, need for physical therapy is antecedent to demand and the true factor to which physical therapist supply should correspond.17,22 Additionally, if we had used physical therapy demand data, we might wrongly assume that all physical therapy appointments were actually needed (eg, ignoring well-known phenomena such as overutilization or supply-driven demand),72–74 in turn, perpetuating system inefficiencies. Physical therapy demand data also might underestimate actual physical therapy need (eg, missing unmet needs because of people forgoing needed care due to access barriers).
Notwithstanding the limitations, our study offers important and novel insights on the role of country-specific contextual factors in determining the right-size physical therapy workforce, how those may differ across countries, and how individual countries are attempting to meet their unique needs for physical therapy.
Conclusion
The issue of how many physical therapists per capita are needed (ie, the right-size physical therapy workforce) requires rigorous examination if physical therapy care is to be available to those who need it, wherever they are. It is evident that the data infrastructure, within and across countries, needs improvement if it is to support data-based international comparisons14 and avoid the reliance on natural change or best guesses for the establishment of workforce policies.16 Moreover, it is clear that relevant data need to include information on diverse contextual factors that influence the optimal supply of physical therapists for an individual country. This article provides a conceptual structure and basis on which future local and international policy makers may evaluate and make informed decisions about the needed data and policies affecting the physical therapy workforce.
Footnotes
Dr Jesus, Dr Koh, Dr Landry, and Dr Hoenig provided concept/idea/project design. All authors provided writing, data collection, and consultation (including review of manuscript before submission). Dr Jesus, Ms Ong, Dr Landry, and Mr Lopes provided data analysis. Dr Jesus and Dr Hoenig provided project management and institutional liaisons.
- Received January 26, 2016.
- Accepted April 28, 2016.
- © 2016 American Physical Therapy Association
References
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