Accepted Manuscript

A theoretical framework for the interpretation of pharmacist workforce studies

throughout the world: The labor supply curve

Manuel J. Carvajal

PII: S1551-7411(17)30694-0
DOI: 10.1016/j.sapharm.2017.11.017
Reference: RSAP 986

To appear in: Research in Social & Administrative Pharmacy

Received Date: 29 August 2017

Revised Date: 6 November 2017
Accepted Date: 27 November 2017

Please cite this article as: Carvajal MJ, A theoretical framework for the interpretation of pharmacist
workforce studies throughout the world: The labor supply curve, Research in Social & Administrative
Pharmacy (2017), doi: 10.1016/j.sapharm.2017.11.017.

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A THEORETICAL FRAMEWORK FOR THE INTERPRETATION OF PHARMACIST

WORKFORCE STUDIES THROUGHOUT THE WORLD:

THE LABOR SUPPLY CURVE

Manuel J. Carvajala,*

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Nova Southeastern University, College of Pharmacy, Department of Sociobehavioral and

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Administrative Pharmacy, 3200 South University Drive, Fort Lauderdale, FL, USA,
33328-2018; Telephone: 954-262-1322; Fax: 954-262-2278; [email protected].

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*Corresponding Author.

Abstract:
Despite geographic, financial, and cultural diversity, publications dealing with the pharmacist

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workforce throughout the world share common concerns and focus on similar topics. Their
findings are presented in the literature in a seemingly unrelated way even though they are
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connected to one another as parts of a comprehensive theoretical structure. The purpose of this
paper is to develop a theoretical model that relates some of the most salient topics addressed in
the international literature on pharmacist workforce. The model is developed along two
fundamental ideas. The first identifies the shape and location of the pharmacist’s labor supply
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curve as the driving force behind all workforce decisions undertaken by pharmacists; the second
argues that gender and age differences are two of the most important factors determining the
shape and location of this supply curve. The paper then discusses movements along the curve
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attributed to changes in the wage rate, as well as displacements of the curve attributed to
disparities in personal characteristics, investments in human capital, job-related preferences,
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opinions and perceptions, and institutional rigidities. The focus is on the individual pharmacist,
not on groups of pharmacists or the profession as a whole. Works in multiple countries that
address each topic are identified. Understanding these considerations is critical as employers’
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failure to accommodate pharmacists’ preferences for work and leisure are associated with
negative consequences not only for them but also for the healthcare system as a whole. Possible
consequences include excessive job turnover, absenteeism, decreased institutional commitment,
and lower quality of work.
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Conflicts of interest: none.

Funding: This research did not receive any specific grant from funding agencies in the public,
commercial, or not-for-profit sectors.

Keywords: labor supply; pharmacist workforce; theoretical framework; worldwide literature

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November 6, 2017

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1
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3 A THEORETICAL FRAMEWORK FOR THE INTERPRETATION OF PHARMACIST

4 WORKFORCE STUDIES THROUGHOUT THE WORLD:

5 THE LABOR SUPPLY CURVE

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7

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9 Abstract

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11 Despite geographic, financial, and cultural diversity, publications dealing with the pharmacist
12 workforce throughout the world share common concerns and focus on similar topics. Their
13 findings are presented in the literature in a seemingly unrelated way even though they are

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14 connected to one another as parts of a comprehensive theoretical structure. The purpose of this
15 paper is to develop a theoretical model that relates some of the most salient topics addressed in the
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16 international literature on pharmacist workforce. The model is developed along two fundamental
17 ideas. The first identifies the shape and location of the pharmacist’s labor supply curve as the
18 driving force behind all workforce decisions undertaken by pharmacists; the second argues that
19 gender and age differences are two of the most important factors determining the shape and
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20 location of this supply curve. The paper then discusses movements along the curve attributed to
21 changes in the wage rate, as well as displacements of the curve attributed to disparities in personal
22 characteristics, investments in human capital, job-related preferences, opinions and perceptions,
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23 and institutional rigidities. The focus is on the individual pharmacist, not on groups of pharmacists
24 or the profession as a whole. Works in multiple countries that address each topic are identified.
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25 Understanding these considerations is critical as employers’ failure to accommodate pharmacists’

26 preferences for work and leisure are associated with negative consequences not only for them but
27 also for the healthcare system as a whole. Possible consequences include excessive job turnover,
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28 absenteeism, decreased institutional commitment, and lower quality of work.

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38 November 6, 2017
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39 INTRODUCTION

40 The last decade has witnessed a surge in the number of publications dealing with the

41 pharmacist workforce throughout the world. Many address conditions in individual countries–

42 Australia,1 Bangladesh,2 Eritrea,3 India,4 Indonesia,5 Iran,6 Japan,7 Jordan,8 Kuwait,9 Lithuania,10

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43 Malaysia11, Nigeria12, Pacific Island Countries,13 Pakistan14; Poland,15 Portugal,16 Saudi Arabia,17

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44 South Africa,18 Switzerland,19 Turkey,20 the United Arab Emirates,21 the United Kingdom,22 and

45 Yemen.23 Others dwell on multicountry comparisons.24-28 Their interests, methodologies, and

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46 arguments are as diverse as their countries of origin.

47 Despite geographic, financial, and cultural diversity, several common topics pervade the

48
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literature: gender disparities in response to socioeconomic stimuli29,30; differences in job-related
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49 perceptions, values, and attitudes exhibited by various generations of pharmacists31,32; ethnic

50 divides along national origin, racial, language, or religious identification that affect work
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51 outcomes33,34; and the prevalence of part-time employment as well as its impact on labor
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52 shortages, wages, and quality of service rendered,26,28,35 among others. Concern over the ongoing
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53 transition from dispensing and quality-control into patient-care roles is ubiquitous,36-38 and

54 references to role conflict experienced by practitioners5,8,39 abound. Inquiries into the

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55 manifestations, determinants, and implications of career success and job satisfaction, or lack

56 thereof,40-42 also appear prominently in the literature.

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57 Judging by the way they are presented, these publications seem to be unrelated to one
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58 another, that is, devoid of any contextual framework. Yet their topics are intertwined, like pieces

59 of a puzzle. The purpose of this paper is to develop and explain a theoretical structure that binds

60 some of the most common topics pertaining to a comprehensive study of the global pharmacist

61 workforce by undertaking a review of the international literature. The focus is on the pharmacist;

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62 not the profession, the services rendered, or even a group of pharmacists, but the individual as a

63 faceless abstraction independent of gender, age, location, type of work, or any other specific

64 attribute. In other words, the analysis centers on the variables that affect the decisions to work,

65 and how much to work, made by one individual practitioner as well as the mechanisms involved in

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66 making such decisions.

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67 FOUNDATION

68 This systematic inquiry into the intricacies of the pharmacist workforce begins with a

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69 fundamental question: why does a pharmacist work? Is it out of righteousness, following an

70 altruistic impulse? Is it out of fear, to avoid being incarcerated for failing to show up for work?

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While there may be some elements of truth in both of these motives, in most parts of the world
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72 pharmacists work primarily in response to a system of incentives and disincentives configured by

73 wages and salaries that allow them to purchase market goods and services. More precisely, the
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74 pharmacist works according to his/her valuation of market goods and services, leisure, and other
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75 pursuits in an attempt to optimize utility. What distinguishes pharmacists’ choices from one
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76 country, region, or culture to another, or even within a country, region, or culture, is the manner in

77 which market goods and services, leisure, and utility are interpreted.
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78 Assumptions

79 The development of this line of thinking is predicated on five basic assumptions, the first of
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80 which is that the pharmacist is able to work; that is, he/she is physically and mentally capable of
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81 delivering healthcare services, plus he/she possesses the necessary qualifications and licenses.

82 The second assumption is that the pharmacist gets paid for rendering his/her labor, most likely in

83 the form of a monetary wage or salary. The third assumption is that work, non-work

84 responsibilities, and leisure compete for the pharmacist’s time, which is finite (e.g., 168 hours per

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85 week); thus, additional time allocated to any of the three activities must occur at the expense of

86 either or both of the alternatives.

87 The fourth assumption is that the pharmacist has some discretion in allocating his/her time

88 among the three activities, and the allocation may change if his/her valuation of market goods and

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89 services, leisure, and other pursuits changes. Finally, the fifth assumption is that the pharmacist

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90 has some discretion in choosing the nature of his/her work; such discretion extends to decisions

91 regarding where to work (e.g., practice site, location), what kind of work will be performed (e.g.,

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92 primary role), and how many hours per week will be allocated to work.

93 Specific Questions

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The theoretical framework developed here proceeds along three specific paths: First, how
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95 does a pharmacist’s amount of work respond to socioeconomic stimuli? In other words, what are

96 the mechanisms that influence the choice of work versus leisure? Second, how much is the
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97 response mediated by gender and age diversity? While ethnic considerations also are influential,
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98 they are country- and culture-specific, not lending themselves to generalizations11,22,43,44; for
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99 example, the issues affecting Black and Hispanic minorities in the United States, and the context

100 within which they unfold, are different from the issues affecting the Wallonian vs. the Flemish in
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101 Belgium, the Malay vs. the Chinese in Malaysia, or the Spanish descendants vs. the Quechua and

102 the Aymara throughout South America, to mention a few locations across the continents where
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103 ethnic conflicts are common. The issues encompass racial differences, language barriers,
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104 religious intolerance, historical animosity and warfare, and many others that segregate, within

105 nations, groups competing with one another for political power and access to economic resources.

106 Hence, they are not being analyzed. Conversely, gender and age diversity are present in similar

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107 ways in virtually all labor markets. Third, what are some of the manifestations of both the

108 response and the mediator in dissimilar cultural settings?

109 Understanding these reflections is important. Failure by employers to accommodate

110 pharmacists’ preferences for work and leisure is likely to lead to excessive job turnover,

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111 absenteeism, decreased institutional commitment, and lower quality of work,45-48 which are costly

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112 not only for individual employers but also for the entire healthcare system.43,49 Moreover,

113 balancing the personal/family- and work-related aspects of practitioners’ lives has been

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114 recognized as a challenge by employers and employees alike not only in pharmacy, but also in

115 other healthcare professions.50,51 Part-time employment, work options (i.e., non-standard work

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and flexible hours), specialized leave policies (i.e., parental leave and career break schemes), and
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117 dependent care benefits are initiatives being implemented worldwide to assist practitioners in

118 reducing conflict between the work and non-work facets of their lives.52
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119 THEORETICAL FRAMEWORK

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120 Every pharmacist exhibits a labor supply curve. This is a schedule showing the number of
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121 hours a practitioner is both willing and able to work at various wage rates. Movements up and

122 down the same curve occur in response to wage-rate changes. Displacements of the curve to the
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123 right or left occur because of changes in factors other than the wage rate.

124 Movements along a Labor Supply Curve

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125 Two mechanisms account for movements up and down a pharmacist’s labor supply curve.
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126 The first mechanism is the substitution effect. As the wage rate goes up, the opportunity cost of

127 leisure increases. With more wages the pharmacist is able to purchase a greater amount of, and/or

128 better, market goods and services. He/she responds by substituting out of leisure into labor time

129 to take advantage of the inducement, work more hours, and consume more and/or better market

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130 goods and services. The substitution effect accounts for an upward slope in the labor supply

131 curve (see Figure 1).

132 However, rising wages cannot lead indefinitely to additional hours of work; eventually the

133 pharmacist would run out of leisure time. As leisure becomes increasingly scarce, the

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134 opportunity cost of work, and of the market goods and services that may be purchased with the

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135 additional income, rises.53 While the pharmacist is able to buy more and/or better goods and

136 services, he/she needs time to consume them. Because of the higher wage rate, he/she is now able

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137 to adjust his/her work-leisure balance; he/she can afford to consume more and/or better goods and

138 services and, simultaneously, have more leisure by reducing the amount of time spent working.

139
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This mechanism, called the income effect, accounts for a backward bend in the labor supply curve
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140 (see Figure 2).

141 A review of the literature reveals that throughout the world, male pharmacists are more
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142 responsive than female pharmacists to changes in wage rates.43 Compared to men, women
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143 generally hold values and interests more compatible with work-family balance, whereas men have
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144 a propensity to engage in jobs that offer opportunities to work overtime and lead to managerial

145 positions.54 Insofar as women are more willing than men to trade off income for other
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146 characteristics that they value more at work,55 the male pharmacist’s typical labor supply curve

147 tends to be flatter than the female pharmacist’s typical labor supply curve.56
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148 The worldwide pharmacist workforce literature also reveals that younger pharmacists are
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149 more responsive than their older counterparts to wage-rate changes.12 As pharmacists approach

150 retirement, their labor supply behavior seems to be conditioned more by institutional factors than

151 by pay.57 Thus, the younger pharmacist’s typical labor supply curve tends to be flatter than the

152 older pharmacist’s typical labor supply curve.

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153 Displacement of a Labor Supply Curve

154 The supply of labor increases when a pharmacist’s supply curve moves to the right. This

155 means that at a given wage rate, he/she is both willing and able to work more hours. Conversely,

156 the supply of labor declines when a pharmacist’s labor supply curve moves to the left. When this

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157 happens, he/she is both willing and able to work fewer hours at a given wage rate. Such

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158 displacements explain why two or more pharmacists, or the same pharmacist at different times,

159 may exhibit different amounts of hours worked at the same wage rate.

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160 Displacements of a labor supply curve occur primarily because of non-monetary reasons

161 that may be grouped into five categories: personal characteristics, investments in human capital,

162
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job-related preferences, opinions and perceptions, and institutional rigidities. The mechanisms
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163 imbedded within each of these categories are heavily mediated by both gender and age. Several

164 studies worldwide show that male pharmacists work longer hours than female pharmacists.26,58,59
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165 Furthermore, the prevalence of part-time work in pharmacy is consistently greater among women
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166 than among men.28,30,35,60 Therefore, the male pharmacist’s typical labor supply curve is not only
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167 flatter than, but also lies to the right of, the female pharmacist’s typical labor supply curve (see

168 Figure 3). Similarly, other things equal, younger pharmacists generally work more hours than
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169 older pharmacists,20,61 especially men. Older male pharmacists also tend to work part time more

170 often than younger male pharmacists.26 Consequently, the younger pharmacist’s typical labor
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171 supply curve is not only flatter than, but also lies to the right of, the older pharmacist’s typical labor
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172 supply curve (see Figure 4). The reasons for these gender and age differentials are explained

173 below.

174 Personal characteristics. The amount of time pharmacists are both willing and able to

175 work is partly determined by individual attributes. For example, a practitioner exhibiting greater

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176 levels of energy and/or professional commitment probably works longer hours than another

177 exhibiting lower levels. While some of these characteristics are subjective and difficult to

178 measure, others lend themselves to gender and age-group generalizations. One of these is the

179 pharmacist’s scope of non-work responsibilities. Women pharmacists around the world often

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180 work fewer hours in the labor market than their men peers because they are expected to do

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181 relatively more work at home.35 Traditionally men and women fulfill different roles; men tend to

182 assume the role of breadwinners and women tend to assume the role of homemakers.62 They are

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183 likely to choose heterogeneous levels of commitment in the careers and home spheres of their lives

184 influenced by socially defined, differentiated involvement with work and non-work

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responsibilities encompassing not only general household upkeep, but also looking after children
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186 and caretaking of older and sick family members.63 In most countries female pharmacists often

187 must make choices between having a family and pursuing a professional career that male
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188 pharmacists are not forced to make.64

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189 Another personal characteristic determining differences in pharmacists’ labor input is the
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190 level of aggregate household income. Access to sources other than one’s own wages and salaries,

191 such as spouse’s or parent’s earnings or wealth, exerts an income effect on labor supply that
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192 reduces the number of hours worked.53,65,66 This is especially the case in countries with relatively

193 high tax rates and/or progressive income tax systems, whereby higher income earners pay
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194 proportionately greater taxes. As a general rule, female pharmacists’ wages and salaries are
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195 viewed as a secondary source of earnings, largely due to the fact that women rely on their

196 husband’s income more commonly than men rely on their wife’s income.67,68 Similarly, some

197 younger pharmacists might depend on their parents’ economic support to compensate for forgone

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198 earnings out of fewer hours of work, or older pharmacists might work part time only to supplement

199 their pensions.69

200 A third instance that manifests the relatively greater burden of female pharmacists in

201 managing work-home conflict can be found in the distribution of costs and benefits of family

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202 migration due to gender asymmetries. Wives are less likely than are husbands to initiate

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203 job-related relocation moves or search for new opportunities because wives’ gains from migration

204 usually are exceeded by their husbands’ losses.66 They also are less likely to resist moves

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205 initiated by their husbands because, as secondary income earners, their income loss resulting from

206 family migration is exceeded by their husbands’ expected earnings gains. In fact, two of the

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reasons why pharmacy is appealing to women are the widespread demand for their professional
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208 services and the fact that remuneration is fairly linear; there is virtually no penalty for working

209 fewer hours.70 Thus, when compared to their men counterparts, the job longevity of female
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210 pharmacists tends to be substantially less.

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211 Still another personal characteristic affecting differences in the position and/or shape of
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212 pharmacists’ labor supply curves is the extent of financial commitments dictated by their stage in

213 the life cycle. Practitioners optimize their utility by smoothing out savings patterns over their
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214 lifetime, consuming as a function of their life-cycle income rather than current income.71

215 Consequently, younger pharmacists are likely to experience a greater average propensity to
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216 consume out of wages and salaries than their older peers because they need to pay off
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217 education-related loans and they are in the process of family formation and estate building; they

218 work more hours to earn higher income levels. Some of these considerations interact strongly

219 with gender. Specifically, younger female pharmacists tend to work fewer hours than younger

220 male pharmacists in order to devote more time to their children,72 while at the other end of the age

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221 continuum, older male pharmacists who engage in a phased retirement process tend to work fewer

222 hours than their older female counterparts.26,69

223 Investments in human capital. The concept of human capital centers around the process of

224 people investing in themselves to become more productive and competitive, get more appealing

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225 jobs, and earn higher wages and salaries. Human capital is the stock of knowledge, information,

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226 skills, and abilities that individuals acquire and exchange in the labor market for returns such as

227 more income, less unemployment, and better working conditions. More training and experience

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228 expand one’s flexibility and adaptability to new situations, which raise one’s marginal

229 productivity. Employers value employees with the right type and amount of human capital, and

230
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usually are willing to pay for it.73 Beyond acquiring the knowledge and skills that go along with
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231 their professional degrees, pharmacists may invest in themselves by concentrating the scope of

232 their practice (i.e., pursuing a specialty or earning another academic degree), learning from
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233 experience working as practitioners, and mastering the complexities of a specific job.
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234 Acquiring a specialty or pursuing an additional academic degree are ways of

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235 demonstrating that a person possesses expertise beyond what is expected from a general

236 practitioner. This prospect is enhanced by the so called reprofessionalization of pharmacy, an

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237 ongoing worldwide transformation in pharmacists’ roles away from the traditional drug

238 dispensing, procurement, manufacturing, and inventory control functions into a comprehensive
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239 focus on patients’ therapeutic needs that calls for inter-professional collaboration and clinical
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240 decision making on medication use.7-9,11,16,19,24,37,38,49,74,75 Insofar as they represent a sign of

241 commitment to the profession, holding a specialty and/or additional degrees and certificates tend

242 to displace pharmacists’ labor supply curve to the right.56

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243 Pharmacists also invest in themselves when they practice and learn from experience,

244 whether it applies to lifetime professional experience or a specific job situation. Pharmacists with

245 more practice experience often are more motivated to work, exhibit more positive attitudes toward

246 providing pharmaceutical care, report fewer medication errors, and derive more satisfaction from

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247 their jobs than those with less experience9,31,76,77; thus, compared to practitioners with less

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248 experience, they are prone to work longer hours (i.e., their supply curve lies further to the right).

249 Continuous, full-time participation in the pharmacist workforce is heavily mediated by

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250 gender. Women experience more interruptions in their careers than men, which affects

251 negatively their acquisition of additional training, work experience, and other human capital

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assets. These disparities often are reflected on lower earnings and wage rates, fewer advancement
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253 opportunities, and less accessibility to management positions,78 and ultimately lead to different

254 standards of career success by men and women.79

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255 While marriage, children, and caregiving are the three main reasons why female
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256 pharmacists interrupt and/or lessen the intensity of their careers, there are other intervening
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257 factors. In industrialized countries workforce participation by men is relatively more

258 procyclical65; that is, participation increases during periods of economic expansion, when more
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259 people join the workforce because jobs are easier to find, and falls during periods of economic

260 downturn as individuals drop out in response to fewer opportunities available. This mechanism is
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261 consistent with the so called added-worker effect, whereby female pharmacists enter the
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262 workforce, or work more hours, to offset their spouses’ job losses. As more men become

263 unemployed or are forced to work fewer hours during a downturn of the business cycle, women

264 move in to compensate for the loss of household income. The fact that female labor force

265 participation is almost three times more volatile than the participation of men reinforces the

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266 commonly held platitude that women are primarily homemakers and secondarily income

267 earners80; while volatility is more likely to apply to bank tellers, waitresses, secretaries, and other

268 lower-income occupations than to female physicians, engineers, and pharmacists, there is evidence

269 of a gender volatility differential for pharmacists.81 Moreover, two key questions arise here: one

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270 is the extent to which Third-World countries will experience this phenomenon as their growing

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271 economies are increasingly affected by internally generated cyclical fluctuations; the other is

272 whether or not the added-worker effect will apply to the United States and other nations in a

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273 longer-term analysis as an ongoing proliferation of pharmacy schools pushes the growth in labor

274 supply to outpace the growth of employment opportunities, thus leading to a tightening pharmacist

275 workforce market.

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276 Job-related preferences. Instead of measuring who the pharmacist is by virtue of

277 ascertaining the extent of his/her human-capital investments, job-related characteristics focus on
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278 what the pharmacist does. The preferences revealed by job-related characteristics are proxies for
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279 compensating differentials, that is, important work conditions for which the pharmacist may be
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280 willing to trade off earnings.70 Men and women assign different values to identical job

281 characteristics55,82; women are less prone than men to identify wages and salaries as the most
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282 important aspect of their job, but place a greater emphasis on social relations at work and the

283 significance of tasks performed. Similarly, not all age groups choose to devote the same amount
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284 of time to pursuing non-work activities.83 Thus, the compensating patterns and their effect on the
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285 labor supply curve are likely to vary by pharmacists’ gender and age group. The characteristics

286 reviewed here encompass type of practice setting, primary role as a practitioner, location of

287 practice site, and distance/time traveled between home and place of work.

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288 Choosing a practice setting results out of various combinations of factors including, among

289 others, job opportunities, intrinsic appeal, and earnings and benefits competing with one another

290 for a favorable or unfavorable determination by the pharmacist. For example, jobs in institutional

291 settings offer opportunities for practitioners to exercise their clinical skills, which are generally

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292 palatable to pharmacists,74 but working in a large-chain pharmacy offers better salary rewards,84,85

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293 and throughout the world large-chain pharmacists report being less satisfied with their jobs than

294 hospital and independent community pharmacists.22,74,86,87 Role ambiguity and role conflict seem

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295 to account for a substantial portion of the inequality, as large-scale pharmacy oparations are widely

296 perceived to be primarily business oriented rather than focused on healthcare services and patient

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welfare.58,88 Little time allowed to interact with patients is viewed as an obstacle to delivering a
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298 quality output.5,8,14,17,89 If the compensating differential is insufficient, dissatisfaction with one’s

299 ongoing professional activities may induce a search for a new job and/or a leftward shift of the
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300 labor supply curve.

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301 The functions performed by a pharmacist also influence the shape and location of his/her
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302 labor supply curve. According to both the American Pharmacist Association90 and the American

303 Society of Health-System Pharmacists,91 practitioners’ primary role is to help individuals make the
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304 best use of medications. Pharmacists address medication use in different venues, and in doing so

305 take on roles that include, among others, drug dispensing, patient care management, administrative
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306 activities, educating the public, providing drug information services, and conducting research.
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307 Practitioners in each of these roles may have a labor supply curve different from the labor supply

308 curves of practitioners in other roles. There is evidence that, other things equal, working

309 primarily in a medication dispensing capacity tends to shift the labor supply curves of both

310 full-time and part-time pharmacists to the left92; the same result was obtained in another study for

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311 male and female pharmacists.56 Conversely, working in an administrative capacity tends to shift

312 the labor supply curve of pharmacists of different age groups to the right.57

313 Another factor influencing the pharmacist’s labor supply curve is the location of his/her

314 practice. Rural households usually earn lower income levels than urban households, and also

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315 experience less access to health care.93 Consequently, the availability of pharmacists in rural and

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316 remote areas is much lower than in cities and small towns,94,95 which causes problems such as

317 non-existent or incorrect medication lists, expired and inappropriate medications, drug

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318 interactions, adverse drug events, and adherence deficiencies.37 The smaller demand for rural

319 than urban practitioners exerts a negative impact on their earnings.84,96

320
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Compared to their urban counterparts, rural pharmacists usually have a broader scope of
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321 practice and work more hours (i.e., a rightward shift in their labor supply curve); they also have

322 access to fewer resources and experience greater isolation. Oftentimes they are the only
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323 healthcare provider in the area, which translates into demanding, unreasonable schedules and
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324 greater difficulties in balancing the personal and professional aspects of their lives.97 Rural
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325 pharmacists are predominantly male and older.98

326 A variant of practice site location for purposes of configuring a pharmacist’s labor supply
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327 curve is the distance and/or time traveled from home to work or any other job-related destination

328 such as a childcare facility. Insofar as distance constitutes a real cost in terms of time and other
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329 expenditures that condition workforce participation, proximity to work contributes positively to
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330 job longevity,43 but practitioners who travel longer distances tend to work more hours to

331 compensate for higher travel costs. Furthermore, distance to work and commuting time may have

332 unequal effects on pharmacists of different genders and age groups. For example, if household

333 and childrearing responsibilities forced younger women to forgo otherwise better jobs for the sake

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334 of working more closely to home, differences in commuting time, workforce attachment and hours

335 of work, and salary across genders and age groups would be logical market adjustments. In

336 general, women are more likely than men to work near home99,100; similarly, older practitioners

337 may prefer to travel shorter distances to their workplace because of health or other reasons.

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338 Opinions and perceptions. Job-related perceptions, attitudes, and opinions lead to, and are

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339 derived from, disparities in labor market outcomes. They reflect how much pharmacists like their

340 jobs as well as specific aspects of their professional activities, and are conditioned by the intrinsic

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341 and extrinsic rewards that different individuals, and different groups of individuals, experience in

342 their work environment. In contrast with persons oriented toward extrinsic rewards such as

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earnings and benefits, advancement opportunities, and prestige, persons with an intrinsic
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344 orientation value primarily the satisfaction derived from doing their work, personal development,

345 and interaction with patients and coworkers. Intrinsically satisfying jobs are characterized by the
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346 absence of excessive supervision, autonomy for workers regarding how to conduct their tasks and
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347 evaluate their own performance, and other forms of “psychic income” that yield higher retention
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348 rates and shift the labor supply curve to the right.101

349 Perceptions, attitudes, and opinions develop in response to values, social cues, and work
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350 experiences that may affect workers of different genders and age groups differently, or are

351 interpreted differently. Whether or not perceptions conform to reality, they ultimately configure
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352 beliefs, shape attitudes, and induce behavior, including the amount of time pharmacists are willing
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353 and able to work at various potential wage rates. Thus, understanding systematic gender and age

354 patterns of perceptions, attitudes, and opinions is important.

355 When pharmacists assess employment opportunities, they review jobs with multiple

356 characteristics such as earnings and fringe benefits, location, working conditions, etc. These

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357 characteristics appear in fixed bundles, and candidates seldom are able to choose all characteristics

358 precious to them and/or eschew all characteristics perceived as negative. For example, jobs that

359 pay well may offer unattractive benefit packages or a promotion may entail moving to an

360 undesirable location. A central metric is needed to compare the entire spectrum of characteristics

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361 and weigh the relative advantages and disadvantages of alternative jobs. Measuring job

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362 satisfaction is an attempt to provide such a metric.

363 Job satisfaction has received worldwide recognition as a proxy for professional

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364 utility.4,8,11,102 A positive or negative emotional state resulting from workers’ self-appraisal of

365 their jobs under unspecified conditions,86,103 it is a comprehensive, multidimensional abstraction

366
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that allows social and administrative pharmacists to approximate the fundamental concept of
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367 aggregate well-being generated from experiences in a position and/or work setting. Practitioners

368 are asked to assess subjectively their job conditions, often by means of comparison groups. Their
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369 responses are influenced by a mixture of intrinsic and extrinsic forces, as defined above, and it is
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370 up to the practitioner to decide the relative importance of each aspect of his/her employment. The
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371 happier workers are with a job, the more satisfied they are said to be.2

372 Job satisfaction indices may be measured in two ways. The first, called a facet item,
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373 focuses on specific features of the job; the second way, called a facet free item, focuses on an

374 aggregate satisfaction scale without reference to particular aspects.3 Regardless of the
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375 measurement technique, job satisfaction plays a crucial role in shaping labor market outcomes. It
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376 has been linked in various countries to professional motivation, job performance, intention to quit,

377 and patient safety.20,26,41,42,47,49,86,104 It also has been linked to gender and age: female pharmacists

378 often report greater levels of job satisfaction than male pharmacists74,88,105-107 and older

379 pharmacists are happier with their work than younger pharmacists.4,9,22,40,74-76,102,104

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380 Other things equal, one would expect that practitioners reporting higher levels of job

381 satisfaction are inclined to work more hours at various wage rates; they generally see their

382 organization in a more positive manner and tend to be more committed to their employers than

383 workers experiencing lower levels of satisfaction with their job.108 In other words, their labor

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384 supply curve would lie to the right of the curve of less satisfied practitioners. Yet, as indicated

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385 earlier, the empirical evidence worldwide points in the opposite direction: female and older

386 pharmacists’ labor supply curves lie to the left of male and younger pharmacists, respectively.

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387 The gender incongruity is known in the literature as the paradox of the contented female

388 worker109-111 and is addressed in terms of women having lower market expectations, feeling less

389
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social pressure at work, and internalizing their feelings of professional disillusionment to a greater
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390 extent than do men. The age incongruity is explained in terms of workers reducing their

391 aspirations, and hence their satisfaction gap, as they grow older and realize that they face limited
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392 choices in the workplace20,58,112 or older workers enjoying privileges such as authority, autonomy,
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393 and occupational prestige not commonly found with younger workers.31
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394 Numerous perceptions configure a pharmacist’s opinion of his/her job satisfaction; some

395 contribute positively, others detract from it. An excessive workload is one of the main causes of
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396 dissatisfaction4,8,11,39,49,59,104; it leads to medication dispensing errors and reduces opportunities to

397 interact with patients,85 and has been linked to repetitive strain injury problems.113 Stress, often a
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398 by-product of excessive workload, also contributes to dissatisfaction8,43,58,104,114 and ultimately

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399 may lead to burnout6,20,39; it tends to occur when pharmacists experience adverse conditions over

400 which they have no control such as unreasonable demands from employers, role ambiguity and/or

401 conflict, inadequate staff support, and inconsistencies in the enforcement of job policies.5,88,115,116

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402 Pharmacists’ perception of available advancement opportunities tends to increase their job

403 satisfaction and consequently shift their labor supply curve to the right.2,8,11,12 The perception of

404 job security also increases pharmacists’ job satisfaction,4,86,88 as do perceptions of autonomy,31,40

405 fairness in the workplace,2,34 interacting with patients and contributing to their well-being,47,104,117

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406 support from supervisors,11,41,79,118,119 a pleasant job atmosphere,31 flexible work

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407 schedules,22,26,43,79 and good relations with coworkers.2,26,102,114

408 Institutional rigidities. These are norms and regulations that prevent or restrict

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409 pharmacists from performing a given job or task within a job. They affect the labor supply curve

410 by constraining the number of hours worked at various wage rates. The rigidities may be job

411
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oriented, apply to a segment of the market (e.g., type of practice, location, etc.), or may be dictated
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412 by law, and often target specific populations defined or mediated by gender and/or age group.

413 Some jobs are available only on a full-time basis or may be fraught with normally
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414 undesirable work schedules (e.g., nights, weekends, double shifts, etc.) that appeal to a limited
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415 number of practitioners. Many female pharmacists with young children and/or caretaking
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416 responsibilities, older pharmacists seeking to work part time to supplement their pensions and

417 remain active, and pharmacists interested only in jobs with standard work schedules would not
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418 consider such opportunities, which would reduce the supply of potential applicants. Other jobs

419 may require some sort of specialization (i.e., human-capital investment) not commonly held by
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420 practitioners such as oncology or infectious diseases, thus limiting the pool of qualified applicants
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421 and shifting the supply curve to the left, while still other jobs may require minimum amounts of

422 experience or entail boring and/or repetitive tasks, dangerous practices, and other conditions that

423 tend to dissuade most workers from applying.

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424 Sometimes institutional rigidities affect the entire labor market of an administrative unit or

425 a segment of it. For example, since 2005 the Ministry of Health and the Pharmacy Board of

426 Malaysia have required from newly pharmacy graduates a four-year mandatory government

427 service to ensure adequate staffing in the public sector; during the four-year period, newly

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428 graduates may work only in a location designated by the government,11,34 which affects the

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429 configuration of both the private-sector and the public-sector labor supply curves and prevents

430 market adjustments based on salaries, work conditions, etc. Similar requirements in other

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431 countries for post-graduation government service in underserved, rural or remote communities are

432 not uncommon. In the United Arab Emirates (U.A.E.) most registered pharmacists are

433
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expatriates (non-citizens) from other Arab countries and South and Southeast Asia.21 Insofar as
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434 their stay in the U.A.E. is governed by the stipulations in their contracts, their bargaining capability

435 is virtually non-existent; for all practical purposes their labor supply curve is fixed. And in
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436 Yemen there is no policy requiring dispensers to be qualified or licensed as pharmacists; fewer
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437 than 10 percent of pharmacists working in pharmacies are graduates of government-recognized

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438 schools because most Yemeni pharmacists have migrated to Saudi Arabia and the U.A.E. in search

439 of better pay.23

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440 Laws can introduce rigidities in the labor market, too. In Spain and Iran chain pharmacies

441 are not allowed; only licensed pharmacists may establish and own a pharmacy.86 In Saudi Arabia
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442 only male pharmacists may work at community pharmacies,17 and in several countries
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443 practitioners are burdened with mandatory retirement ages.26 All these restrictions push the

444 pharmacist labor supply curve to the left.

445 SUMMARY AND CONCLUSION

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446 Despite obvious cultural and economic diversity, pharmacist workforce analysts

447 throughout the world share common concerns and focus their research on similar topics. Their

448 findings are presented in the literature in a seemingly unrelated way, when in fact they are

449 connected to one another as parts of a comprehensive theoretical structure that coalesces them.

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450 This paper adds significantly to understanding the nature, mechanics, and interactions of the topics

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451 by relating them to one another within a conceptual model and identifying works in multiple

452 countries that address each topic.

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453 The conceptual model is developed along two fundamental ideas. The first idea is the

454 identification of both the shape and location of the pharmacist’s labor supply curve as the vortex

455
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driving virtually all workforce decisions undertaken by pharmacists. Movements along the same
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456 curve are distinguished from displacements of the curve, the latter being attributed to disparities in

457 personal characteristics, investments in human capital, job-related preferences, opinions and
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458 perceptions, and institutional rigidities. The second fundamental idea of the conceptual model
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459 contends that gender and age differences are two of the most, if not the most, important
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460 determinants of the shape and location of the pharmacist’s labor supply curve.

461 Some analysts may consider the views presented here oversimplistic and argue that
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462 individual workforce decisions are influenced by a much broader array of variables. Yet

463 throughout the paper multiple authors across continents are referenced as examining recurrent
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464 topics both affecting and affected by the labor supply curve and mediated by gender and age. In
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465 any event, the focus and development of this paper may provide a meaningful contribution toward

466 ascertaining the forces shaping practitioners’ perceptions of their own general roles as well as

467 specific job conditions. They also may be instrumental in making future publications dealing

468 with the pharmacist workforce more coherent and helping individual countries with their

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469 workforce condition assessments. As current trends in the self-identity and composition of the

470 pharmacy profession continue and even accelerate in the foreseeable future, proper identification

471 of inter-gender and inter-age disparities in opinions and behavior is likely to gain relevance in the

472 process of matching successfully job opportunities and availability with skills and preferences in

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473 search of a more rational and efficient allocation of resources in the pharmacist labor market.

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474 Figure 1. Illustration of pharmacists’ typical labor supply curve showing the substitution effect.
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475 Figure 2. Illustration of pharmacists’ typical labor supply curve showing both the substitution
476 effect and the income effect.
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477 Figure 3. Illustration of typical labor supply curves for male and female pharmacists.
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479
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484 Figure 4. Illustration of typical labor supply curves for younger and older pharmacists.
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486
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• Despite cultural, financial, and economic diversity, the pharmacist workforce literature
throughout the world shares common themes.
• A theoretical model that ties the most common themes is warranted.
• Gender and age differences are two of the most important determinants of the shape and
location of the pharmacist’s labor supply curve.
• Throughout the world, male pharmacists are more responsive than female pharmacists to

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changes in wage rates.
• Younger pharmacists are more responsive than their older counterparts to wage-rate changes.
• Displacements of the labor supply curve occur due to non-monetary reasons including personal

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characteristics, investments in human capital, job-related preferences, opinions and
perceptions, and institutional rigidities.

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