euroobserver vol 13, no 2, summer 2011

Health professional mobility and health systemsevidence from 17 European countries

Matthias Wismar Irene A Glinos Claudia B Maier Gilles Dussault Willy Palm Jeni Bremner and Josep Figueras

Health professionals move between countriesin search of higher salaries better workingconditions training and career opportunitiesor new professional and personal experiencesWhen crossing borders they change the com-position of the workforce in both sendingand receiving countries affecting the sizeskill-mix geographical distribution and demographic profile This can have conse-quence on the workforcersquos contribution tothe performance of the health system by miti-gating or aggravating workforce shortagesthe lack of specific skills or the situation inunderserved areas

With 12 Member States acceding to the Euro-pean Union (EU) in 2004 and 2007 a new impetus for health professional mobility wasexpected As the EU became more diverse insocio-economic terms with larger salary differentials incentives to seek employmentin another Member State have increased Thethreshold to move across borders is relativelylow in the EU due to the mutual recognitionof professional qualifications1 in the Euro-pean free movement area this provides an automatic procedure for the lsquoregulated pro-fessionsrsquo among which are medical doctorsnurses dentists midwifes and pharmacists

Increasing health professional mobility and itsgrowing impact on health systems havemoved the issue up the political agenda Con-cerns have been voiced about brain-drain andthe accessibility quality and safety of servicesin both sending and receiving countries Some

Member States imposed for a transitional period labour market restrictions on the newMember States while others actively invitedhealth professionals from abroad

Evidence from European countries

Despite the growing political attention healthprofessional mobility has received in Europerelatively little is known about its magnitudethe dynamics resulting from the process of enlargement the balance of losing and receiv-ing health professionals between old and newMember States the drivers of mobility and theimpacts on health systems To shed more lighton the phenomenon the PROMeTHEUSproject has documented and analyzed healthprofessional mobility in Europe (Box 1)

Scale of mobility significant butdiverse

The scale of mobility is significant for a num-ber of European countries in terms of relianceon foreign health professionals and in propor-tion to new entrants to the health workforce

Figures from 2008 show that foreign healthprofessionals make up over 10 of doctors inBelgium Portugal Spain Austria NorwaySweden Switzerland Slovenia Ireland andthe United Kingdom (Figure 1) Reliance onforeign health professionals exceeds 10 ofthe nursing workforce in Italy the UnitedKingdom Austria and Ireland

Contents

Health professional 1 mobility and health systems evidence from 17 European countries

A destination and 5a source country Germany

A source country 6 Lithuania

Opportunities in an 7expanding health service Spain

A major destination 9country the United Kingdom

Emerging challenges 10after EU accession Romania

When the grass is 11greener at home Poland

Euro ObserverThe Health Policy Bulletinof the European Observatory on Health Systems and Policies

Summer 2011

Volume 13 Number 2

The Observatory is a partnership between the WHO Regional Office for Europe the Governments of Belgium FinlandIreland the Netherlands Norway Slovenia Spain Sweden and the Veneto Region of Italy the European Commission the European Investment Bank the World Bank UNCAM (French National Union of Health Insurance Funds) the London School of Economics and Political Science and the London School of Hygiene amp Tropical Medicine

This article is based on the volume Health Professional Mobility and Health Systems Evidence from 17European Countries edited by Wismar M Maier CB Glinos IA Dussault G and Figueras J (2011) WorldHealth Organization on behalf of the European Observatory on Health systems and Policies

E u r o O b s e r v e rE u r o O b s e r v e r V o l u m e 1 3 N u m b e r 2V o l u m e 1 3 N u m b e r 2

2

Reliance on foreign health professionalshas accumulated over decades and formany countries inflows remain signifi-cant In 2008 the proportion of foreign-ers within all new health workforce entrants was particularly high for medicaldoctors in the United Kingdom (426)Belgium (253) and Austria (135)for nurses in Italy (28) the UnitedKingdom (147) and Belgium (135)and for dentists in Austria (408) theUnited Kingdom (337) Belgium(193) and Hungary (97) In Finland432 of newly licensed dentists from2006 to 2008 were foreign trained

While some countries rely heavily on foreign health professionals Figure 1shows the diversity across Europe withseveral countries showing little or no reliance on foreign health professionals

Effects of EU enlargement lessthan expected

EU enlargement since 2004 has generateda new impetus for mobility although itdid not generate outflows as large as ini-tially expected ndash with mobility intentionsas expressed by the number of requestsfor conformity certificates in the EU-12 hovering at around 3 of health professionals (see Figure 2) and actualmigration being even lower since not allrequests are followed by emigration

Recent data from Estonia Hungary andRomania (see case study in this issue)seem to suggest a new surge in outflowspresumably related to the economicdownturn since 2008 However a reversetrend has also been observed with Polishmedical doctors returning to Poland

East-West asymmetries worsened

The new mobility triggered by the EUenlargement in 2004 and 2007 has furtheremphasized East-West asymmetries interms of in and outflows of health profes-sionals with the EU-15 as the main desti-nation for migrants from the then newMember States The asymmetry does notlie in the outflows per se Many of theEU-15 have considerable outflows of thesame magnitude as the EU 12 Howeverunlike the EU-15 the EU-12 countrieshave only negligible inflows

Box 1 PROMeTHEUS ndash Health Professional Mobility in the European Union Study

The issue of health professional mobility was discussed during the informalmeeting of health ministers organized by the Hungarian Presidency of theCouncil of the European Union in Goumldoumlll (Hungary) on 4ndash5 April 2011 On thisoccasion a new study on which this Euro Observer issue is based was pre-sented by the European Observatory on Health Systems and Policies in partner-ship with the WHO Regional Office for Europe This volume Health ProfessionalMobility and Health Systems evidence from 17 European countries draws onthe first results of a research project funded by the EU (grant agreement 223383)on health professional mobility in the EU (PROMeTHEUS) that started in 2009The countries covered include Austria Belgium Estonia Finland France Germany Hungary Italy Lithuania Poland Romania Serbia Slovakia SloveniaSpain Turkey and the United Kingdom Based on evidence provided by the 17

country case studies the book looks into the scope of health professional migration in the EU both in termsof the flows and the reliance on foreign health professionals The study also provides a better understand-ing of the underlying push and pull factors influencing health professional mobility the impact on healthsystems the broader domestic workforce issues and the policies to address the related challenges

0

5

10

15

20

25

30

35

40

Percentage of foreign medical doctors

foreign-trained foreign-national foreign-born

New

Zealand

Romania

Serbia

Lithuania

Turkey

Estonia

Slovakia

Poland

Hungary

Italy

France

Germ

any

Finland

Belgium

Portugal

Spain

Austria

Norw

ay

Canada

Sweden

Switzerland

Slovenia

Australia

United States

Ireland

United Kingdom

Figure 1 Reliance on foreign medical doctors 2008 or latest available year

0

2

4

6

8

10

0

1000

2000

3000

4000

5000

Estonia Hungary Lithuania Poland Romania

2004

2005

2006

2007

2008

2009

2004

2005

2006

2007

2008

2009

2004

2005

2006

2007

2008

2009

2004

2005

2006

2007

2008

2009

2004

2005

2006

2007

2008

2009

Number of doctors intending to leave

Percentage amongmedical doctors

Figure 2 Yearly outflow intentions of medical doctors from selected 2004 and 2007 enlargement countries

V o l u m e 1 3 N u m b e r 2V o l u m e 1 3 N u m b e r 2 E u r o O b s e r v e rE u r o O b s e r v e r

3

Outflows from Eastern Europe startedwell before accession following the polit-ical transitions of the late 1980s and early1990s For example high numbers ofhealth professionals from Bosnia andHerzegovina Croatia and Serbia in Germanyrsquos workforce in 2003 reflectdecades of out-migration from the former Yugoslav Republic (see case studyon Germany)

Money a main driver for mobility

The enlargements of 2004 and 2007 haveincreased the economic diversity of theEU and salary differentials An Estonianmedical doctor can earn six times more inFinland and a Romanian general practi-tioner can earn ten times more in FranceIncome is the most cited factor in decid-ing to migrate and influences leavers returnees and those who remain

In Lithuania annual salary increases of20 for medical doctors and nurses between 2005 and 2008 (see case study inthis issue) helped to reverse high dropoutrates from medical studies as well as attri-tion and emigration In Poland better remuneration is reported to have dimin-ished outflows and motivated returns (seecase study in this issue) In Slovenia increases in salaries arguably contributedto a smaller than expected loss of healthprofessionals Conversely a 25 cut inthe salary of health professionals in Romania may have contributed to higheroutflow numbers in 2009

Money is not the only factor influencingmobility patterns it is less important between countries where the salary differ-entials are slight Working conditionsworking environments and work contentsalso have an important influence on decisions by health professionals to move

Impacts on health systemsrsquo per-formance subtle but significant

In spite of intense debates in some countries there is surprisingly little evidence on the impact of health profes-sional mobility and there appear to have been no systematic studies in the countries Impacts on the performance of health systems are subtle in the sensethat they are often indirect and hard to

discern but there are evident impacts ontheir functioning Although some may beinsignificant at country-level they may besubstantial at regional or hospital level

Some receiving countriesrsquo health systemshave benefited substantially inflows ofmedical doctors nurses and dentists haveincreased service capacities in the UnitedKingdom Spain Austria and Italy Un-filled positions in the less affluent easternparts of Germany are increasingly filledby foreign medical doctors ndash their numbers tripled between 2000 and 2008In France medical doctors from non-EUcountries fill gaps in public hospitals andin socioeconomically disadvantaged orisolated areas

Other countries have faced losses Slovakia lost a reported 3243 health professionals between January 2005 andDecember 2006 In Romania rural areaswith the lowest coverage of medical doc-tors report some of the highest emigra-tion rates of medical doctors and nursesImpacts are not always related to the sizeof flows Hungary Estonia and Lithuanianoted that the departure of even a fewspecialists can upset service provisionCertain specialties appear to be more vulnerable In Poland most vacant postsconcern anaesthetists and emergencydoctors ndash specialists that show greatestintention to leave In Belgium the emigration of child psychiatrists has beenreported as problematic given importantshortages in the profession

Data are still limited

Policy makers workforce planners andhealthcare managers need to understandthe mobility trends as they occur in orderto react adequately However the datasituation in many countries is far fromsatisfactory In 13 of the 17 country case-studies (Belgium France GermanyHungary Italy Lithuania Poland Romania Serbia Slovakia Spain TurkeyUnited Kingdom) insufficient availabilityof updated comprehensive and reliabledata on migration was reported Manycountries worried about significant lossesof health professionals have used lsquointen-tion-to-leaversquo data based on certificatesissued when applying in another MemberState for the recognition of diplomas

But intentions do not equal factual movement rather this data represents aproxy for movements with several limita-tions An emigration study conducted inRomania showed that the actual outflowwas more than three times lower than theintention-to-leave data suggested On the other hand certificate data does not always overestimate mobility since somecountries wave the need to produce certificates and some forms of mobilitydo not require these documents

Measuring inflows is a tricky businesssince the three indicators available showdifferent aspects of mobility with largevariations ndash see Austria and Poland inFigure 1 Data on nurses suffer fromgreater limitations and inaccuracies thandata for medical doctors in most coun-tries Even where data are available theprofessions and qualifications includedvary widely between countries Time series data is only available for a fewcountries in Europe making the monitor-ing of trends particularly challenging

Policy implications

When considering whether health profes-sional mobility is an issue importantenough to take action policy makers willwant to understand future trends andpossible scenarios However grasping the phenomenon and taking the right decisions is made more difficult by a se-ries of factors

First there are uncertainties surroundingthe impact of the economic crisis Insome countries public budgets wereslashed including those for health careand for the training of health profession-als while in others budgets remained relatively unaffected Health workersworried about their professional futuremay decide to seek work or trainingabroad and with it contribute to healthprofessional mobility A new economicenvironment changes opportunities andincentives adding to the unpredictablenature of flows

Another source of uncertainty is thehealth workforce development in EuropeAccording to a recent forecast by the Eu-ropean Commission a shortage of around1 million health professionals is expectedby 2020 Vacancies in the more affluent


4

Member States may attract health profes-sionals from the poorer parts of the EUthus aggravating existing asymmetries

To compensate for workforce shortagesby recruiting from third countries is increasingly restricted by ethical con-straints The World Health Assemblyadopted in 2010 a Code of Practice forthe International Recruitment of HealthPersonnel The code provides ethicalguidance on international recruitmentand discourages recruitment from coun-tries facing workforce shortages There-fore countries with a high demand forhealth professionals will face increasingdifficulties to fill vacancies with healthprofessionals from other countries

The overarching implication of our find-ings is that health professional mobilityshould be addressed in the first placewithin countries This includes improve-ments in data intelligence and evidence a focus on general workforce strategiesincluding good-quality education andmeasures for retention the further devel-opment of workforce forecasting andplanning and to complement this the useof international frameworks to managehealth professional mobility

The first set of policy implications fo-cuses on data intelligence and evidenceDue to the unavailability or unreliabilityof outflow data policy makers and healthworkforce planners cannot factor in cur-rent out-migration It is also crucial thatinflow data becomes available on a timelybasis The lack of robust and comparablenursing data will need to be addressedtoo However the need to be better informed goes beyond the data issueWith the free-mobility framework short-ages and changes in workforce policieshave almost immediate effects on othercountries especially if there are large dif-ferences in the level of income Changesof recruitment policies in the UnitedKingdom and the increasing inflow fromEU-12 countries provide an example ofhow important it is to have timely intelli-gence available on the sustainability ofthe workforce including workforce poli-cies and training capacities And finally itwill be essential to better understand theeffectiveness of measures to retain inte-grate or re-integrate health professionals

A second set of policy implications is related to the strengthening of generalworkforce strategies Health professionalmobility is mostly the consequence ofunderlying domestic workforce issues related to the working conditions work-ing environment skill-mix supply andtraining opportunities available Salarydifferentials also play an important role

A third policy implication is to sustain there-emerging interest in workforce plan-ning methods and techniques that go beyond extrapolating past staffing trendsbut rather taking into account the chang-ing demands for and needs of the healthworkforce of the future That includes thefeminization and aging of the workforce

Finally there are international frame-works that can help to manage healthprofessional mobility including theWHO code According to the experi-ences from the United Kingdom withtheir code the timely monitoring of inflows the existence of accountabilityframeworks and national workforcestrategies can help Bi-lateral agreementsbetween consenting countries can struc-ture or exclude international recruit-ment They can also facilitate recognitionof diplomas from third countries Thereare other international mechanisms whichcan contribute to the management ofhealth professional mobility on the orga-nizational level for example twinningschemes and joint training programmes

The way forward

It is now time to lay the foundations forfuture actions The policy implicationslisted here should provide guidance Furthermore the role of the EU vis-agrave-visthe Member States needs to be clarifiedHealth care is a competence of MemberStates but it is clear that mobility whichis a competence of the European Unioninteracts with service provision

Aware of this issue of competence Mem-ber States the European Commissionand the European Parliament have fostered discussion and collaboration on workforce issues including healthprofessional mobility Under the BelgianPresidency in 2010 the Member Statesadopted Council Conclusions on thehealth workforce2 encouraging exchangeof good practices but also the develop-ment of an action plan and a joint actiona method which allows the Commissionto collaborate with Member States Thiswas further endorsed by the HungarianPresidency in 2011 which put healthprofessional mobility on the agenda ofthe Council (see Box 1) The initiatives ofthe Member states were preceded by aCommission Green Paper and a consulta-tion process on the European Workforcefor Health3 In parallel the EuropeanParliament adopted a declaration on theEU Workforce for Health4 This mayconstitute a splendid window of oppor-tunity to address the challenges ahead

REFERENCES

1 Directive 200536EC of the EuropeanParliament and of the Council of 7 Sep-tember 2005 on the recognition of profes-sional qualifications OJ L 255 3092005

2 Investing in Europes Health Workforceof Tomorrow Scope for Innovation andCollaboration [wwwconsiliumeuropaeuuedocscms_datadocspressdataenlsa118280pdf accessed 30 May 2011]

3 European Commission Green paper onthe European Workforce for HealthCOM(2008) 725 final [httpeceuropaeuhealthph_systemsdocsworkforce_gp_enpdf accessed 30 May 2011]

4 European Parliament [wwweuroparleuropaeusidesgetDocdopubRef=-EPNONSGML+WDECL+P7-DCL-2010-0040+0+DOC+PDF+V0ENamplanguage=EN accessed 30 May 2011]

Matthias Wismar European Observatory on Health Systems and PoliciesIrene A Glinos European Observatory on Health Systems and PoliciesClaudia B Maier European Observatory on Health Systems and Policies (at the time ofthe PROMeTHEUS study)Gilles Dussault Instituto de Higiene e Medicina Tropical Universidade Nova de Lisboa Willy Palm European Observatory on Health Systems and PoliciesJeni Bremner European Health Management Association BrusselsJosep Figueras European Observatory on Health Systems and Policies


Mobility profile

Germany is both a destination and asource country for migration in thehealth care sector Foreign health profes-sionals have long had a presence withinGermanyrsquos health services and nearly halfof these hold EU citizenship Howeverthe EU enlargements of 2004 and 2007have not produced the expected strongeffect on the migration inflows of healthprofessionals In 2008 foreign nationalhealth professionals still represented arelatively small percentage (about 6) ofthe total health workforce in the countryAt the same time a number of Germanhealth professionals are leaving the coun-try to work abroad attracted by betterworking conditions and higher pay

Inflows

Medical doctors The numbers of regis-tered and active (practising) foreign-na-tional doctors have increased since 2000as have the percentages of total numbers1

At the end of 2008 there were 21 784 registered doctors of foreign nationalityin Germany (approx 52) and 18 105active foreign doctors (approx 57)

This growth has been considerablyhigher in eastern Germany from 2000 to2008 the number of active foreign doctorsin the states of the former West Germanyrose by 40 while the corresponding figure for the former East Germany wasroughly 309 Only 6 of all active foreign doctors were practising in easternGermany in 2000 but this proportion hadreached 15 by 20082 While the numberof foreign doctors from the new MemberStates working in Germany has increasedconstantly since 2000 the highest growthrate (around 21) occurred in 2003when demand was first diagnosed to behigh but the restrictive immigration

policy for non-EU nationals still appliedto these countries

It is quite rare for foreign doctors to become self-employed In 2008 only 3534foreign doctors ran private practices ndash28 of all practice-based doctors Theabsolute number and share of foreigndoctors is considerably higher in the hospital sector ndash 13 207 (86)1 In 2008the main source countries for foreigndoctors were Austria Greece the Russ-ian Federationformer USSR Poland theIslamic Republic of Iran and Romania

Nurses The share of foreign-nationalnurses and midwives subject to social in-surance contributions has been decliningfrom 37 in 2003 to 34 in 2008 Thenumbers with foreign EU nationalityshow only a slight decrease (3) whilethere were more pronounced decreases inthe numbers from Asia (30) Europe(excluding the EU 7) and Africa (5)The share of nursing assistants also de-creased from 76 in 2003 to 70 in20083 The main source countries forlegally employed nurses are CroatiaTurkey and Poland followed bySerbiathe former Federal Republic ofYugoslavia Bosnia and Herzegovina andAustria

While the number and share of foreignnurses and midwives subject to social insurance contributions is decliningother forms of employment such as self-employment and illegal employment offer eastern European nurses the possi-bility to work in Germany mainly ashome-care workers for elderly people

Dentists Data on foreign dentists areonly partially available Federal Chamberof Dentists figures for 2007 give a total of1573 dentists with foreign EU national-ity representing around 2 of all den-

tists in the country Microcensus datashow that the number of dentists of for-eign nationality in Germany hoveredaround 2000 (3 of all dentists) between2003 and 2006 and increased to 3000 (5of all dentists) in 2008

Outflows

Data on the annual outflows of healthprofessionals from Germany are partiallyavailable Data compiled by the regionalchambers of physicians show that in 2008a total of 3065 medical doctors who orig-inally practised in Germany (approxi-mately 1 of all active medical doctors)moved abroad 67 of these held German nationality The most populardestination countries were the German-speaking countries of Switzerland (729)and Austria (237) followed by theUnited States (168) the United Kingdom(95) and Sweden (86)

Data on the outflow of nurses is notavailable but according to German Nursing Association estimates the annual outflow does not exceed 1000 An important destination country isSwitzerland which offers better training opportunities higher incomes and flatterworkplace hierarchies

Health system impacts

The scale of health professional migrationto and from Germany is relatively limitedin comparison to major destination andsource countries and therefore there hasbeen little research on its impact on thecountryrsquos health care system While thedecentralized and corporatist health caresystem in Germany hampers active nationwide recruitment of health profes-sionals mainly in the less affluent andsparsely settled regions of eastern Ger-many federal states and hospitals affectedby a shortage of medical doctors are increasingly recruiting personnel fromabroad Demand for nurses is expected torise as a result of demographic changes

5

A destination and a source country Germany

Diana Ognyanova and Reinhard Busse

Data from the Federal Employment Agency No registry data is available as nurses andmidwives are organized through voluntary membership of a variety of professional organizations and are not required to register with a particular organization or chambers


6

and the declining appeal of the profes-sion especially in times of economic upturn The health systemrsquos dependenceon foreign-trained health personnel is already noticeable in areas such as elderlycare and is likely to increase

Policy responses

Germany lacks a comprehensive nationalhealth workforce strategy that takes intoaccount the inflows and outflows ofhealth professionals There is also no ex-plicit national self-sufficiency policy Thecountryrsquos federal and corporatist systemin which healthcare goals are fixed andimplemented within a complex set of in-stitutional mechanisms acting at differentlevels impedes adequate planning Somead hoc responses to workforce shortagestypically implemented at state or hospitallevel include recruitment of medical doc-tors from the new EU Member States byhospitals in eastern Germany easing ofbureaucratic hurdles concerning workpermits and legal occupational regula-tions by regional authorities particularlyin eastern Germany retraining schemesfor foreign trained doctors in the state ofBrandenburg and offering extra bonuses(such as cheap loans low rent and mort-gages) by some hospitals to attract youngdoctors

REFERENCES

1 Federal Chamber of Physicians Aumlrztes-tatistik 2009 Berlin (www bundesaerztekammerdepageasphis=03 accessed 22June 2009)

2 Kopetsch T Dem deutschen Gesund-heitswesen gehen die Aumlrzte aus Studie zurAltersstruktur- und ArztzahlentwicklungBerlin Bundesaumlrztekammer undKassenaumlrztliche Bundesvereinigung 2010

3 Federal Employment Agency Unpublished data 2009

Diana Ognyanova Research Fellow Department of Health Care Manage-mentBerlin University of TechnologyGermany

Reinhard Busse Professor of Health CareManagement Berlin University of Tech-nology and Associate Head for ResearchPolicy European Observatory on HealthSystems and Policies Germany

Mobility profile

EU accession has not produced the antic-ipated outflows of health professionalsfrom Lithuania The most likely reasonsfor this include improved working condi-tions within the country (enabled by EUstructural funds for the health care system) and increasing salaries HoweverLithuania is still best described as asource country for medical personnelwith pull factors that include betterworking conditions abroad better quality of life higher prestige and higherpay The main destination countries forLithuanian health professionals are theUnited Kingdom followed by the Scandinavian countries

Outflows

Medical doctors During the first year ofEU membership (1 May 2004 to 30 April2005) 357 (27) Lithuanian doctors obtained certificates of good standing(CGSs) which are issued by the Ministryof Health to health professionals wishingto practise abroad That number almosthalved to 186 (14) in the followingyear and fell to 132 (09) in 2009

Nurses Nurses show a different patternto doctors ndash 107 (04) nurses were issued with CGSs in 2004ndash2005 with increases to 166 (07) in 2005ndash2006 and267 (11) in 2009

Dentists Dentists show fluctuating numbers of CGSs ndash 81 (36) dentistswere issued with certificates during 2004ndash2005 These numbers fell to 42 (17) in2005ndash2006 but rose to 72 (31) in 2009

Inflows

Ministry of Health data indicate that only10 basic medical degrees 12 medical

specialty degrees 10 nursing degrees and11 dentistry degrees from countries out-side the EEA (Armenia Belarus RussianFederation Ukraine and Uzbekistan)were accredited between 2005 and 2008Three dentistry degrees (from Norwayand Poland) were recognized throughEuropean Directive 200536EC Thusthe numbers represented by these accred-itations remain very low in comparisonto the total economically active healthworkforce in 2008 (13 403 medical doctors 24908 nurses and 2287 dentists)

Stock data on foreign health professionalspractising in Lithuania is more problem-atic as it is not systematically collectedThe only data available are the number ofwork permits issued to foreign nationalsDuring 2005ndash2008 15 medical doctors 6 nurses and 2 dentists were issued withpermits Lithuanian Labour Exchangedata show that foreign health profession-als mainly come from third countries(Belarus China Israel Lebanon Pakistan Russian Federation Syria andUkraine) only three came from EEAcountries (Latvia and Norway)


While domestic data sources indicate anunmet demand for medical doctorsnurses and dentists this does not indicatea general shortage Rather certain special-ties and sectors experience recruitmentproblems for example a study from20061 shows that the demand for psychi-atrists was 24 times higher than supplydemand for other medical doctors (sur-geons ophthalmologist) was higher by3ndash10 times Another study2 revealed thatgynaecologists paediatricians anaes-thetists surgeons internists doctors oflaboratory medicine general practitioners

A source country Lithuania

Žilvinas Padaiga Martynas Pukas and Liudvika Starkienė

While the number of certificates issued does not reflect the real migratory flows ndash as the holders may choose not to leave the country or may leave for a short while ndash other evidence such as listings of Lithuanian health professionals in foreign registries shows thatcertificate holders have serious migration intentions


7

and medical doctors with basic trainingmigrated most often in 2004ndash2006 Themagnitude of vacant positions might haveadverse consequences for health servicedelivery especially when the mobility of particular specialties is taken into account

At the current rate of migration thehealth care system is not dependent onforeign health professionals but vigilanceis required as the country is dependenton the health workforce situation inwealthier EU and EEA countries that ac-tively recruit foreign medical personnelsuch as Ireland Norway and the UnitedKingdom Moreover the current un-favourable economic situation may sig-nificantly accelerate outflow rates whichare unlikely to be remedied by an inflowof professionals from EU-15 countriesany shortages are more likely to be metby professionals from Commonwealth ofIndependent States countries

Policy responses

Health professional mobility began withLithuanian independence but it was onlyafter EU accession that politicians starteddiscussions on its possible negative effects on the health system and initiatedplanning processes at governmental regional and local levels to determine thefuture supply and needs The StrategicPlanning of Health Human Resources inLithuania 2003ndash2020 programme is a primary example

The domestic health workforce outflowshave not led to the development of explicit policies to attract a foreign work-force to supplement the domestic stockRather the Ministry of Health has concentrated on reform and restructuringto retain and motivate Lithuanian healthprofessionals to practise in LithuaniaAlso in 2005 the Ministry of Health andthe medical associations signed a memo-randum on salary increases (20 annu-ally for doctors and nurses in 2005ndash2008)

REFERENCES

1 Institute of Labour and Social ResearchStudy of Workforce Demand and Problemswith Filling Vacancies Report of the Sec-ond Stage of the Study (2006) Definitionof a Source Country the Case of Lithuania

415 Vilnius 2006 (wwwldbltInformacijaApieDocumentsldv_2etapaspdf accessed 13 September 2010)

2 Pukas M Lithuanian Health-Care Pro-fessionals Migration Study [thesis] Kau-nas Kaunas University of Medicine 2008

Žilvinas Padaiga Professor of Public Health Department of PreventiveMedicine and Dean of International Relations and Study Centre MedicalAcademy Lithuanian University of Health Sciences LithuaniaLiudvika Starkienė Associate Professor Department of Preventive MedicineMedical Academy Lithuanian University of Health Sciences LithuaniaMartynas Pukas PhD student Department of Preventive Medicine Medical AcademyLithuanian University of Health Sciences Lithuania

Opportunities in an expanding healthservice Spain

Beatriz Gonzaacutelez Loacutepez-Valcaacutercel Patricia Barber PeacuterezCarmen Delia Daacutevila Quintana

Mobility profile

Market forces have made Spain a corridorfor health professional mobility betweenLatin America and Europe In particulardoctors from Latin America have responded to shortages by immigratingto work as general medical doctors and to train as specialists In turn Spanishdoctors and nurses have been leaving forother EU countries presumably attractedby better working conditions but thistrend has been in decline since the mid-2000s

Inflows

Medical doctors In 2001 75 of doctorsworking in Spain were foreigners1 TheOrganization of Medical Colleges(OMC) estimates that in 2007 about125 of the 203 305 doctors registeredin Spain were of foreign origin with widegeographical variations ranging from02 of doctors in the Basque Countryto 155 in the Balearic Islands

Between 1998 and 2002 4318 degrees in general medicine (licenciaturas) fromcountries outside the EU were recog-nized most from Latin America Between 2003 and 2008 the numberjumped almost six-fold to 24 330

The number of medical degrees recognized through European Directive200536EC averaged 230 per year between 1998 and 2004 but the trend has been upward ever since Far fewerspecialty decrees are recognized ndash 702 in2007 or 13 of the specialist medical resident slots in 2007

Nurses Data for 2004ndash2008 show thataround 1 of nurses working in Spainare foreign nationals around 48 ofwhom come from Latin America 39from the EU 10 from Africa and 3from other parts of the world2 The inflows of Latin American nurses haveincreased since 2000

In 2007 recognized or homologated foreign nursing degrees represented theequivalent of 20 of new nursing gradu-ates up from 3 in 2002 Among the1195 degrees of EU nurses and midwivesrecognized during 2002ndash2007 23 werefrom the United Kingdom 20 fromGermany and 18 from Portugal

Dentists The number of registered den-tists has increased threefold in Spain from7471 in 1988 to 24 515 in 20073 There aresignificant proportions of foreign dentistswith foreign degrees ndash for example 20of all dentists in Madrid Catalonia and


8

Shortages were due to three demand shocks (i) regional governments became responsible for health care and they invested in new hospitals and clinics (ii) a buoyant economy supported a flourishing private sector in medical services and (iii) Spanish doctors were attracted by other European countries with doctor shortages and strong demand

Such certificates indicate an intention to emigrate but do not represent actual migration to another country

Valencia ndash and in tourist areas There arealso a large number of Spanish dentistswith foreign degrees mainly obtained inLatin America or the EU in 2007 theserepresented 37 of Spanish dental schoolgraduates

Outflows

Doctors In 2001 59 of practisingSpanish doctors were registered in othercountries Of these just under half werepractising in the EU and most of the restwere in the United States1 Within theEU most migrating Spanish doctors goto Portugal France and the United King-dom with a considerable number contin-uing to live in Spain while commuting towork in neighbouring Portugal Since2008 there has been a trend towards re-turning to Spain with returnees attractedby a domestic labour market that movedfrom a surplus to a shortage of doctors in the mid 2000s In 2007 650 Spanishdoctors requested a certificate from the OMC in order to work abroad equivalent to only 034 of practisingregistered doctors

Nurses The number of Spanish nurseswho validated their degrees to work inthe EU increased sharply in 2002 equivalent to 19 of that yearrsquos nursingschool graduates However the increasein internal demand has led numbers todecline sharply since 2003 falling to only3 of nursing graduates in 2007

Dentists The main destination for Spanish dentists is the United Kingdomfollowing a bilateral agreement in 2001The number of dental degrees recognizedfor practise in the EU grew significantlyfrom 2002 to 2005 (from 25 to 177) andhas been decreasing since (to 125 in2007)


The inflow of foreign professionals particularly medical doctors relieved theacute shortages in 2000ndash2005 and added

flexibility to the market but it also led topublic debate about the quality of someforeign professionals In recent years re-gional health services have compensatedfor shortages of doctors in some special-ties by hiring non-EU doctors whosespecialty degrees have not yet been rec-ognized by the Ministry of Education4 The OMC estimates that between 10 000 and 12 000 medical doctors are working in Spain under theseirregular conditions5

Despite medical salaries increasing considerably over the past five yearsthey have not risen to the levels thatwould be expected This is due to foreignprofessionals mainly from Latin America who are willing to accept lowersalaries and poorer working conditionsFrom this perspective since 70 ofhealth financing is funded by taxes foreign professionals have produced savings for Spanish taxpayers

Policy responses

There is no defined national strategy forhealth in Spain and therefore recruitmentand training of foreign professionals isimprovised and reactive rather thanplanned Despite the need for more systematic planning measures that havebeen implemented include

- In 2005 a formal planning process fordoctors (based on analysis of needsand supply with a temporal horizon to2025) was established

- A simulation model to estimate theshortages and surpluses of medicalspecialists is being used to set adequateenrolment limits in medical schoolsand to establish individual specialtynumbers in the annual residency competition based on need

- A register of health professionalsfunded by the Ministry of Health isbeing set up with the participation ofSpainrsquos regional governments and

- A royal decree for the professionalrecognition of health specialist fromoutside the EU was published in May2010

REFERENCES

1 Dumont J Zurn P Immigrant healthworkers in OECD countries in thebroader context of highly skilled migra-tion In International Migration Out-look Paris Organization for EconomicCo-operation and Development 2007

2 INE database (2004ndash2008) Economi-cally active population survey MadridNational Statistics Institute Online database accessed 18 February 2011

3 INE Profesionales sanitarios colegiadospor tipo de profesional antildeos y sexo 2007[Collegiate health professionals by typeof professional years and sex 2007]Madrid National Statistics Institute2007

4 del Burgo P La OMC exige a Sanidadun censo de los meacutedicos extranjeros contratados que carecen de la especiali-dad [The Medical Association requeststhe Ministry of Health for a census offoreign doctors working without diplomas] Levante-EMVcom 27 January 2009

5 OMC Informe sobre homologacioacuten de tiacutetulos de Medicina obtenidosen paiacuteses extracomunitarios [Report on approval of medical titles obtained in countriesoutside the EU] Madrid Organizationof Medical Colleges 2009

Beatriz Gonzaacutelez Loacutepez-Valcaacutercel Professor University of Las Palmas deGran Canaria Spain

Patricia Barber Peacuterez Associate ProfessorUniversity of Las Palmas de Gran Canaria Spain

Carmen Delia Daacutevila Quintana Associate Professor University of Las Palmas de Gran Canaria Spain


9

Mobility profile

The United Kingdom has a long historyas a destination country for health professionals In areas such as hospitalservices the National Health Service(NHS) has consistently depended on immigrants while in areas such as nursing and general practice the reliancehas fluctuated with domestic shortagesToday more than a third of medical doctors and every tenth nurse registeredin the UK are internationally trained

Inflows

Medical doctors Foreign trained doctorsaccounted for 345 of all registereddoctors in 1988 (or 57 575 in absolutenumbers) growing to 368 (or 91 064)in 2008 Around one quarter came fromthe EEA and three quarters from the restof the world Overall EEA-qualifiedmedical doctors accounted for 6 ofthose registered in 1988 76 in 2003and 9 in 2008 Overall Germany is themost significant EU-15 source countrywith 3201 more medical doctors registered in 2008 than in 1988 Ireland remains a major migration source butnumbers are declining Moreover num-bers from the newer EU Member States(the EU-12) are catching up to thosefrom the EU-15 In 2008 the EU-15 andEU-12 accounted for 1166 and 970 newregistrant medical doctors respectively1

Nurses In 2008 86 947 foreign-trainednurses and midwives were registered inthe UK equivalent to 129 of all registered nurses and midwives The maincountries of origin lie outside the EUnamely India the Philippines AustraliaSouth Africa Nigeria Zimbabwe NewZealand and the West Indies 13 of allnurses and midwives came from the EEAcountries compared to 116 for the restof the world However the relativelysmall share of health professionals fromthe European region has been growing

since 2003 particularly from the newerEU Member States For example in 2008among newly registered nurses and mid-wives 437 were from the EU-15 while932 came from the EU-12 countries23

Reliance on mobile health professionalsfrom different sources differs across pro-fessional groups For example it appearsthat certain professions (eg dentistrymidwifery general practice) are propor-tionally more reliant on European migrants especially following the 2006introduction of restrictions on othersources The relative increase inEUEEA-qualified health professionalsregistered in the last ten years is note-worthy although the numbers remainlower than for non-EEA sources

The most important drivers for migrationto the UK are the potential economic andprofessionalcareer opportunities in com-parison to source countries This appliesto differing degrees to individuals fromdeveloping and CEE countries and toricher nations such as the EU-15 Theinteraction of economic and family cir-cumstances also appear to be important ndashwhether to generate remittances to thecountry of origin or the perception thatthe family will have a better life in theUK Linguistic and cultural ties as wellas shared traditions in educational curric-ula and professional practice also play arole in attracting migrants to the UK

Outflows

The numbers of health professionals leaving the UK appear to be significantlylower than inflows but data are scarceVerification of qualification requests andCertificates of Good Standing (CGSs) canonly give an approximation of outflows asthey indicate an intention to leave thecountry rather than actual migrations

In this respect between November 2007and May 2009 a total of 9820 CGSs wereissued to medical doctors to work

abroad1 For nurses and midwives datashow that 8070 applications for qualifica-tion validation were received in 20022003 increasing to 11 178 in 20072009For both doctors and nurses approxi-mately ten times more verifications are issued for Ireland than for any other EUcountry followed by Spain and FranceOutside Europe Australia is the maindestination country with New Zealandthe United States Canada and the MiddleEast also featuring strongly in the rank-ings Several African countries are alsodestination countries for doctors However it is not known how much ofthis is due to emigrating UK nationals orto foreign-qualified professionals return-ing home or moving onto a third countryfor which the UK was a stepping stone


While the benefits and challenges ofhealth professional mobility have notbeen systematically quantified certainobservations can be made4 First theUKrsquos recent openness to mobility ful-filled its purpose of improving staff cov-erage rates In turn this is perceived tohave contributed to reductions in waitingtimes for NHS treatment Second NHSorganizations were able to make financialsavings on agency fees for temporarystaff and greater workforce stability alsoenabled increases in the UKrsquos training capacity More generally mobility clearlyhas resource benefits for the health sys-tem in that it reduces domestic spendingon health professionalsrsquo education andpost-graduate training

Policy responses

The British government began a policy ofmassive NHS investment and workforceexpansion across all health professionsfrom 1998 to 2006 and increased domes-tic training capacity alone was not suffi-cient for the timescale required Thustargeted international recruitment ofhealth professionals was a central elementof this process At the same time manyhealth professionals were recruited intoprivate sector hospitals nursing homesand social care The policy of active inter-national recruitment was reversed in 2006and more restrictive immigration rules

A major destination country the United Kingdom

Ruth Young

were introduced as earlier expansion inthe UK training numbers came onstream Within the European region theBritish Government also signed recruit-ment agreements targeting (for instance)general practitioners nurses and pharma-cists in Spain nurses in Greece nursesand GPs in Germany hospital doctorsand GPs in Italy and Austria and GPs inFrance Scandinavian countries were theother main sources targeted

It is noteworthy that policy-makers haveused internationally recruited health personnel as an approach to influence absolute numbers in the workforce ratherthan channelling migrants specifically toaddress geographical imbalances More-over workforce planning has not elimi-nated cyclical shortagessurpluses andthe recruitment retention problems ofless popular specialties and geographicalareas A centre of excellence for work-force planning has been established toprovide intelligence and develop plan-ning capacity at all levels Nationally theWorkforce Review Team provides annualevidence to the Home Office MigrationAdvisory Committee that reviews theshortage occupation list This arrange-ment is intended to enable clearer linksbetween health professional mobility andNHS workforce analysis and planning

REFERENCES

1 General Medical Council Unpublisheddata 2009

2 Nursing and Midwifery Council Unpublished data 2009

3 UKCC Annual report 1988ndash1989 London Central Council for NursingMidwifery and Health Visiting 1989

4 Young R et al International recruitmentinto the NHS evaluation of initiatives forhospital doctors general practitionersnurses midwives and allied health professionals FNSNM Kingrsquos CollegeLondon Open University Centre for Education in Medicine Manchester Business School and NPCRDC University of Manchester 2008

Ruth Young Reader in Health PolicyEvaluation Florence Nightingale Schoolof Nursing and Midwifery Kingrsquos College London United Kingdom


10

Mobility profile

Romania is predominantly a sourcecountry for health professionals and professional mobility represents an emergent challenge for policy-makersThis situation is the result of EU accession in 2007 and (probably more importantly) other dynamics related todemographics and poor planning andmanagement of the workforce The scaleof migration in 2007 was high but alsosince the end of 2009 the economic crisishas begun to impact deeply on Romaniansociety including the health system

Romania has no accurate information oninternational inflows or outflows ofhealth professionals particularly fornurses and data is based on estimates orproxies Diploma verification certificatesissued by the Ministry of Health and thecertificates of good standing (CGSs) issued by the Romanian College ofPhysicians provide an indication of inten-tions to leave the country but are not anaccurate measure of mobility as not allactually emigrate For example in 2007only 28 of doctors who requested veri-fication certificates actually emigrated

Outflows

Medical doctors Official data on diplomaverification certificates show that in 2007about 4990 (10) active doctors had theintention of leaving the country In thetwo years following accession the totalnumber of applications (2683) showed aclear decrease to just over half the 2007figure1 Nevertheless unofficial datashow substantial increases in requests forverification certificates in 2010 ndash with ap-plications averaging over 300 per month2

CGSs are considered to be better proxiesthan verification certificates About 3(1421) of the total number of practising

doctors left Romania in 2007 and morethan 90 of these requested CGSs forother EU Member States3 The majorityof medical doctors applying for CGSscame from the Iasi district situated in thecountryrsquos most economically deprived region The most common medical specialties of applicants were family medicine intensive care and psychiatry

Nurses The extent of nurse emigration isunderestimated by the existing datasources which are of insufficient qualityand do not cover all nurses leaving thecountry After accession official datashow that 2896 nurses and midwives ap-plied for diploma verification certificatesin 2007 equivalent to 34 of the work-force with a fall in the applications insubsequent years1 Data from destinationcountries such as Italy Germany and theUnited Kingdom show considerablenumbers of newly registered Romaniannurses and that out-migration is consid-erably higher than that suggested bydiploma verification data In particulardata from Italy shows that 25 (or 8497)of all foreign nurses registered in thatcountry in 2008 are from Romania

France Germany Italy and the UK ap-pear to be the favoured destination coun-tries for migrating health personnel Themain push factors are low salaries unsat-isfactory social status difficult workingconditions and limited opportunities forcareer development In 2010 disincen-tives for health professionals such as a25 cut in salaries and staff reductions inhealth care institutions were introduced

Inflows

There are almost no data on foreign medical doctors or nurses working in Romania but it is likely that the constanthigh numbers of immigrants from theRepublic of Moldova include medicaldoctors and nurses

Emerging challenges after EU accession Romania

Adriana Galan Victor Olsavszky Cristian Vladescu

Data for 2009 includes only JanuaryndashMay


Overall the high annual loss of healthprofessionals is a major issue while thereare various reasons for leaving the healthsystem the total loss is estimated to be10ndash30 of the workforce While there islittle evidence of its direct impact on thehealth care system there is a generalproblem of access to primary care serv-ices Given that family medicine is one ofthe most demanded specialties in someEU countries (eg France) it is likely ac-cess problems will increase in Romania ifthe emigration of family doctors contin-ues or increases Another possible effectof doctor migration is long-term scarcityof some specialties and skills in hospitals

Increased emigration of doctors andnurses in 2010 is jeopardizing the properrunning of many facilities especially insmall municipal hospitals Large districthospitals are also facing staffing problemswith many vacancies unfilled This situa-tion is compounded by the government-imposed freeze on all new recruitment inthe public system since January 2010

Policy responses

To date there is no comprehensive healthworkforce policy in Romania The draft-ing of a national strategy commissionedin 2007 has seen several delays and doesnot seem to be a priority Evidence fromother EU countries shows that thousandsof Romanian doctors and (especially)nurses have migrated Hence it is vitalfor Romania to develop (i) good monitor-ing and control systems for cross-bordermobility and other factors related to en-tries and exits from the health workforceand (ii) better tools to manage the flowsof health professionals to minimise anylosses for the national health care system

REFERENCES

1 Ministry of Health Unpublished data2009

2 Ministrul Sanataii Migratia medicilor vacontinua icircn urmatorii 15ndash20 de ani [Minis-ter of Health Doctorsrsquo migration will continue for the next 15ndash20 years] Reali-tateanet 12 August 2010 (wwwrealitateanetministrul-sanatatii-migratia-medicilor-va-continua-in-urmatorii-15-20-de-ani_729148html accessed 151110)

3 Dragomiristeanu A et al Migratiamedicilor din Romania [The migration ofmedical doctors from Romania] Revista

Medica 17 March 2008 (wwwmedicalnetrocontentview49831 accessed 286 09)


11

When the grass is greener at homePoland

Marcin Kautsch and Katarzyna Czabanowska

Mobility profile

Although commonplace before EU acces-sion health workforce mobility escalatedsignificantly in 2004 with the removal ofbarriers hindering those seeking jobplacements abroad After reaching a peakin 2006 recent years have seen consider-able changes to migration patterns prob-ably largely due to substantial increases inthe income levels of health professionalsparticularly doctors in Poland

The main destination countries are theUnited Kingdom Ireland GermanySweden and Denmark The main pushfactors are low salaries difficult workingconditions and limited possibilities forprofessional development

Outflows

Medical doctors 3 of doctors are estimated to have considered emigratingin 20041 After accession (2005ndash2008)over 7000 (61) doctors obtained pro-fessional qualification certificates issuedby the professional chambers and associa-tions to allow them to work abroadWhile certification requests initially increased rapidly following accession therate slowed from mid-2007 The majorityof doctors applying for certification wereanaesthetists and intensive care special-ists followed by thoracic surgeons plas-tic surgeons and specialists in emergency

care This may be because these groupshave rather limited contact with patientsand so do not need the degree of languagefluency that is normally required for non-surgical specialties Moreover it appearsthat younger specialists having justgained their qualifications are willing tomigrate permanently to other Europeancountries while more senior doctors withlong experience and families prefer shortduties abroad rather than complete relo-cation2 Other evidence from professionalchambers also suggests that most doctorswork abroad for a set period of time before returning home or work part-timein another country (for example weekend work) to earn extra money

Nurses 12 of nurses are estimated tohave considered emigrating in 20041Arelatively low number of nurses and midwives applied for certification during2004ndash2006 approximately 19 of regis-tered or 3 of practising nurses and mid-wives This may be because employers(such as long-term care providers) did notrequire documents or because they wereemployed to perform care activities thatdid not require professional qualifications

Dentists 36 of dentists are estimated tohave considered emigrating in 20041

Around 2000 (67) dentists obtainedprofessional qualification certificates in2005ndash2008

Not all those who obtain a certificate actually migrate Also some doctors leave Polandwithout certification ndash although it is unclear how these individuals are employed abroad While there are more than 300 000 registered nurses in Poland nurse organizations estimate that around 200 000 actually work as nurses

Adriana Galan Public Health Consultant National Institute of Public Health RomaniaVictor Olsavszky Head of World Health Organization Country Office RomaniaCristian Vladescu Professor of Public Health University of Medicine and PharmacyTimisoara Romania

World Health

Organization

Regional Office

for Europe

Government

of Finland

Government

of Norway

Government

of Ireland

UNCAM

Government

of the

Netherlands

European

Commission

Government

of Spain

Government

of Slovenia

European

Investment

Bank

Veneto

Region of

Italy

World Bank

London School

of Economics

and Political

Science

London School

of Hygiene amp

Tropical

Medicine

THE EUROPEAN OBSERVATORY ONHEALTH SYSTEMS ANDPOLICIES PARTNERS

Government

of Belgium

EditorAnna Maresso

Editorial TeamJosep FiguerasMartin McKee

Elias MossialosSarah Thomson

To join the mailing list please contact

Anna MaressoObservatory ndash London HubEmail amaressolseacuk

The views expressed inEuro Observer are those of the authors alone and not

necessarily those of the European Observatory on

Health Systems and Policies orits participating organizations

copy European Observatory onHealth Systems and Policies

2011

No part of this document maybe copied reproduced stored

in a retrieval system or transmitted in any form without

the express written consent ofthe European Observatory on

Health Systems and Policies

For information and orderingdetails on any of the Observa-

tory publications mentioned inthis issue please contact

The European Observatory onHealth Systems and Policies

WHO ECHPRue de lrsquoAutonomie 4

B - 1070 Brussels Belgium Tel +32 2 525 09 33Fax +32 2 525 0936

Email infoobseurowhoint wwweurowhointobservatory

Design and production by Westminster European

ISSN 1020-7481

Government

of Sweden

12


Inflows

Only a limited number of health professionals choose Poland as theirtarget country mainly due to the language barrier and the lack of aproactive recruitment policy ndash it cantake up to 18 months to obtain a workpermit and recognition of professionaldiplomas3 Estimates for 2009 put theshare of foreign doctors and dentists tobe less than 1 of registered person-nel Those who do come are mostlyfrom countries in which GDP is lowerthan in Poland mainly Ukraine Thereare also indications that Poland may beattracting individuals from the Polishcommunity abroad especially fromthe countries of the former USSR whowere born and trained overseas


It is difficult to evaluate the exact impact of health professional mobilitydue to the absence of data or studiesHowever while it is not so large that itposes a significant threat to the healthcare system in the short-term it is anoticeable phenomenon It can be argued that emigration contributes tostaff shortages in general and in certainspecialties Smaller towns and hospitalsare particularly affected The data indi-cate that the specialties first affected arethose where relatively high proportionsof doctors are applying for certifica-tion particularly anaesthetics intensivecare and emergency medicine

Policy responses

Health policy concerning the healthworkforce and mobility is not well developed and government activitiesare limited to general declarationsabout the need to keep health profes-sionals at home Market mechanismsof compensation levels demand levelsand exchange rates determine the behaviour of health professionals byinfluencing whether or not they perceive working abroad as attractiveThus ad hoc policy interventions haveincluded

ndash In 2001 the salaries of all fully con-tracted health professionals in pub-lic health institutions were raised by

203 PLN (euro56) per month what-ever their positions years of experi-ence qualifications or implicationsfor their health care institutions

ndash Preferred loans were offered tohealth professionals to start theirown private businesspractice thusproviding financial career-relatedand entrepreneurial incentives topromote domestic opportunities forprofessional development

ndash Recruitment of new candidates forhealth and health-related studieshave been instigated particularly inpriority areas which attract highersalaries for medical interns and

ndash Managers of health care institutionsare offering changes in employmentstatus from full-time employmentto fee-for-service self employmentagreements (with smaller obligatoryinsurance contributions) These willallow self-employed doctors to in-crease their working hours (beyondthe limits of the EU working timedirective) and increase income

REFERENCES

1 Nosowska KT Gorynski P Migration of medical personnel to workabroad during the first year of joiningthe EU Problemy Higieny in Epidemi-ologii 200687(1)55ndash60 [in Polish]

2 Polish doctors choose Ireland for additional duty hours Gazetapl Wiado-mosci 20 September 2008 [in Polish]httpwiadomoscigazetaplWiadomosci10887215715555Polscy_lekarze_wybieraja Irlandie_ na_dodatkowe_ dyzuryhtml accessed 1 December 2010)

3 Kicinger A Between Polish interestsand the EU influence ndash Polish migrationpolicy development 1989ndash2004 CentralEuropean Forum for Migration Research Working Paper 92005 Warsaw CEFMR 2005

Marcin Kautsch Assistant ProfessorInstitute of Public Health JagiellonianUniversity Medical College Poland

Katarzyna Czabanowska AssistantProfessor Department of InternationalHealth Faculty of Health Medicineand Life Sciences Maastricht University Netherlands

Health professional mobility and health systems evidence from 17 European countries



Opportunities in an expanding health service Spain



When the grass is greener at home Poland


2

Reliance on foreign health professionalshas accumulated over decades and formany countries inflows remain signifi-cant In 2008 the proportion of foreign-ers within all new health workforce entrants was particularly high for medicaldoctors in the United Kingdom (426)Belgium (253) and Austria (135)for nurses in Italy (28) the UnitedKingdom (147) and Belgium (135)and for dentists in Austria (408) theUnited Kingdom (337) Belgium(193) and Hungary (97) In Finland432 of newly licensed dentists from2006 to 2008 were foreign trained

While some countries rely heavily on foreign health professionals Figure 1shows the diversity across Europe withseveral countries showing little or no reliance on foreign health professionals

Effects of EU enlargement lessthan expected

EU enlargement since 2004 has generateda new impetus for mobility although itdid not generate outflows as large as ini-tially expected ndash with mobility intentionsas expressed by the number of requestsfor conformity certificates in the EU-12 hovering at around 3 of health professionals (see Figure 2) and actualmigration being even lower since not allrequests are followed by emigration

Recent data from Estonia Hungary andRomania (see case study in this issue)seem to suggest a new surge in outflowspresumably related to the economicdownturn since 2008 However a reversetrend has also been observed with Polishmedical doctors returning to Poland

East-West asymmetries worsened

The new mobility triggered by the EUenlargement in 2004 and 2007 has furtheremphasized East-West asymmetries interms of in and outflows of health profes-sionals with the EU-15 as the main desti-nation for migrants from the then newMember States The asymmetry does notlie in the outflows per se Many of theEU-15 have considerable outflows of thesame magnitude as the EU 12 Howeverunlike the EU-15 the EU-12 countrieshave only negligible inflows

Box 1 PROMeTHEUS ndash Health Professional Mobility in the European Union Study

The issue of health professional mobility was discussed during the informalmeeting of health ministers organized by the Hungarian Presidency of theCouncil of the European Union in Goumldoumlll (Hungary) on 4ndash5 April 2011 On thisoccasion a new study on which this Euro Observer issue is based was pre-sented by the European Observatory on Health Systems and Policies in partner-ship with the WHO Regional Office for Europe This volume Health ProfessionalMobility and Health Systems evidence from 17 European countries draws onthe first results of a research project funded by the EU (grant agreement 223383)on health professional mobility in the EU (PROMeTHEUS) that started in 2009The countries covered include Austria Belgium Estonia Finland France Germany Hungary Italy Lithuania Poland Romania Serbia Slovakia SloveniaSpain Turkey and the United Kingdom Based on evidence provided by the 17

country case studies the book looks into the scope of health professional migration in the EU both in termsof the flows and the reliance on foreign health professionals The study also provides a better understand-ing of the underlying push and pull factors influencing health professional mobility the impact on healthsystems the broader domestic workforce issues and the policies to address the related challenges

0

5

10

15

20

25

30

35

40

Percentage of foreign medical doctors

foreign-trained foreign-national foreign-born

New

Zealand

Romania

Serbia

Lithuania

Turkey

Estonia

Slovakia

Poland

Hungary

Italy

France

Germ

any

Finland

Belgium

Portugal

Spain

Austria

Norw

ay

Canada

Sweden

Switzerland

Slovenia

Australia

United States

Ireland

United Kingdom

Figure 1 Reliance on foreign medical doctors 2008 or latest available year

0

2

4

6

8

10

0

1000

2000

3000

4000

5000

Estonia Hungary Lithuania Poland Romania

2004

2005

2006

2007

2008

2009

2004

2005

2006

2007

2008

2009

2004

2005

2006

2007

2008

2009

2004

2005

2006

2007

2008

2009

2004

2005

2006

2007

2008

2009

Number of doctors intending to leave

Percentage amongmedical doctors

Figure 2 Yearly outflow intentions of medical doctors from selected 2004 and 2007 enlargement countries


3















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Organization

Regional Office

for Europe

Government

of Finland

Government

of Norway

Government

of Ireland

UNCAM

Government

of the

Netherlands

European

Commission

Government

of Spain

Government

of Slovenia

European

Investment

Bank

Veneto

Region of

Italy

World Bank

London School

of Economics

and Political

Science

London School

of Hygiene amp

Tropical

Medicine


Government

of Belgium

EditorAnna Maresso









2011












ISSN 1020-7481

Government

of Sweden

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Policy responses







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3















Policy implications





4








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Organization

Regional Office

for Europe

Government

of Finland

Government

of Norway

Government

of Ireland

UNCAM

Government

of the

Netherlands

European

Commission

Government

of Spain

Government

of Slovenia

European

Investment

Bank

Veneto

Region of

Italy

World Bank

London School

of Economics

and Political

Science

London School

of Hygiene amp

Tropical

Medicine


Government

of Belgium

EditorAnna Maresso









2011












ISSN 1020-7481

Government

of Sweden

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Inflows




Policy responses







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for Europe

Government

of Finland

Government

of Norway

Government

of Ireland

UNCAM

Government

of the

Netherlands

European

Commission

Government

of Spain

Government

of Slovenia

European

Investment

Bank

Veneto

Region of

Italy

World Bank

London School

of Economics

and Political

Science

London School

of Hygiene amp

Tropical

Medicine


Government

of Belgium

EditorAnna Maresso









2011












ISSN 1020-7481

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of Sweden

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World Health

Organization

Regional Office

for Europe

Government

of Finland

Government

of Norway

Government

of Ireland

UNCAM

Government

of the

Netherlands

European

Commission

Government

of Spain

Government

of Slovenia

European

Investment

Bank

Veneto

Region of

Italy

World Bank

London School

of Economics

and Political

Science

London School

of Hygiene amp

Tropical

Medicine


Government

of Belgium

EditorAnna Maresso









2011












ISSN 1020-7481

Government

of Sweden

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Policy responses







REFERENCES














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Organization

Regional Office

for Europe

Government

of Finland

Government

of Norway

Government

of Ireland

UNCAM

Government

of the

Netherlands

European

Commission

Government

of Spain

Government

of Slovenia

European

Investment

Bank

Veneto

Region of

Italy

World Bank

London School

of Economics

and Political

Science

London School

of Hygiene amp

Tropical

Medicine


Government

of Belgium

EditorAnna Maresso









2011












ISSN 1020-7481

Government

of Sweden

12


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Policy responses







REFERENCES














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REFERENCES







Mobility profile


Inflows








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World Health

Organization

Regional Office

for Europe

Government

of Finland

Government

of Norway

Government

of Ireland

UNCAM

Government

of the

Netherlands

European

Commission

Government

of Spain

Government

of Slovenia

European

Investment

Bank

Veneto

Region of

Italy

World Bank

London School

of Economics

and Political

Science

London School

of Hygiene amp

Tropical

Medicine


Government

of Belgium

EditorAnna Maresso









2011












ISSN 1020-7481

Government

of Sweden

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Outflows








Policy responses






REFERENCES










9

Mobility profile


Inflows






Outflows






Policy responses



Ruth Young



REFERENCES







10

Mobility profile



Outflows






Inflows








Policy responses


REFERENCES






11



Mobility profile



Outflows








World Health

Organization

Regional Office

for Europe

Government

of Finland

Government

of Norway

Government

of Ireland

UNCAM

Government

of the

Netherlands

European

Commission

Government

of Spain

Government

of Slovenia

European

Investment

Bank

Veneto

Region of

Italy

World Bank

London School

of Economics

and Political

Science

London School

of Hygiene amp

Tropical

Medicine


Government

of Belgium

EditorAnna Maresso









2011












ISSN 1020-7481

Government

of Sweden

12


Inflows




Policy responses







REFERENCES














9

Mobility profile


Inflows






Outflows






Policy responses



Ruth Young



REFERENCES







10

Mobility profile



Outflows






Inflows








Policy responses


REFERENCES






11



Mobility profile



Outflows








World Health

Organization

Regional Office

for Europe

Government

of Finland

Government

of Norway

Government

of Ireland

UNCAM

Government

of the

Netherlands

European

Commission

Government

of Spain

Government

of Slovenia

European

Investment

Bank

Veneto

Region of

Italy

World Bank

London School

of Economics

and Political

Science

London School

of Hygiene amp

Tropical

Medicine


Government

of Belgium

EditorAnna Maresso









2011












ISSN 1020-7481

Government

of Sweden

12


Inflows




Policy responses







REFERENCES















REFERENCES







10

Mobility profile



Outflows






Inflows








Policy responses


REFERENCES






11



Mobility profile



Outflows








World Health

Organization

Regional Office

for Europe

Government

of Finland

Government

of Norway

Government

of Ireland

UNCAM

Government

of the

Netherlands

European

Commission

Government

of Spain

Government

of Slovenia

European

Investment

Bank

Veneto

Region of

Italy

World Bank

London School

of Economics

and Political

Science

London School

of Hygiene amp

Tropical

Medicine


Government

of Belgium

EditorAnna Maresso









2011












ISSN 1020-7481

Government

of Sweden

12


Inflows




Policy responses







REFERENCES
















Policy responses


REFERENCES






11



Mobility profile



Outflows








World Health

Organization

Regional Office

for Europe

Government

of Finland

Government

of Norway

Government

of Ireland

UNCAM

Government

of the

Netherlands

European

Commission

Government

of Spain

Government

of Slovenia

European

Investment

Bank

Veneto

Region of

Italy

World Bank

London School

of Economics

and Political

Science

London School

of Hygiene amp

Tropical

Medicine


Government

of Belgium

EditorAnna Maresso









2011












ISSN 1020-7481

Government

of Sweden

12


Inflows




Policy responses







REFERENCES













World Health

Organization

Regional Office

for Europe

Government

of Finland

Government

of Norway

Government

of Ireland

UNCAM

Government

of the

Netherlands

European

Commission

Government

of Spain

Government

of Slovenia

European

Investment

Bank

Veneto

Region of

Italy

World Bank

London School

of Economics

and Political

Science

London School

of Hygiene amp

Tropical

Medicine


Government

of Belgium

EditorAnna Maresso









2011












ISSN 1020-7481

Government

of Sweden

12


Inflows




Policy responses







REFERENCES











