Traditionally, since the seminal contribution of Gary S. Becker (1964),1 the period of time dedicated to training is considered an investment, but in this case in human capital. In a classic sense, human capital corresponds to any stock of knowledge or other characteristics of the workers that contributes to their productivity.2 Even with this point of view, human capital is not only referred to as the school quality, it also includes personal attitudes towards work, and their capacity to adapt to different conditions.

For candidates it can be expected that increasing their training is one of the motivations for the people who apply for a masters programme in health economics (MPHE). It is a clear competitive advantage, for the people, the firms, and even the countries that increase their GDP.3 It has been proposed that human capital has a higher social return than investment in physical capital.4

Masters programme are a way to introduce a differentiation between candidates,5,6 and consequently people opt to do a MPHE in order to get into the job market. Ruiz-Adame7,8 in this sense found recently positive results in a similar study, but with graduates of masters programme in gerontology.

The paper authors contacted the directors of the most renowned MPHE to request assistance in this research. Participants were mailed a letter explaining the purpose of the study by each university. The participants were anonymous and the researchers were completely blind to the personal data of participants, who voluntarily submitted an online survey comprised of 30 items designed specifically for the purpose. The master programmes and rate of answers can be seen on Table 1. The sample consisted of 439 graduates of MPHE.

The items of the survey were organised in four big blocks: a) demographic questions; b) previous educational situation, working situation, and motivation for doing the MPHE; c) evaluation of the consequences of doing the MPHE in the labour market (only for those who found a job in health economics after the MPHE); and d) evaluation of the MPHE. We also included a last item in which participants could give an opinion or make an open comment.

The graduates were from all over Spain and the years of finishing ranged from 1986 to 2016. The average year of finishing the MPHE was 2009 (standard deviation [SD]: 6.8). The general profile of the sample is that of a woman (55.5%) who was 37.8 (SD: 8.7) years old when she did the MPHE and currently is 44.5 (SD: 8.6) years old. Graduates came, on the whole, from health degrees (74.7%). The two most common educational backgrounds were in Medicine (37.0%) and in Pharmacy (19.2%). From the social sciences the most frequent previous training was in Economics (14.8%). Only 35.6% responded that they had ever had any kind of previous training in health economics.

The principal motivation (44.1%) for doing the MPHE was to acquire new knowledge or to enhance previous knowledge (17.8%). Only 20.1% demonstrated that they did the MPHE for employment reasons: 12.8% to improve their employment opportunities and 7.3% to get promoted from their current position. Most of the sample (87.0%) were employed when they applied for the MPHE. The proportion increased (94.7%) when we asked for their current situation.

When we only analyse the profile of the people who have found a job in health economics after the masters (n=91, 20.7% of the sample) the profile is very similar to the general profile: a woman (57.1%), but slightly younger, of 34.3 (SD: 7.9) years old when she did the MPHE, and is currently 43.6 (SD: 10.3) years old. The average year of finishing the MPHE is 2007 (SD: 7.6). The graduates also mainly came from health specialities (74.7%). The two most common educational backgrounds were Medicine (35.2%) and Pharmacy (16.5%). From the social sciences the most frequent previous training was in Economics (15.4%). The prime motivation for doing the MPHE was also mainly academic (Table 2), by an even higher proportion (56.1%); 38.5% answered that they did it to acquire new knowledge or to enhance previous knowledge (17.6%).

As seen on Table 3, the people who found a job did it mainly in the first (54.9%) or in the second (29.7%) year after finishing the MPHE. The employment was for long-term and stable positions. The most common type of contract was permanent employment (37.4%) and for more than 12 months (23.1%). The wages were most frequently between 1,500 € and 2,000 € (27.5%), but the second most frequent wages were higher than these figures, in this case they were between 2,000 € and 2,500 € (25.3%). The reason the people found a job in health economics after the MPHE was attributed, in a very high proportion (71.4%) to their personal training and their curriculum vitae. Only a low proportion attributed the fact that they had found a job to personal contacts (9.9%) or to contact with fellows (9.9%).

The evaluation of the MPHE was high as can be seen on Table 4. The area of knowledge that was considered as the most useful was health management (46.3%), followed by methodology of research (13.0%) and data analysis (12.6%). Either way, the MPHE seems to have a social aspect that remains after the end of the training; 55.3% of the graduates say that they maintain professional contacts and 62.3% also have social contacts with their classmate.

Concerning the utility of doing these training programmes and the potential repercussion on the labour market, we analysed the relationship between doing the MPHE and finding a job after it. Contingency tables were performed. Correlations were found using the chi-square test. We use confidence levels of 1% and 5%. Although the two main handicaps to getting a job in health economics are: Being a woman (p=0.002, significant at 5%), and doing the MPHE after 2008 (p=0.000, significant at 1%). Education in a health degree still facilitated access to the job market in health economics (p=0.043, significant at 5%).

There is a significant relationship (p=0.000, significant at 1%) between those who gave a positive answer to the question as to whether previous to the MPHE they considered that doing it would help them in getting a job after graduation and obtaining one.

The main motivation, as previously stated was academic, and there is a positive correlation between this variable and getting a job (p=0.008, significant at 5%). But we did not find any significant association between getting a job and the time needed to get one, or the type of contract, or the revenue obtained for that job.

We studied the effect of the economic crisis of 2008 on the financing of education. The two main relevant factors seem to be doing MPHE previous or after the economic crisis of 2008 and the type of education (in the health field or the social field). We analysed the effect using a binomial hierarchical logistic model to predict if the dependent variable, the financing of training (totally or partially public vs private), could be forecast by these two variables.

The block 0 (empty model) shows that there is 50.2% probability of matching the results of the dependent variable, if we assume that every person finances the MPHE privately. For block one, the statistical efficiency test of ROA shows that there is a significant improvement (p<0.050) with the prediction of the probability of occurrence of the categories of the dependent variable for the variable crisis (chi-squared: 42.16; df: 1; p<0.001). The values of the R2 of Naglekerke are 0.122. We repeated the process and included the variable type of education. The statistical efficiency test of ROA shows that there is again a significant improvement (p<0.050) with the prediction of the probability of occurrence of the categories of the dependent variable for the variable type of education (chi-squared: 4.73; df: 1; p<0.005). The values of the R2 of Naglekerke increase to 0.135. Block 2 shows that there is 63.9% probability of matching the results of the dependent variable when we know the values of the variables crisis and type of education. The significant results that we have found are that those who did the MPHE after the crisis (B: 1.497; Exp(B): 4.469; Sig: 0.000) and those who had previous health education (B: 0.504; Exp(B): 1.655; Sig: 0.030) are more likely to privately fund their MPHE.

MPHE in Spain have existed for a similar amount of time as the most prestigious MPHE in other countries but very little is known about the people who graduate from these specific training programmes. This is the first study in that sense.

From our data, health economics in Spain is a field of special interest for health professionals that are currently working and want specialised training in the field of economics and management. Surprisingly, very few economists are interested in this area of knowledge, this may be because very few have studied this subject during their university years.

The large proportion of working professionals could explain the high average age at the moment of applying for the MPHE. This is an investment that people do not make to get a job (only 12,8% declared doing the MPHE for that reason) but to improve the way they do their jobs.

Human capital theory says that individuals use their experience and education to signal their skills. This kind of investment gives a competitive advantage, consequently it should also be useful when getting a job in this area if you are not previously working in the field. This is what we have found. The majority of people who apply for a MPHE are already in work, but the people who are not and are looking for a job in health economics find one in the first or in the second year after finishing the MPHE. It is therefore a good investment because most of the graduates believe that they got the job thanks to their training.

Graduates show a high degree of confidence in the utility of training. We analysed the kind of financing and, most of the financing (50.2%) was in general private (partially or totally), this figure increased (59.9%) after the economic crisis of 2008. People, especially in the health sector, gamble on investing in training when the general economic situation is bad. This is in line with human capital theory which states that training helps to differentiate between candidates and allows better access to jobs positions.

On the other hand, the contents of the MPHE are highly evaluated independent of the job consequences. The subjects in which the curriculum vitae of the health professionals are weaker, such as those concerning management, are the best valued as they are assumed to enhance promotion opportunities. We think it could be as a consequence of a change in the orientation of the professional career from a clinical position to an executive role. The other two most valued subjects, methodology and data analysis, are linked to those profiles of people who use the MPHE training as a step towards getting into (or to enhancing) an academic career.

We have seen that the general profile of graduates is that of a female (55.5%), but there is still a statistically significant increased gender inequality in getting into the job market, that is greater for those who finished their training after the 2008 economic crisis. In the Spanish job market, the participation of women is lower than men, the employment rate for women is 42.15% and 53.20% for men23 and in this case, it seems that the difference also exists, though it is statistically significant that it is less of a differentiation than the general population. The proportion of women who found a job after the MPHE (48.7%) is closer to the statistic for men who found one (51.3%). Despite the gender handicap, doing a MPHE is a good investment for women who want to get into this field.

Finally, it should be into account that it is difficult to compare our results with other studies mainly because the previous studies that were performed in United States of America, United Kingdom or even in Spain are based on the characteristics of people who were self-declared health economists, independent of their basic education.

From our point of view, future research should deep in the gender differences. It would also be interesting to know more about the private job market in health economics.

David Cantarero.

Main author was responsible of the data collection. All authors have participated in the design of the methodology of the study. Ruiz-Adame was responsible of the data analyses and the writing of the manuscript. All authors have done a supervision and review of the manuscript.

The authors wish to thank the directors of the masters programmes at the universities of Cantabria, Castilla-La Mancha, Málaga, Pompeu Fabra, and the Andalusian School of Public Health for their contribution. And specially to the Chair in Health Economics and Rational Use of Medicine University of Málaga-Janssen for its economic support. We also want to thank Katherine Burton for her writing and style advice.

We have received a grant of the Chair in Health Economics and Rational Use of Medicine University of Málaga-Janssen to pay the fee for publishing this paper.

None.