Policy Brief
As the Australian Government considers how to create pathways to more employment opportunities for more Australians in the context of low unemployment rates and significant skills shortages,[1] this brief outlines why industry-run accreditation processes present a significant barrier to skilled refugee and humanitarian entrants working in their chosen profession, despite the relevance of their qualifications and skills to the current Australian labour market and wider community.
The brief focuses on the dentistry industry as a case study, outlining the process of accreditation that allows overseas-qualified dentists to work in Australia, why this accreditation process is ineffective and unfair, and makes recommendations for how to facilitate better pathways to entry into this profession.
While this brief focuses on one profession, the Refugee Council of Australia (RCOA), Australian Syrian Charity (ASC) and many other bodies representing or working with refugees and migrants are aware of common issues in other professional and trade fields, with a common denominator being the complexity of qualification and skills recognition processes and the problematic power of industry bodies overseeing accreditation processes where there is weak accountability and oversight, and vested interests at play in limiting access to professions.[2]
You can download the brief here or continue to read in html.
How many overseas-trained (refugee) dentists are there in Australia?
Australia has permanently welcomed an average of 14,000 refugee and humanitarian entrants per year since the late-1970s. In 2022-23, the Humanitarian Program will provide 17,875 permanent visas to refugees, many of whom will arrive with significant overseas qualifications, skills and work experience.
Although it is not possible to find an accurate number of refugee and humanitarian arrivals who are dentists, the 2018/19 Australian Dental Council annual report showed that just under 10% of applicants for accreditation that year had qualifications obtained in major refugee source countries (particularly: Syria, Iraq and Iran).[3]
Case study: Carmen
‘Carmen’ arrived on a permanent (Refugee) visa in 2018. Carmen obtained her general dentistry qualification from Damascus University, a top university in Syria, and worked professionally as a dentist in Saudi Arabia for over 20 years.
In order to practice in Australia, Carmen is required to pass written and practical dentistry exams and an occupational English test. Carmen enrolled in a (pilot) career pathways program shortly after arriving in Australia and was supported to prepare for the accreditation process for one year. In this time, she studied for and passed the written exam. Since then, Carmen has sat the 2-day practical exam on three occasions without success. As accreditation exams are expensive, infrequent and success rates low, Carmen is not sure how to proceed and is frustrated after four years.
Despite extensive overseas work experience, qualifications, professional-level English and a strong motivation and willingness to work in a recognised skills shortage area, Carmen does not know if she will be able to work as a dentist in Australia. Carmen does not understand why peers who studied and worked alongside her in Syria and Saudi Arabia and then moved to Germany, Austria or France are all working as dentists within a year of arrival. Carmen is currently working in a hardware store and is struggling to save enough money to re-engage with the accreditation process as well as support her family.
The dentistry accreditation process
To work as a dental practitioner in Australia, you must be accredited through the industry body, the Australian Dental Council (ADC). There are two ways to attain accreditation: (1) by completing a university degree that has been accredited by the ADC, or (2) by having your overseas qualifications and skills assessed by the ADC. [4] The second pathway, relevant to overseas-trained dentists like ‘Carmen’ and ‘Joseph’, involves four steps:
- Initial assessment of eligibility to complete the dental practitioner assessment process – minimum being a 4-year full-time degree/diploma and previous registration (cost: $610, plus cost of translating documents).
- Written examination (cost: $2,000 per attempt)
- Practical examination (cost: $4,500 per attempt, plus ~$2,500 for equipment)
- Occupational English Test for dentists (not run by ADC)[5] (cost: $587)
If these steps are successfully navigated in the shortest possible time, it would cost an applicant around $10,000 and at least 18 months. As the success rates at steps 2 and 3 are extremely low (see Figure 1), it is highly likely that an applicant seeking accreditation through the ADC-run assessment process will have to re-sit exams, meaning costs and timeframes for successful accreditation are likely much higher and more protracted.
Figure 1. Success rates of ADC-run assessments, FY 2018/19 to 2020/21[6]
| Stage | Number of assessments | Number passed | Success rate |
| Initial assessment | 2,074 | – | N/A |
| Written examination | 1,855 | 859 | 46.3% |
| Practical examination | 2,859 | 565 | 19.8% |
Case study: Joseph
‘Joseph’ worked as a dentist in Syria for 27 years before civil conflict forced his family to flee and resettle in Australia. Since arriving in Australia five years ago, Joseph has been unsuccessful in passing the ADC-run practical exam on two occasions. He received a ‘Fail’ in technical skill areas where he considers he is experienced and proficient. He does not fully understand the expectations of examiners and how to meet these. Joseph has not wanted to contest his examination results as it costs $5,000 for a review and he is not confident the outcome will change.
Joseph has applied for multiple jobs as a dental assistant but has not been successful. He is aware that his resume will likely discourage dentists from employing him, considering his qualifications and extensive past professional experience. (He was a supervising dentist in his own practice before leaving Syria.)
Joseph has taken out a $35,000 loan to re-train as a dental technician. He is currently enrolled in a 3-year diploma course, even though the course covers much of what he did in his original degree and he has received no recognition of prior learning. He says: “I will do it, even if this kind of dental work is at a much lower skill level than what I was previously doing.”
Why is it so hard for overseas-trained dentists to get accredited to practice in Australia?
Looking at Figure 1, we see that only 1 in 4 of the 2,074 overseas-trained dentists deemed eligible to be assessed since 2018 managed to successfully pass the ADC-run accreditation process. This very low (27%) pass rate is concerning in the context of dentistry-related jobs featuring on the Australian Government’s skills shortage list[7], and presumably more overseas-qualified dentists arriving on skilled visas with a low chance of being able to attain the necessary accreditation to practice in Australia.
There are a range of reasons for the low success rate put forward by dentists who have both successfully and unsuccessfully navigated this accreditation process[8], including:
1. The accreditation examination process lacks transparency and fairness
Overseas-trained dentists report that the ADC-run examination process (particularly the practical exam) lacks transparency and fairness. The criteria under which candidates are assessed to either ‘pass’ or ‘fail’ are not always clear, and there is a lack of confidence that performance is assessed consistently. While there are assessment guidelines, there is insufficient time in how the exam is administered to realistically meet all expectations within these guidelines, even if a candidate understands and can demonstrate required skills. In some cases, the guidelines are too vague and refer to a range of texts where there can be conflicting advice as to the accepted practice. There is also insufficient feedback given to unsuccessful candidates to know which skills areas they should focus on when re-applying (results are ‘pass’ or ‘fail’ with no grade indication). ADC reporting of exam outcomes also seems to recognise a lack of discernible trends in testing, with candidates failing different ‘clusters’ in equal measure. If a candidate fails one cluster, they fail the exam and have to re-sit the whole exam. Many report passing a cluster in one exam and failing it in the next, suggesting testing variability rather than skills deficiency.
Finally, the option to review exam outcomes is limited by cost and the understandable fear that candidates have of contesting a decision. As the ADC exam is the only pathway to accreditation, those who have failed the exam say they do not wish to ask for a review that will cost $5,000 (more than the cost of re-sitting the exam) and which may jeopardise a future attempt if the exam outcome review is unsuccessful.
We don’t see the real criteria to understand the expectations. For example, you have 10 minutes to complete each station. Sometimes they are trying to waste our time during the exam; the ‘patient’ keeps speaking and we don’t have time to meet all requirements before we have to move to the next station. They are trying to make us fail.
There is insufficient feedback to know specifically which areas I should work on. I might get 80% or 79% or maybe I get 0%. I don’t know. All we see is Pass/Fail.
I know someone who passed on their fourth time. He felt like he did the worst on the exam that time. Results don’t make sense.
Someone who was an applicant called me before her exam because I am a specialist in this area, and I explained a procedure to her that she was not familiar with. She passed this in the exam. I didn’t. This is my area of specialisation, but I didn’t pass! I have done this procedure many, many times. I don’t know why I did not pass this.
ADC charge $5,000 to review exam results. If you do contest it, you have to send someone else – another dentist – as your representative in this review. You can’t even speak for yourself. It is better to re-sit than risk upsetting ADC and requesting a review. I don’t know anyone who has asked for a review even though we all have similar experiences and questions about how our performance was assessed.
Source: RCOA and ASC consultation with overseas-qualified dentists, October 2022
2. It is not in the interests of the ADC to accredit overseas-trained dentists
While accreditation processes run by industry bodies can be seen as an important risk mitigation strategy – i.e., reducing the chance of malpractice or poor standards by vetting the skill level of dentists who are trained in other country contexts – it has also been suggested that there are other and more important ways of upholding professional standards beyond gatekeeping entry into the profession.[9]
Overseas-trained dentists instead see the very low accreditation rates and the enormous expense and difficultly of navigating accreditation processes as a reflection of the interests of an industry that benefits from limiting the supply of dentists. As one person said:
I think the ADC are just wasting the time of candidates, which is why it is such a lengthy process. I don’t think they want us to pass, especially if we are specialists, because it is competition and increases supply of dentists (and potentially what can be charged to members of the community).
In the context of most of the dental care in Australia being left in the hands of the private rather than public sector, an industry body that controls the supply of qualified dentists is a very effective means of distorting the market.
Linked to this, the lack of alternative pathways to accreditation as a dentist in Australia means that power lies completely in the hands of one body and the interests it serves. This raises questions about accountability and the role of Government in ensuring that industry bodies are in some way answerable to the broader Australian community, particularly in such a critical industry as dental care.
Case study: Mohammed
‘Mohammed’ is a dental specialist who settled in Australia 10 years ago. Prior to arrival, Mohammed qualified in general dentistry in Syria and attained four post-graduate certificates with top marks from the University of Paris. Mohammed has attempted the practical dental examination in Australia on four occasions without success. He first passed the written examination in 2015 but has had to re-sit this after it expired.
Mohammed has explored alternative pathways to accreditation and utilising his skills. He applied for provisional accreditation through the ‘Limited Registration in an Area of Need’ initiative,[1] successfully applying for a job as a dentist in a regional town under the supervision of a dental practitioner who was desperate to attract someone with his skills to the area. The request was refused when it became known that Mohammed was scheduled to re-sit his practical exam with ADC (which he subsequently failed). Mohammed volunteered in the Northern Territory with the Closing the Gap initiative, happy to use his dental skills to improve access to dental care. Neither of these attempts brought him closer to accreditation, although Mohammed is happy to work in a regional area or for a community program if it means he can be accredited to practice.
Mohammed feels like he has lost a decade of his life trying to navigate accreditation processes to practice as a general dentist in Australia. He said: ‘Even if I got accreditation, I wouldn’t be able to work as a specialist because I would not feel confident to do so. I have missed out on 10 years of conferences; of maintaining my skill level. I have gone backwards.’
3. Lack of support to successfully navigate accreditation processes
Finally, overseas-trained dentists point to the lack of support to navigate accreditation processes. For example, if receiving assistance through Workforce Australia, there is limited support to pay for professional accreditation processes that are lengthy and have low success rates. Instead, employment service providers push skilled professionals to take other work. As one man said:
If I want to work selling blinds, they will pay for my tools and help with transport. If I want to work as a dentist where my skills and interests are, there is no support to pay for or prepare for the exams. They are pushing us to find full-time jobs, but if I do this I will not have time to study and apply for exams. They are suffocating us.
More importantly, there are no ADC-endorsed programs that help overseas-trained dentists prepare for the accreditation exams, meaning candidates are left without support to understand expectations of this process and fill any potential gaps in knowledge to increase the chance of success.
Recommendations
In the current context of low unemployment rates, there are opportunities for refugee and humanitarian entrants with considerable skills and overseas professional experience to contribute to the challenges facing the Australian economy and get a foot in the labour market door sooner with the right support.
This could be done by the Australian Government:
- Introducing accountability mechanisms that are used in other country contexts to provide oversight of industry accreditation processes, such as the Office of the Fairness Commissioner (Ontario) in Canada.[10]
- Investing in targeted career pathways programs to support refugees and other migrants navigate accreditation processes, such as the now-defunct Career Pathways Pilot for Refugees.[11]
- Reviewing the Workforce Australia model to ensure the right incentives are in place for providers to invest in meaningful work outcomes for overseas-trained professionals.
- Ensuring there are multiple pathways to accreditation for overseas-trained professionals, such as:
- University bridging course that is endorsed by the industry accreditation body.
- Supervised provisional accreditation initiatives, such as ‘Limited Registration in an Area of Need’, with a process of attaining full accreditation through participation in the program.[12]
- Commissioning a transparent and independent review of ADC’s accreditation process and how to increase accreditation rates through, for example, introduction of short technical skills training units that unsuccessful applicants can undertake in lieu of re-sitting entire exam.
- Exploring pathways for overseas-trained dentists to receive recognition of prior learning that would facilitate entry into other allied health professions, such as dental hygienist, paramedic, or phlebotomist, without requiring complete re-training.
References
[1] Employment White Paper: https://treasury.gov.au/consultation/c2022-322158
[2] SCOA (2019). Recognising Overseas Skills and Qualifications; FECCA (2022). A Secure and Successful Multicultural Workforce
[3] Australian Dental Council 2018/19 Annual Report, p.19. https://adc.org.au/files/corporate/annual-reports/2019_ADC_Annual_Report.pdf
[4] See: https://adc.org.au/assessments/dentists/
[5] See: https://www.occupationalenglishtest.org/test-information/healthcare-professions/dentistry/
[6] ADC Annual Report 2020/21, pp. 27-29. https://adc.org.au/files/corporate/annual-reports/2021_ADC_Annual_Report.pdf
[7] Listed: Dental Hygienist (411211), Dental Prosthetist (411212), Dental Specialist (252311), Dental Technician (411213), Dental Therapist (411214), Dentist (252312). Note: Only Dental Specialists and Dentists are accredited through ADC. Others are assessed through VETASSESS or Trades Recognition Australia. See: https://immi.homeaffairs.gov.au/visas/working-in-australia/skill-occupation-list#
[8] RCOA in partnership with ASC undertook a consultation with a group of Syrian dentists in October 2022. At least two petitions have been previously circulated by overseas-trained dentists: https://www.change.org/p/health-minister-demand-for-fair-evaluation-system-for-overseas-dentists; and https://www.change.org/p/australian-dental-council-the-dilemma-of-overseas-dentists-with-the-australian-dental-council
[9] See CEDA (2022). Skills Recognition
[10] See: https://www.fairnesscommissioner.ca/en/About/Pages/About-the-Commissioner.aspx
[11] https://www.dss.gov.au/sites/default/files/documents/03_2017/final_-_employers_information_sheet_-_march_2017.pdf
[12] A similar program to that which exists for medical doctors.
