health professionals and health sistems _migratie

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Evidence from17 European countries

Edited by

Matthias Wismar

Claudia B. Maier

Irene A. Glinos

Gilles Dussault

Josep Figueras

23Health ProfessionalMobility and HealthSystems

Ob

servatory

Stud

iesSeries


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Health Professional Mobility and Health Systems


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Te European Observatory on Health Systems and Policies supports and promotes evidence-

based health policy-making through comprehensive and rigorous analysis o health systems inEurope. It brings together a wide range o policy-makers, academics and practitioners to analysetrends in health reorm, drawing on experience rom across Europe to illuminate policy issues.

Te European Observatory on Health Systems and Policies is a partnership between the WorldHealth Organization Regional Oce or Europe, the Governments o Belgium, Finland, Ireland,the Netherlands, Norway, Slovenia, Spain, Sweden and the Veneto Region o Italy, the EuropeanCommission, the European Investment Bank, the World Bank, UNCAM (French NationalUnion o Health Insurance Funds), the London School o Economics and Political Science, andthe London School o Hygiene & ropical Medicine.


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Health Professional Mobilityand Health Systems

Evidence from 17 European countries

Edited by

Matthias Wismar, Claudia B. Maier, Irene A. Glinos,

Gilles Dussault, Josep Figueras


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Keywords:DELIVERY OF HEALH CARE organization and administrationHEALH PERSONNEL trendsEMIGRAION AND IMMIGRAIONEUROPE

World Health Organization 2011, on behal o the European Observatory on Health Systems and Policies

All rights reserved. Te European Observatory on Health Systems and Policies welcomes requests orpermission to reproduce or translate its publications, in part or in ull.

Te designations employed and the presentation o the material in this publication do not imply theexpression o any opinion whatsoever on the part o the European Observatory on Health Systems andPolicies concerning the legal status o any country, territory, city or area or o its authorities, or concerningthe delimitation o its rontiers or boundaries. Dotted lines on maps represent approximate border lines orwhich there may not yet be ull agreement.

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All reasonable precautions have been taken by the European Observatory on Health Systems and Policies toveriy the inormation contained in this publication. However, the published material is being distributedwithout warranty o any kind, either express or implied. Te responsibility or the interpretation and use othe material lies with the reader. In no event shall the European Observatory on Health Systems and Policiesbe liable or damages arising rom its use. Te views expressed by authors, editors, or expert groups do notnecessarily represent the decisions or the stated policy o the European Observatory on Health Systems andPolicies or any o its partners.

ISBN 978 92 890 0247 9

Printed in the United Kingdom

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Address requests about publications to: Publications, WHO Regional Oce or Europe, Schergsvej 8,DK-2100 Copenhagen , Denmark.

Alternatively, complete an online request orm or documentation, health inormation, or or permissionto quote or translate, on the Regional Oce web site (http://www.euro.who.int/pubrequest).
http://www.euro.who.int/pubrequesthttp://www.euro.who.int/pubrequest


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Contents

Foreword by Paola Testori Coggi, Director-General, Directorate-General for

Health and Consumers ix

Foreword by Zsuzsanna Jakab, Regional Director, WHO Regional Ofce for Europe xi

Acknowledgements xiii

List of tables, gures and boxes xv

List of abbreviations xxvii

List of contributors xxix

Part I Setting the scene, results and conclusions 1

Chapter 1 Health professional mobility and health systems in Europe: 3

an introductionMatthias Wismar, Claudia B Maier, Irene A Glinos, Jeni Bremner,


Chapter 2 Cross-country analysis of health professional mobility in Europe: 23

the results

Claudia B Maier, Irene A Glinos, Matthias Wismar, Jeni Bremner,


Chapter 3 Health professional mobility and health systems in Europe: 67

conclusions from the case-studies Irene A Glinos, Matthias Wismar, Claudia B Maier, Willy Palm, Josep Figueras

Part II Case studies from countries that joined the EU before 2004 87

Chapter 4 Mobility, language and neighbours: Austria as source and 89

destination country

Guido Oermanns, Eva Maria Malle, Mirela Jusic

Chapter 5 Of permeable borders: Belgium as both source and host country 129

Anna Sauta, Rita Baeten

Chapter 6 Changing context and priorities in recruitment and employment: 163

Finland balances inows and outows of health professionals

Hannamaria Kuusio, Meri Koivusalo, Marko Elovainio, Tarja Heponiemi,

Anna-Mari Aalto, Ilmo Keskimki


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vi Health Proessional Mobility and Health Systems

Chapter 7 Nationally moderate, locally signicant: France and health 181

professional mobility from far and near

Marie-Laure Delamaire, Franois-Xavier Schweyer

Chapter 8 A destination and a source: Germany manages regional health 211workforce disparities with foreign medical doctors

Diana Ognyanova, Reinhard Busse

Chapter 9 Oversupplying doctors but seeking carers: Italys demographic 243

challenges and health professional mobility

Luigi Bertinato, Irene A Glinos, Elisa Boscolo, Leopoldo Ciato

Chapter 10 Opportunities in an expanding health service: Spain between 263

Latin America and Europe

Beatriz Gonzlez Lpez-Valcrcel, Patricia Barber Prez,Carmen Delia Dvila Quintana

Chapter 11 A major destination country: the United Kingdom and its 295

changing recruitment policies

Ruth Young

Part III Case studies from countries that joined the EU in 337

2004 or 2007

Chapter 12 Migration and attrition: Estonias health sector and cross-border 339mobility to its northern neighbour

Pille Saar, Jarno Habicht

Chapter 13 From melting pot to laboratory of change in central Europe: 365

Hungary and health workforce migration

Edit Eke, Edmond Girasek, Mikls Szcska

Chapter 14 Awareness, planning and retention: Lithuanias approach to 395

managing health professional mobility

ilvinas Padaiga, Martynas Pukas, Liudvika Starkien

Chapter 15 When the grass gets greener at home: Polands changing 419

incentives for health professional mobility

Marcin Kautsch, Katarzyna Czabanowska

Chapter 16 Emergent challenge of health professional emigration: 449

Romanias accession to the EU

Adriana Galan, Victor Olsavszky, Cristian Vladescu

Chapter 17 Regaining self-sufciency: Slovakia and the challenges of health 479professionals leaving the country

Kvetoslava Beuov, Miloslava Kovov, Marin Nagy, Matthias Wismar


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viiContents

Chapter 18 Addressing shortages: Slovenias reliance on foreign health 511

professionals, current developments and policy responses

Tit Albreht

Part IV Case studies from third countries having applied for 539

EU membership

Chapter 19 Geopolitics, economic downturn and oversupply of medical 541

doctors: Serbias emigrating health professionals

Ivan M. Jeki, Annette Katrava, Maja Vukovi-Krmar,

Vesna Bjegovi-Mikanovi

Chapter 20 At the crossroads:Turkeys domestic workforce and restrictive 569

labour laws in the light of EU candidacyHasan Hseyin Yldrm, Sdka Kaya


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Foreword

Tis work contributes a great deal to the current reection o the EuropeanCommission and Member States about the uture o the European Unionhealth workorce. Te Europe 2020 Strategy or smart, sustainable and inclusive

growth highlights the need to reorm labour markets, upgrade skills and matchthem with market demand. In parallel, we also need to plan or our ageingsociety and the additional health care which will be needed in the uture. It isestimated that by 2020 there will be a shortall o 1 000 000 health proessionalsin the European Union. We need to work together with all actors, nationalauthorities, health proessionals and civil society to address this challenge.

When the Commission published its Green Paper on the European Workorce

or Health, it emerged rom the public consultation that one o the mostsignicant barriers to efective workorce planning is the lack o data andinormation. O this, the biggest challenge or planners has been the lack odata on mobility o health proessionals where they go, how long they stayaway, whether they come back or not.

Indeed, the need or better quantitative and qualitative data to support decision-making proved to be one o the most pertinent issues. It is the human ace, thecase histories, which provides us with greater understanding o the motivations,

aspirations and personal circumstances that inuence health proessionals.Te testimonials in this book illustrate this point.

I, thereore, commend this book as a contribution to addressing the biggerpicture and putting a human ace to some o the challenges we need to overcome.I hope readers will derive inspiration rom it.

Paola Testori CoggiDirector-General, Directorate-General or Health and Consumers


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Foreword

Migration o health proessionals has globally increased over the last decades.By losing health workers, already ragile health systems in low- and middle-income countries may be urther weakened. In the context o the globalhealth workorce crisis, these migratory ows became a matter o global policy

concern. o respond to this challenge the World Health Assembly adopted in2010 the WHO Global Code o Practice or the International Recruitmento Health Personnel. Te Code discourages recruitment rom countries withworkorce shortages and provides guidance to strengthen the workorce andhealth systems across the globe, including an emphasis on improving stafretention, workorce sustainability and efective workorce planning.

Te WHO Regional Oce or Europe and the Member States stronglysupported the development and adoption o the Code, building on theirexperience with national and regional codes, ethical workorce policies andother instruments or steering and managing health proessional mobility, aswell as broader aspects o health workorce policy and planning. Te Codehas relevance or Europe and the European Union and provides a rameworkor health workorce development and health system sustainability. It stressesthe strengthening and urther development o education and training andthe monitoring and coordination o labour market activities; it addressesmaldistribution o health proessionals through educational measures, nancialincentives, regulatory measures and social and proessional support.

Tis volume gives a comprehensive analysis o mobility patterns, the impactso migration on health systems and its relevance or policy-making and policyresponses across Europe. It will enhance our knowledge not only on healthworkorce mobility but also on workorce development. I appreciate theinsights given by the inclusion o a wide range o countries across the EuropeanRegion, both within and outside the European Union.

I, thereore, welcome this volume with its emphasis on the need to put healthproessional mobility into the wider country and health systems context.

Zsuzsanna Jakab, Regional Director, WHO Regional Oce or Europe


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Acknowledgements

Tis volume is one o a series o books produced by the European Observatoryon Health Systems and Policies. We would like to express our gratitude tothe country authors or their dedication and expertise; to Jonathan Northor his patience and support in the production process; to Jo Woodhead or

her diligence and precision in language editing; and to Peter Powell or hisproessionalism and typesetting skill. Tis book would not have been possiblewithout their outstanding work and persistence.

Te editors would also like to express their gratitude to Christiane Wiskow andNiamh Humphries or rigorously reviewing the drat chapters o this book. Wehave all benetted substantially rom their comments

For Chapter 5, the authors would like to thank Mr Sohab Azibou, Ms Caroline

Jadot, Mr Henk Vandenbroele and Mr oon De Geest (FPS Public Health);Mr Chris Segaert and Mr Pascal Meert (NIHDI); Mr Danil De Schrijver(NARIC-Vlaanderen); Ms Anne Hellemans and Mr Julien Boudart (Ministryo the French Community); and Ms Hellen Sjerps-de Boer and Mr Jurian Luiten(Dutch Ministry o Public Health). Tis research would not have been possiblewithout their help in providing us with data and/or valuable inormation.

For Chapter 7, the authors would like to thank G Le Breton-Lerouvillois,F Montan and O Uguen (CNOM); DHD Bui (Centre or Sociology and

Medical Demography); E Quillet (DHOS, Ministre de la Sant et des Sports);S Guigner and A Le Vigouroux (EHESP); M Millan (Ministre de la Santet des Sports), P Garel (European Hospital and Healthcare Federation), J-CDumont and G Laortune (OECD); C Aguilella and C Couzinou (ONCD);and M Burdillat (ONDPS).

For Chapter 10, the authors thank Jaime Pinilla and Sara Santiago or their help.

For Chapter 12, the authors are grateul to Evi Lindme (Head, Department

o Registers and Licences, Health Board), Erna Mering (Head, Bureau oRegistries, Health Board) and Eero Mttus (Chie Specialist, Inormation-and Communication echnology Department, Ministry o Social Afairs oEstonia) or their assistance in providing statistical inormation. Te authorsare also grateul to aavi Lai (Senior Analyst, Health Inormation and Analysis


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xiv Health Proessional Mobility and Health Systems

Department, Ministry o Social Afairs o Estonia) and riin Habicht (Head,Health Economics Department, Estonian Health Insurance Fund) or theirvaluable eedback and comments during the report review process.

For Chapter 13, we would like to thank Dr Pter Balzs who was a specialcontributor to this study. We used data, analytical results and studies rom hisrelevant publications and consulted with him on some issues that arose.

For Chapter 15, the authors would like to acknowledge the valuable contributiono Agata Grudzie, Marcin Mikos and Dariusz Poznaski in the process ocollecting data and supporting inormation on the migration o Polish healthproessionals.

For Chapter 16, the authors are grateul to Ioana Pertache (Deputy Director,NCOEHIS, Bucharest) or providing valuable input about the National Registryo Physicians. Tey are also grateul to Proessor Vasile Astrstoae (President othe Romanian College o Physicians); Mircea imote (President o the Ordero Nurses and Midwives); Proessor Alexandru Rala (University o Medicineand Pharmacy Bucharest, ormer Adviser or Health Policies, Ministry oHealth); Beatrice Nimereanu (Head, Human Resources Department, Ministryo Health); Cassandra Butu (echnical Ocer, WHO Country Oce,Romania); and Cezar Popa-Canache (Legal Adviser, Institute o Public Health,Bucharest) or their useul inormation, comments and revisions.

For Chapter 19, the Ministry o Health o the Republic o Serbia gave ullsupport in the process o preparation and review o this Case Study. Specialthanks go to Prim Dr Elizabet Paunovic, State Secretary in charge o EUIntegration and international collaboration, and to Dr Ivana Mii, AssistantMinister and Head o Department o Health Service Organization, Ministry oHealth. Te authors would also like to express their gratitude to the ollowing

institutions and their representatives who contributed valuable insights and dataon health proessionals: Dr anja Radosavljevi (President, Serbian Chambero Physicians); Mr Dragan ai (Director, Serbian Chamber o Nurses andHealth echnicians); Mrs Radmila Nei (President, Association o HealthWorkers o Serbia); Mrs Verica Milovanovi (President) and Mrs ivka Miti(Association o Nurses, echnicians and Midwives o Serbia); Serbian Chambero Dentists, Serbian Medical Association, Institute o Public Health Dr MilanJovanovic Batut, Clinical Center o Serbia, Belgrade and others. Proessor

Vladimir Grei (School o Economics, University o Belgrade), a renownedexpert in the eld o migration, gave us valuable expert opinion. Special thanksto Ms Miroslava Narani or data entry and ormatting.


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List o tables, fguresand boxes

TablesTable 1.1 Cross-border instruments and tools for steering and managing

health professional mobility 13

Table 1.2 Country coverage 15

Table 2.1 Yearly outows/outow intentions of medical doctors from

selected 2004 and 2007 EU Member States 42

Table 2.2 Medical doctors, nurses and midwives from EU-12 countries

newly registered in the United Kingdom, 20032008 43

Table 2.3 Cross-border frameworks for steering and managing health

professional mobility 59

Table 4.1 Foreign medical doctors in Austria, from different data sources

and indicators 92

Table 4.2 Newly registered native and foreign medical doctors in Austria,

by nationality, 2000 and 20032008 94

Table 4.3 Native and foreign-national medical doctors (stock) in Austria,20032008 96

Table 4.4 Foreign-trained nurses applying for diploma validation in Austria,

20032008 98

Table 4.5 Foreign-national nurses from eastern European and non-EU

countries applying for work permits, 20032008 98

Table 4.6 Newly registered foreign midwives in Austria, by nationality,

20032008 101

Table 4.7 Newly registered native and foreign dentists in Austria, by

nationality, 20032007 102

Table 4.8 Registered dentists (stock) in Austria, by nationality, 20052007 103


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xvi Health Proessional Mobility and Health Systems

Table 4.9 Country-level instruments for steering and managing health


Table 4.10 Cross-border instruments and tools for steering and managing

health professional mobility 114

Table 4.11 Foreign-national medical doctors in Austria, 20032008

(stock data) 121

Table 4.12 Foreign-trained nurses in Austria: diploma validation applications,

20032008 122

Table 4.13 Nurses from eastern European countries: applications for work

permits in Austria, 20032008 122

Table 4.14 Newly registered dentists in Austria, by nationality, 20032007 123

Table 4.15 Practising dentists in Austria, by nationality, 20052007 124

Table 4.16 Newly registered midwives in Austria, by nationality, 20032008 125

Table 4.17 Practising foreign-national, foreign-born and foreign-trained

midwives in Austria by country of origin, 2008 126

Table 4.18 Outows of midwives from Austria, 20032008 127

Table 5.1 Number of conformity certicates requested by specialists with

Belgian diplomas, 20062008 132

Table 5.2 Estimated numbers of foreign-trained medical doctors with basic

training licensed in Belgium per year, 20052008 135

Table 5.3 Medical doctors with non-EEA diplomas undertaking part of their

specializations in Belgium under Royal Decree No. 78 135

Table 5.4 General practitioners and specialists in Belgium, 20052008 136

Table 5.5 Newly licensed nurses in Belgium, 20052008 137

Table 5.6 Foreign nursing diplomas recognized or declared equivalent

in Belgium 139

Table 5.7 Newly licensed dentists in Belgium, 20052008 139

Table 6.1 Employment rates of Finnish and foreign-born medical doctors,

dentists and nurses of working age in Finland, 20002007 172

Table 7.1 Main data sources and data holders on health professional

mobility in France 183

Table 7.2 Foreign-national medical doctors from EU and third countries

(stock), 19902010 185

Table 7.3 Annual inows: newly registered foreign-national medical doctors

in France, 19882006 187


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xviiList o tables, fgures and boxes

Table 7.4 Nurses registered in France (stock) by nationality and origin of

degree, 1 January 2006 189

Table 7.5 Authorizations to practise issued to foreign nurses and foreign-

trained nurses by the competent authority, 2005 and 2006 189

Table 7.6 General medical doctors and specialists: percentages with

degrees from practice regions and with foreign degrees 196

Table 7.7 Medical doctors in France by nationality and origin of degree,

1 January 2006 206

Table 7.8 Foreign-born, foreign-national and foreign-trained nurses applying

for professional registration on completion of studies in France,

2003 and 2008 207

Table 8.1 Registered foreign-national medical doctors in Germany, by

nationality, 1988 and 20032008 216

Table 8.2 Foreign-national nurses and midwives subject to social insurance

contributions in Germany, by nationality, 20032008 223

Table 10.1 Registered doctors (stock) in autonomous regions in Spain, 2007 266

Table 10.2 Foreign degrees in general medicine recognized in Spain,

19982008 266

Table 10.3 Registered nurses (stock) working in Spain, 20042008 268

Table 10.4 Nationality of dentists and origin of dental degree, 1998 and 2007 270

Table 10.5 Inows and outows of dentists in Spain, 20022007 270

Table 10.6 Inows and outows of pharmacists in Spain, 20022007 271

Table 10.7 Inows of health professionals from new Member States,

20052008 272

Table 10.8 MIR entrance examination candidates, 2007 and 2008 276

Table 10.9 University degrees in the health professions: students,

universities and graduates, 20072008 276

Table 10.10 Factors inuencing health professional mobility in Spain 278

Table 10.11 National-level instruments for guiding and managing health


Table 10.12 Country zones used with EAPS microdata 290

Table 10.13 Main data sources for stock and ows of health professionals

in Spain 291

Table 10.14 Application requirements for MIR candidates 292

Table 11.1 Data sources on mobility: coverage, availability and limitations 297


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Table 11.2 Total and newly registered medical doctors from United Kingdom,

EEA and other world regions, 1988 and 20032008 299

Table 11.3 Total and newly registered nurses/midwives from United Kingdom,

EEA and other world regions, 1988 and 20032008 301

Table 11.4 Medical doctors from EEA and other international source

countries on the GMC Medical Register: total new registrants

20032008 and change in numbers registered 19882003 302

Table 11.5 Nurses/midwives from EEA and other international source

countries: total new registrants on NMC Register, 20032008 303

Table 11.6 Cleared, individual work permit applications for health professional

groups by world region and main countries, 20032008 305

Table 11.7 Verication applications from nurses/midwives considering work

abroad main European and other international destinations,

20022008 306

Table 11.8 CGSs issued for medical doctors to work abroad main

European and other international destinations, 20072009 307

Table 11.9 Factors attracting health professionals to the United Kingdom 314

Table 11.10 Timeline of immigration and mobility policy for health professionals 317

Table 12.1 Registry data on domestic and foreign-trained medical doctors in

Estonia according to activity, 20032009 342

Table 12.2 Mutual recognition of diploma certicates issued to practising

registered medical doctors in Estonia, by intended destination

country, 20042009 342


registered medical doctors in Estonia, 20042009 343


registered nurses in Estonia, by intended destination country,

20042009 344


registered nurses in Estonia, 20042009 344

Table 12.6 Registry data on domestic and foreign dentists in Estonia,

20032009 345

Table 12.7 Mutual recognition of diploma certicates issued to practisingregistered dentists in Estonia, by intended destination country,

20042009 346


registered dentists in Estonia, 20042009 346


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xixList o tables, fgures and boxes

Table 12.9 Average monthly gross salaries () of health personnel in Estonia,

20022008 358

Table 13.1 Applications for certication, by health profession, 1 May 2004 to

31 December 2009 369

Table 13.2 Health professionals resident in Hungary as proportions of all

health professionals applying for certication, 1 May 2004 to


Table 13.3 Declared target countries among all health professionals applying

for certication, 1 January 2009 to 31 December 2009 371

Table 13.4 Diplomas held by medical doctors applying for certication,

1 May 2004 to 31 December 2009 372

Table 13.5 Specialties of medical doctors applying for certication,

1 January 2009 to 31 December 2009 372

Table 13.6 Foreign newly registered and all newly registered medical doctors

(inows), foreign active and all active medical doctors (stock) in

Hungary, 1 May 2004 to 31 December 2008 373

Table 13.7 Foreign newly registered and all newly registered nurses (inows),

foreign active and all active nurses (stock) in Hungary,

1 May 2004 to 30 June 2009 374

Table 13.8 Foreign newly registered and all newly registered dentists

(inows), foreign active and all active dentists (stock) in Hungary,

1 May 2004 to 31 December 2008 374

Table 13.9 Inows of medical doctors of Hungarian descent, 19582008 375

Table 13.10 Inows of dentists of Hungarian descent, 19722008 375

Table 14.1 Data sources for information on human resources for health

in Lithuania 397

Table 14.2 Work permits issued to foreign health professionals in Lithuania,

20052008 398

Table 14.3 Specialist posts with highest number of vacancies in Lithuania 404

Table 14.4 Health professional stock and distribution in Lithuania, 2007 406

Table 14.5 Educational institutions and students, by health profession, 2008 408

Table 14.6 Factors inuencing mobility of Lithuanian health professionals 411

Table 14.7 Main national stakeholders involved in planning, production,

management and regulation of health professionals in Lithuania 413

Table 15.1 Practising medical doctors and dentists (stock) and certications

of professional qualications issued in Poland, 20052008 423


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xx Health Proessional Mobility and Health Systems

Table 15.2 Certications of professional qualication certications by

medical specialty, at end 2008 424

Table 15.3 Professionally certied nurses and midwives (stock) and

certications of professional qualications issued in Poland,20042006 426

Table 15.4 Polish health professionals working in European countries,

circa 2000 426

Table 15.5 Total numbers (stock) and new registrations (inows) of foreign-

national medical doctors and dentists in Poland, 2009 429

Table 15.6 Total numbers (stock) and new registrations (inows) of foreign

medical doctors and dentists among all registered and active

medical doctors and dentists in Poland, 2009 431

Table 15.7 Vacancies and registered unemployment in health professional

groups, 2006 435

Table 15.8 Vacancies (2008) and numbers of certications of professional

qualications issued (20042006 and 2008), by medical speciality 436

Table 15.9 Health professionals eligible to practise per 1000 population,

20032007 436

Table 15.10 Vacancies in public hospitals (full-time equivalents) by

voivodship/region 438

Table 16.1 Main data sources and data holders on health professional

mobility in Romania 450

Table 16.2 Practising medical doctors applying for diploma verication to

work in EU Member States, 20072009 452

Table 16.3 Romanian regions and declared destination countries of medical

doctors applying for CGSs, 2007 453

Table 16.4 Applications for diploma verication from nurses and midwives

applying to work in EU Member States, 20072009 455

Table 16.5 Immigrants (permanent settlers) by country of origin, 20002007 456

Table 16.6 Emigration trends among highly educated population in Romania,

by ethnic group, 19892000 458

Table 16.7 Emigration trends among highly educated population in Romania,

by profession, 19852000 458

Table 16.8 Health professionals per 100 000 inhabitants, Romania and EU,

20002007 461

Table 16.9 Coverage of medical doctors by development regions and

residence in Romania, 2005 462


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xxiList o tables, fgures and boxes

Table 16.10 Health professionals at primary health-care level in Romania, 2005 462

Table 16.11 Primary health professional coverage by administrative regions

and by urban/rural area in Romania, 2005 465

Table 16.12 Medical doctors in Romania by age group and sex, 2007

and regulation of health professionals 466

Table 17.1 Increase/decrease in numbers of medical doctors in Slovakia by

selected specializations 485

Table 17.2 Foreign-national medical doctors working in Slovakia, 2007 485

Table 17.3 Foreign-national dental doctors working in Slovakia, 2007 486

Table 17.4 Foreign-national nurses working in Slovakia, 2007 486

Table 17.5 Applications for equivalency of education conrmations for

medical doctors, dental doctors and nurses: numbers issued

and refused, 20042009 489

Table 17.6 Overview of inows to and (potential) outows from the Slovak

health workforce, by selected indicators 491

Table 17.7 Medical doctors, dental doctors and nurses approaching

retirement (natural persons), 20042007 495

Table 18.1 Foreign-trained medical doctors within all active medical doctors

in Slovenia, 1992 and 20032008 514

Table 18.2 Foreign-born, foreign-trained and foreign-national active medical

doctors (stock) in Slovenia in 1992, 2000 and 20032008 515

Table 18.3 Foreign-born, foreign-trained and foreign-national active dentists

in Slovenia, 1992, 2000 and 20032008 516

Table 18.4 Countries of origin of foreign nursing professionals in Slovenia,

1992, 2000 and 20052008 517

Table 18.5 Foreign-trained medical doctors and dentists among all active

and practising medical doctors and dentists in Slovenia 520

Table 18.6 New admissions to medical, dental and nursing studies in

Slovenia, 20062008 521

Table 18.7 Numbers graduating in medical, dental and nursing studies in

Slovenia, 20052007 521

Table 18.8 Numbers, specializations and percentages of foreign-trainednewly registered medical doctors (ow data), 20032008 533

Table 18.9 Numbers and percentages of medical doctors returning to

Slovenia after practising abroad, 20032008 534


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xxii Health Proessional Mobility and Health Systems

Table 18.10 Foreign-trained medical doctors working as medical doctors in

Slovenia (stock), by specializations, 1992 and 20032008 535

Table 18.11 Sex and mean age of foreign-trained medical doctors in

comparison with all medical doctors in Slovenia, 1992 and20032008 536

Table 18.12 Medical doctors applying for diploma verication to work in EU

Member States (including specializations), 20032008 536

Table 18.13 Foreign-trained newly registered dentists (including specializations),

20032008 537

Table 18.14 Numbers and percentages of dentists returning to Slovenia after

practising abroad, 20032008 537

Table 18.15 Foreign-trained dentists working as dentists in Slovenia (stock),

1992 and 20032008 537

Table 18.16 Sex and mean age of foreign-trained dentists in comparison

with all dentists in Slovenia, 20032008 538

Table 18.17 Dentists applying for diploma verication to work in EU Member

States (including specializations), 20032008 538

Table 19.1 Regional distribution of public sector health professionals in Serbia,

2007 554

Table 19.2 Graduate medical doctors, dentists and pharmacists in Serbia,

19982005 555

Table 19.3 Male and female doctors per region in Serbia, 2008 556

Table 20.1 OECD destination countries of Turkish-educated health

professionals, 20042007 572

Table 20.2 Turkish-born doctors and nurses by country of residence

(selected OECD countries), circa 2000 573

Table 20.3 Foreign-trained medical doctors and nurses in Turkey, by

country of training, 2005 574

Table 20.4 Foreign-born (selected OECD countries) doctors residing in Turkey,

circa 2000 575

Table 20.5 Foreign health professionals with Turkish work permits, by

employment status, 20042008 577

Table 20.6 Health professionals per 100 000 population in Turkey, by

geographical region, 2003 579

Table 20.7 Specialist training places and medical faculty graduates in

Turkey, 20012007 583


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xxiiiList o tables, fgures and boxes

Table 20.8 Health education faculties, students and staff in Turkey,

19882007 584

Table 20.9 Factors inuencing potential emigration of medical doctors and

nurses, Ankara and Mu provinces, 2008 586

Figures

Fig. 1.1 Categorizing the impacts of health professional mobility

according to the functions and objectives of the health system 11

Fig. 2.1 Reliance on foreign medical doctors in selected European and

non-European OECD countries, 2008 or latest year available 27

Fig. 2.2 Reliance on foreign nurses in selected European and non-European

OECD countries, 2008 or latest year available 28

Fig. 2.3 Reliance on foreign dentists in selected European and non-European

OECD countries, 2008 or latest year available 29

Fig. 2.4 Inows of foreign medical doctors (countries with annual inows

below 1000) 19882008 31

Fig. 2.5 Inows of foreign medical doctors (countries with annual inows

above 1000) 19882008 32

Fig. 2.6 Inows of foreign dentists 19882008 34

Fig. 4.1 Newly registered German, Italian and other foreign-national medical

doctors, 2000 and 20032008 93

Fig. 4.2 Newly registered foreign-national medical doctors in Austria 95

Fig. 4.3 Source countries of foreign-national nurses applying for work

permits in Austria, 20032008 99

Fig. 5.1 Annual outows to the Netherlands of health professionals with

Belgian diplomas, comparison of Belgian and Dutch data,

20062008 133

Fig. 5.2 EEA medical diplomas recognized in Belgium, 20012008 137

Fig. 5.3 EEA diplomas for medicine, nursing and dentistry recognized in

Belgium, 20012008 140

Fig. 5.4 Recognition or equivalence route for medical doctors, dentists or

nurses with EEA nationality 151

Fig. 5.5 Recognition or equivalence route for medical doctors, dentists or

nurses with non-EEA nationality 152

Fig. 6.1 Total accumulated numbers of foreign-born health professionals

with licence to practise in Finland, 20002006 166


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xxiv Health Proessional Mobility and Health Systems

Fig. 6.2 Inows based on numbers of newly licensed Finnish and foreign-

born medical doctors and dentists in Finland, 20062008 167

Fig. 6.3 Yearly outows of Finnish medical doctors and nurses, 20002007 168

Fig. 8.1 Registered and active foreign-national medical doctors (stock) in

Germany, 20002008 214

Fig. 8.2 Registered and active foreign-national medical doctors as

percentages of all registered and all active medical doctors in

Germany, 20002008 215

Fig. 8.3 Annual gross inows of registered foreign-national medical doctors

in Germany, 20002008 217

Fig. 8.4 Active foreign-national medical doctors in western and easternGermany (stock), 20002008 218

Fig. 8.5 Active foreign-national medical doctors as percentages of all active

medical doctors in western and eastern Germany, 20002008 218

Fig. 8.6 Eastern European medical doctors as percentages of all medical

doctors in western and eastern Germany, 20002008 219

Fig. 8.7 Annual outows of medical doctors from Germany, 20002008 219

Fig. 8.8 Annual outows of German and foreign-national medical doctorsfrom Germany, 20062008 220

Fig. 8.9 Foreign-national nurses and midwives subject to social insurance

contributions in Germany, 20032008 221

Fig. 8.10 Registered foreign-national medical doctors from new and old EU

Member States (stock) in Germany, 20002008 227

Fig. 8.11 Foreign-national nurses and midwives subject to social insurance

contributions from new and old EU Member States (stock) in

Germany, 20032008 227

Fig. 10.1 Nursing degrees homologated or recognized in Spain, 20022007 269

Fig. 10.2 Evolution of the number of new students in medical schools

19642009 277

Fig. 10.3 Agesex pyramids of professionals registered in Spain,


Fig. 12.1 Health professionals intending to migrate from Estonia, cumulative

numbers, 20042008 356

Fig.13.1 Registered and active medical doctors per 10 000 population by

geographical units, 2006 383


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xxvList o tables, fgures and boxes

Fig.13.2 Reasons to emigrate among resident doctors intending to work

abroad, 2008 387

Fig.13.3 Reasons to stay among resident doctors not considering working

abroad, 2008 387

Fig. 14.1 Proportion of Lithuanian medical doctors registered in destination

countries, 1 May 2004 to 30 April 2005 and 1 May 2005 to

30 April 2006 402

Fig. 14.2 Proportion of Lithuanian nurses registered in destination countries,

1 May 2004 to 30 April 2005 and 1 May 2005 to 30 April 2006 402

Fig. 14.3 Proportion of Lithuanian dentists registered in destination countries,

1 May 2004 to 30 April 2005 and 1 May 2005 to 30 April 2006 403

Fig. 14.4 Annual visits to general practitioners in 59 practices with senior

population (more than 50% aged over 50), 2006 405

Fig. 14.5 Number of medical doctors per 10 000 population, by

administrative region, 2008 407

Fig. 14.6 Percentage of medical doctors older than 60 years, 2009 409

Fig. 15.1 New registrations of Polish medical doctors in EU-15, 20002007 427

Fig. 15.2 Total registrations of Polish medical doctors in host countries,20002007 428

Fig. 15.3 Annual minimum and maximum salaries of public- and private-

sector health professionals and the country average salary in

Poland, January 2008 439

Fig. 16.1 Density of medical doctors in the six most important university

cities and average density in Romania, 2005 462

Fig. 17.1 Health professionals with equivalence conrmations, by declared

destination country, 1 May 2004 to 30 April 2007 483

Fig. 17.2 Age groups of health professionals with equivalence conrmations,

1 May 2004 to 30 April 2007 483

Fig. 17.3 Comparison of average monthly salaries of medical doctors and

nurses and average monthly salary in Slovakia (), 20052009 500

Fig. 19.1 Public sector health workers in Serbia, 2008 552

Fig. 19.2 Public health sector workers in Serbia, 1988 552

Fig. 20.1 Medical doctors per 100 000 population in selected three richest

and three poorest provinces of Turkey, 2006 580

Fig. 20.2 Health professionals in Turkey, 19952006 581

Fig. 20.3 Specialists and practitioners in Turkey, 19502006 581


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xxvi Health Proessional Mobility and Health Systems

Boxes

Box 1.1 Denition of health professional mobility emerging from the project 14

Box 2.1 Hot-spots for mobility between neighbouring countries 40

Box 7.1 Hidden mobility: foreign-trained French nationals and foreign

nationals trained outside the EU 186

Box 7.2 A clear denition of the nurse statute in France 190

Box 7.3 Activating, facilitating and mitigating factors in health professional

mobility 197

Box 7.4 Bilateral agreements 199

Box 7.5 International exchanges 207

Box 7.6 Recognition of diplomas in France 208

Box 8.1 Statutory bodies and other organizations representing the interests

of physicians 217

Box 8.2 Medical and nursing training in Germany 236

Box 18.1 Registration regulations and procedures in Slovenia 518


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List o abbreviations

ADELI Automatisation des Listes

AFS attestation o specialized training (attestation de ormation spcialise)

AFSA attestation o specialized training, advanced level (attestation de ormationspcialise approondie)

AMS Public Employment Service Austria (Arbeitsmarktservice sterreich)APSEP Association o Spanish Health Proessionals in Portugal (Associao deProfssionais da Sade Espanhis em Portugal)

azM University Hospital o Maastricht

BMG Austrian Federal Ministry o Health (Bundesministerium r Gesundheit)

CEE central and eastern Europe

CGS certicate o good standing

CNOM National Medical Council(Conseil National de lOrdre des Mdecins)

SGB Ministry o Labour and Social Security, urkey (alma ve Sosyal Gvenlik

Bakanl)DDASS Departmental Directorate o Health and Social Afairs (Direction Dpartementaledes Aaires Sanitaires et Socials)

FNOMCeO Order o Medical Surgeons and Dentists (Federazione Nazionale Ordini MediciChirurghi e Odontoiatri)

GMC General Medical Council (United Kingdom)

EAPS Economically Active Population Survey (Spain) (Encuesta de Poblacin Activa)

EEA European Economic Area

ERDF European Regional Development Fund

ESF European Social FundETFA European Free rade Association

EU European Union

EU-10 countries joining the EU in May 2004.

EU-15 countries belonging to the EU in May 2004

EU-27 countries belonging ater January 2007

EURES European Job Mobility Portal

FFI medical trainee working in a hospital but with student status (aisant onctiondinterne)

FPS Federal Public Service (Belgium)GDP gross domestic product

HCB Estonian Health Care Board (became Health Board in 2010)

HMC Hungarian Medical Chamber

HTP Health ransormation Programme (urkey)

INE Spanish National Statistics Institute (Instituto Nacional de Estadstica)


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xxviii Health Proessional Mobility and Health Systems

INPS National Institute or Social Security, Italy (Instituto Nationale Previdenza Sociale)

IPASVI National Board o Nursing, Italy (Federazione Nazionale Collegi Inermieri)

KASTE National Development Programme or Social Welare and Health Care (Finland)

MCS Medical Chamber o Slovenia

MIR specialist resident, Spain (mdico interno residente)NCOEHIS National Centre or Organising and Ensuring the Health Inormation System

(Romania)

NCS Nursing Chamber o Slovenia

NHCPD National Health Care Providers Database (Slovenia)

NHIC Slovak National Health Inormation Centre (Nrodn centum zdravotnckychinormci)

NHS National Health Service (United Kingdom)

NIHD National Institute or Health Development (Estonia)

NIS Spanish National Immigration Survey (Encuesta Nacional de Inmigrantes)NMC Nursing and Midwiery Council (United Kingdom)

K Austrian Medical Chamber (sterreichische rztekammer)

OAMMR Order o Nurses and Midwives, Romania (Ordinul Asistenilor Medicali iMoaelor din Romnia)

BIG Austrian Federal Institute or Health Care (sterreichisches Bundesinstitut rGesundheit)

OECD Organisation or Economic Co-operation and Development

OHAAP Oce o Health Authorisation and Administrative Procedures (Hungary)

HG Austrian Association o Midwives (sterreichisches Hebammengremium)OMC Organization o Medical Colleges, Spain (Organizacn Mdica Colegial)

ONCD National Order o Dental Surgeons, France(Ordre National des ChirurgiensDentistes)

ONDPS National Observatory on the Demography o Health Proessions, France(Observatoire National de la Dmographie des Proessions de Sant)

PAC associate practitioner, France (praticiens adjoints contractuels)

PADHUE practitioner trained outside the EU (Praticiens diplme Hors Union Europenne)

RCP Romanian College o Physicians

SHU Slovak Health University in BratislavaSU HSMTC Semmelweis University Health Services Management raining Centre

THL National Institute or Health and Welare (Finland)

TTB urkish Medical Association (Trk Tabipleri Birlc)

UCL Universit catholique de Louvain

ULSS local health authorities, Italy(unita locale socio sanitaria)

Valvira National Supervisory Authority or Welare and Health (Finland)

WHO World Health Organization

WIFO Austrian Institute o Economic Research (sterreichisches Institut r

Wirtschatsorschung)WRT Workorce Review eam (United Kingdom)


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List o contributors

Anna-Mari Aalto, Head o Unit, National Institute or Health and Welare(HL), Finland

Tit Albreht, Head o the Department o Health System Analyses, National

Institute o Public Health, SloveniaRita Baeten, Senior Policy Analyst, European Social Observatory, Belgium

Patricia Barber Prez, Associate Proessor, University o Las Palmas de GranCanaria, Spain

Kvetoslava Beuov, Assistant Proessor, St Elizabeth University o Healthand Social Sciences, Bratislava, Slovakia

Luigi Bertinato, Director o Service or International, Social and Health

Relations, ULSS 20 Veneto Region, ItalyVesna Bjegovi-Mikanovi, Head o the Centre School o Public Health,Director o the Institute o Social Medicine, School o Medicine, BelgradeUniversity, Serbia

Elisa Boscolo, EU Policy Adviser; ULSS 5 Veneto Region, Italy

Jeni Bremner, Director, EHMA (European Health ManagementAssociation), Brussels, Belgium

Reinhard Busse, Proessor o Health Care Management, Berlin University oechnology and Associate Head or Research Policy, European Observatoryon Health Systems and Policies, Germany

Leopoldo Ciato, Director o Human Resources, ULSS 5 Veneto Region, Italy

Katarzyna Czabanowska, Assistant Proessor, Department o InternationalHealth, Faculty o Health Medicine and Lie Sciences, Maastricht University,Netherlands

Carmen Delia Dvila Quintana, Associate Proessor, University o LasPalmas de Gran Canaria, Spain

Marie-Laure Delamaire, Associate Researcher, Ecole des Hautes Etudes enSant Publique (EHESP), France


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xxx Health Proessional Mobility and Health Systems

Gilles Dussault, Proessor, Instituto de Higiene e Medicina ropical,Universidade Nova de Lisboa, Portugal

Edit Eke, Human Resources or Health Expert, at Health Services

Management raining Centre, Semmelweis University, HungaryMarko Elovainio, Research Proessor, National Institute or Health andWelare (HL), Finland

Josep Figueras, Director o the European Observatory on Health Systemsand Policies and head o the WHO European Centre on Health Policy,Belgium

Adriana Galan, Public Health Consultant, National Institute o Public

Health, RomaniaEdmond Girasek, Assistant Lecturer, Health Services Management rainingCentre, Semmelweis University, Hungary

Irene A Glinos, Researcher, European Observatory on Health Systems andPolicies, Belgium

Beatriz Gonzlez Lpez-Valcrcel, Proessor, University o Las Palmas deGran Canaria, Spain

Jarno Habicht, WHO Representative/Head o Country Oce, Republic oMoldova (Head, WHO Country Oce, Estonia until end 2010)

Tarja Heponiemi, Senior Researcher, National Institute or Health andWelare (HL), Finland

Ivan M Jeki, National Coordinator/Health Services Expert, EuropeanInvestment Bank echnical Assistant to the Ministry o Health Project or theModernization o the Four Clinical Centres in Serbia, Serbia

Mirela Jusic, Research Assistant, Faculty o Management and Economics,University o Klagenurt, Austria

Annette Katrava, International Consultant - eam Leader and HealthAccreditation Expert, Delegation o the European Union to the Republico Serbia; echnical Assistant to Ministry o Health Project or theEstablishment o the Public Agency or Accreditation and ContinuousQuality Improvement o Health Care in Serbia, Canada and Greece

Marcin Kautsch, Assistant Proessor, Institute o Public Health, JagiellonianUniversity, Poland

Sdka Kaya, Proessor, Department o Health Care Management, Faculty oEconomics and Administrative Sciences, Hacettepe University, urkey


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xxxiList o contributors

Ilmo Keskimki, Research Proessor, National Institute or Health andWelare (HL), Finland

Meri Koivusalo, Senior Researcher, National Institute or Health and Welare

(HL), FinlandMiloslava Kovov, Senior Expert, Ministry o Health o the SlovakRepublic, Slovakia

Hannamaria Kuusio, Researcher, National Institute or Health and Welare(HL), Finland

Claudia B Maier, echnical Ocer, European Observatory on HealthSystems and Policies, Brussels, Belgium

Eva Maria Malle, Research Assistant, Faculty o Management andEconomics, University o Klagenurt, Austria

Marin Nagy, Senior Expert, Ministry o Health o the Slovak Republic,Slovakia

Guido Ofermanns, Associate Proessor, Faculty o Management andEconomics, University o Klagenurt, Austria

Diana Ognyanova, Research Fellow, Department o Health CareManagement, Berlin University o echnology, Germany

Victor Olsavszky, Head o WHO Country Oce, Romania

ilvinas Padaiga, Proessor o Public Health, Department o PreventiveMedicine and Dean o International Relations and Study Centre, MedicalAcademy, Lithuanian University o Health Sciences, Lithuania

Willy Palm, Dissemination Development Ocer, European Observatory on

Health Systems and Policies, BelgiumMartynas Pukas, PhD student, Department o Preventive Medicine, MedicalAcademy, Lithuanian University o Health Sciences, Lithuania

Pille Saar, Adviser, Health Care Department, Ministry o Social Afairs oEstonia, Estonia

Anna Sauta, at the time o the study Researcher, European SocialObservatory, OSE, Belgium; presently PhD student, Catholic University o

Louvain-la-Neuve, UCL, BelgiumFranois-Xavier Schweyer, Senior Lecturer, EHESP, France

Liudvika Starkien, Associate Proessor, Department o Preventive Medicine,Medical Academy, Lithuanian University o Health Sciences, Lithuania


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xxxii Health Proessional Mobility and Health Systems

Mikls Szcska, Minister o State or Health, Ministry o NationalResources, Hungary; ormerly Director and Associate Proessor, HealthServices Management raining Centre, Semmelweis University, Hungary

Cristian Vladescu, Proessor o Public Health, University o Medicine andPharmacy, imisoara, Romania

Maja Vukovi-Krmar, Project Manager, Health & Social Afairs,Delegation o the European Union to the Republic o Serbia, Serbia

Matthias Wismar, Senior Health Policy Analyst, European Observatory onHealth Systems and Policies, Belgium

Hasan Hseyin Yldrm, Assistant Proessor, Department o Health Care

Management, Faculty o Economics and Administrative Sciences, HacettepeUniversity, urkey

Ruth Young, Reader in Health Policy Evaluation, Florence NightingaleSchool o Nursing and Midwiery, Kings College, London, United Kingdom


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Part ISetting the scene,

results and conclusions


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Chapter 1Health professional

mobility and health

systems in Europe:

an introductionMatthias Wismar, Claudia B Maier, Irene A Glinos, Jeni Bremner,


1.1 Introduction

Tis volume presents an analysis o health proessional mobility in Europe

rom a health system perspective. Te central policy issue o this analysis is that

health proessional mobility impacts on the perormance o health systems and

that these impacts are increasing in line with increasing mobility in Europe.

Health proessional mobility impacts on the perormance o health systems by

changing the composition o the health workorce in both sending and receiving

countries. Tese gains and losses may strengthen or weaken the perormanceo health systems and, while they may seem negligible, produce visible impacts

when numbers increase or through continuous mobility over years. Health

proessional mobility also aects the skill-mix since skills travel with the mobile

health proessional. When these skills are rare and essential, outows o even

small numbers o health proessionals can impact on health system perormance.

Health proessional mobility can also aect the distribution o health workers

in a country. A disproportionately high outow rom a region may cause or

aggravate maldistribution, resulting in undersupplied and underserved areas inwhich the local population is let without sucient health workers. However,

the impacts on health system perormance are oten indirect and part o a

complex chain o causalities.


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4 Health Professional Mobility and Health Systems

Te European Union (EU) enlargements in 2004 and 2007 introduced

100 million citizens rom 12 new Member States (EU-12) and have caused

substantial expansion o the pool o health proessionals within the EU

labour market. Tis has uelled mobility as some o these health proessionals

have joined those already moving around Europe in search o better career

opportunities, better salaries and better working conditions. Migrants may be

motivated by the desire to acquire new skills, by amily reasons or by curiosity;

they may commute or days or weekends; stay or short periods or several years;

and may move on, return or settle permanently. In addition, enlargement has

increased the economic diversity o the EU. Larger salary dierentials and

larger dierences in inrastructures and in the use and availability o modern

medical technology have urther incentivized health proessional mobility rom

the EU-12 countries.

But what do we know about this important phenomenon? Knowledge on health

proessional mobility in Europe is limited. For example, there are gaps in the

understanding o the magnitude o health proessional mobility, particularly

concerning EU enlargement. Tere is also no overview o the motivators that

drive the mobile European health workorce (not just health workers rom third

countries) or any systematic mapping o the impacts o health proessional

mobility. Also our knowledge on country responses to health proessionalmobility is very limited.

Tis volume aims to enhance knowledge on the nature and extent o health

proessional mobility in the EU, assess its impact on country health systems

and outline some major policy strategies to address mobility. Te book seeks

to provide not only a rigorous and systematic analysis o the mobility patterns

in Europe but also a series o evidence-base and policy-relevant lessons that

contribute to the policy debate in the EU.

Te analytical ramework or the study is, thereore, structured around a set o

key policy-makers questions, which will orm the conceptual backbone o this

volume.

What are the scale and characteristics o health proessional mobility in the

EU?

What have been the eects o EU enlargement on proessional mobility?

What are the motivations o the mobile workorce? Why do some healthproessionals leave their country while others stay or return?

What positive or negative impacts on the perormance o health systems

result rom mobility ows?


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5Health professional mobility and health systems in Europe: an introduction

What is the policy relevance o those impacts vis--vis other workorce

challenges? In other words, should policy-makers address health proessional

mobility as a priority?

What policy options and regulatory inventions (recruitment policies,international rameworks, workorce planning and general workorce

measures) are needed to address health proessional mobility issues? Is their

evidence on their impact and applicability?

Te analysis presented in this volume results rom the Health PROMeHEUS1

project. Tis three-year research began in 2009 with the aim o addressing

gaps in the knowledge on health proessional mobility in order to generate

recommendations or more eective human resources or health policies.

Te project is co-unded through the European Commissions SeventhFramework Programme.2

Tis publication will be ollowed by a second volume structured around a series

o themes on health proessional mobility including the changing dynamics,

monitoring and measuring, the mobile individual and changing responses and

will conclude with scenarios on the uture o health proessional mobility.

Tis chapter will frst outline the policy context in which proessional mobility

takes place in EU countries. Te next section will explain the conceptualramework employed to analyse country experiences and will be ollowed by a

description o the study methodology. Te fnal section will provide an outline

o the rest o this volume.

1.2 The EU context

Health proessional mobility impacts on the composition o the health workorce,

which, in turn, impacts on health system perormance. Tis cannot be viewedin isolation as health proessional mobility interacts with many other actors

and challenges that also aect the health workorce and with it health system

perormance. Tese include new technologies, globalization, eminization o the

workorce, training capacities, working conditions and working environments

(Dubois et al. 2006, Wiskow et al. 2010). Such interactions have to be taken

into account in order to gain ull understanding o the phenomenon and how

best to address it. Tis study places health proessional mobility in this broader

context and needs to consider all these elements. Here we briey illustratethe role o three o these contextual elements: (i) demographic transition, (ii)

strategies addressing general workorce issues, and (iii) the unique EU context.

1 Health PROMeHEUS = Health PROessional Mobility in He European Union Study.

2 Grant agreement number 223383.


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First, the ageing o the health workorce imposes some restrictions on policy

responses as increases in training capacities or recruitment rom other sectors

are no longer eective in all countries. In Europe, the pool o young people

is decreasing at a ast pace (OECD 2007) and this will bring increasing

competition or recruitment between dierent employers and sectors. Finland

has already reacted to this development by introducing nationwide workorce

planning (Dussault et al. 2010).

Second, health proessional mobility needs to be understood within the wider

strategies addressing the general workorce issues with which it interacts (Dubois

et al. 2006). A Europewide debate on the topic was initiated by the European

Commissions Green Paper on the European workorce or health (Commission

o the European Communities 2008), ollowed by a consultation process(Directorate-General or Health and Consumers Aairs 2009). Connected to

this, the Belgium Council Presidency, together with the European Commission

and the EU Member States, explored three topics: (i) assessing uture health

workorce needs, (ii) adapting skills and redistribution o tasks, and (iii) creating

a supportive working environment to attract motivated health proessionals.3

Health proessional mobility can undermine attempts to orecast workorce

needs i inows and outows are not well understood and actored into

the planning. Good understanding o the trends and early warnings otheir uctuations are even more essential in times o uncertainty. Similarly,

inadequate monitoring or poor understanding o the inows and outows

o skills will reduce the eectiveness o strategies to change the skill-mix and

task distribution. Improvement o the working environment is an important

strategy or retaining health proessionals in health-care organizations and it

is essential to understand whether retention strategies also work or health

proessionals with intentions to migrate.

Finally, several actors shape the unique conditions under which the EU can

respond to health proessional mobility. Tese include the ree-movement

ramework, European social values and the policy instruments o the EU.

Te ormulation o any response to health proessional mobility in the EU

must take account o the very limited potential or imposing such restrictions

on EU citizens. Te free movement o workers is an economic imperative

and a civil right enshrined in the reaties, supported by a host o secondary

legislation.4

Most importantly, Directive 2005/36/EC on the recognition3 In support o these activities, policy bries and summaries were published on orecasting (Dussault et al. 2010), skill-mix(Horsley et al. 2010), working conditions (Wiskow C et al. 2010) and quality and saety (Flottorp et al. 2010). Also, policydialogues were conducted in Leuven, Belgium, 2630 April 2010. Under the Belgium Council Presidency, the Member Statesadopted Council conclusions on investing in Europes health workorce o tomorrow (Council o the European Union 2010).

4 Tis reedom o movement applies to the European Economic Area (EEA), which includes the EU-27 Member Statesand three European Free rade Association (EFA) members Iceland, Liechtenstein and Norway. Switzerland is amember o the EFA but not o the EEA and has a separate bilateral agreement on mobility with the EU.


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o proessional qualifcations ensures a high portability o qualifcations or

medical doctors, nurses and dentists by acilitating an automatic procedure

in which qualifcations are checked by the conormity o their qualifcation

levels and training periods rather than by individual assessment o the skills and

competencies acquired (Peeters et al. 2010).

Research on European integration in health and health care has reerred to the

imbalance between the social values o the EU and the economic imperative o

European integration (Mossialos et al. 2010). Yet these social values are relevant

when ormulating responses to health proessional mobility. Te European

Court o Justice has ound repeatedly that patient mobility (technically the

mobility o services) can be restricted on the grounds that it may threaten the

economic viability o hospitals by increasing the diculty o human resourceplanning (Palm et al. 2011). It remains to be seen whether similar legal

arguments will be made or concerns regarding quality and patient saety in

health proessional mobility.

Te EU has a large set opolicy instruments (including regulations, directives

and decisions) with which to respond to health proessional mobility issues.

In addition, budgets or public health and research and or social development

and social cohesion are available to address workorce issues within countries.

Tis distinguishes the EU response to health proessional mobility romthe global response articulated in the WHO global code o practice on the

international recruitment o health personnel (WHO 2010),which builds on

voluntary commitments rom Member States.

1.3 Conceptual framework

Te analysis o proessional mobility presented in this volume is structured

around a series o policy questions (outlined in the introductory section), whichorm the basis or the presentation o main results in the ollowing chapter.

In turn, these results summarize the evidence drawn rom the country case

studies in Part II. Tis section will outline the policy questions and the policy

relevance and highlight research gaps. It will conclude with a brie explanation

o how we tackle the questions.

1.3.1 Mobility profles

Policy-makers and stakeholders ace a pressing question what are the scale

and characteristics o health proessional mobility in the EU?

Quantifcation o health proessional mobility is a centrepiece o the research

because the magnitude o health proessional mobility determines the


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magnitude o the impacts on health system perormance. Policy responses and

ethical concerns also require understanding o mobility patterns and the source

regions o proessionals, including the wider Europe (WHO European Region

countries outside the ree-movement area, comprising the European Economic

Area (EEA) and three European Free rade Association (EFA) members

(Iceland, Liechtenstein and Norway)) and third countries.

But what do we know about health proessional mobility in Europe? A World

Health Organization (WHO) study (Dussault et al. 2009) reports that migratory

ows o health workers are generally documented poorly. Currently, there is no

mechanism to compile migration data and monitor ows in either the EU or

the wider Europe and existing data tend to be ragmentary and unreliable since

they do not represent direct measurement o migration (Dussault et al. 2009).Some important international publications shed some light on the situation

in Europe. Te aorementioned WHO study provides an overview o the 53

countries in the WHO European Region. Published in 2009, the data or most

countries are or 2005 or earlier (Dussault et al. 2009). Tree Organisation

or Economic Co-operation and Development (OECD) studies provide

relevant inormation. Te frst reports a substantial rise in health proessional

mobility between 1995 and 2005 in 12 selected OECD countries, including

eight European countries5 (OECD 2007). Te second is a comprehensivestudy o looming workorce crises, which includes analysis o the reliance on

oreign health proessionals as well as some ow data (OECD 2008). Te third

examines how the fnancial and economic crisis has aected mobility trends.

It includes the European ree-movement area and makes reerence to Norway,

Poland, Switzerland and the United Kingdom (OECD 2010). However, the

results or those countries are inconclusive and do not explicitly reer to health

proessionals. Finally, a joint OECD/WHO policy brie presents data on levels

o reliance on oreign health proessionals including 17 countries or medicaldoctors and 11 or nurses (WHO & OECD 2010).

At country level, some European countries are paying greater attention to

health proessional mobility and developing solid inormation bases through

high-quality data collection and research. Case studies have been published on

Member States that acceded to the EU beore 2004, including France (Cash

& Ulmann 2008), Italy (Chalo 2008), Germany (Buchan 2006b), Ireland

(Humphries et al. 2008) and the United Kingdom (Buchan 2002, 2006a,

Buchan & OMay 1999, Jinks et al. 2000). Other case studies cover the 2004

and 2007 accession countries, including the Czech Republic (Angelovski et

al. 2006), Poland (Leniowska 2007), Estonia (Buchan & Peflieva 2006),

Lithuania (Buchan 2006b) and Romania (Galan 2006). Tere are also case

5 Denmark, Finland, Ireland, the Netherlands, Norway, Sweden, Switzerland and the United Kingdom.


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studies on EU candidate countries such as Croatia (Dakula et al. 2006) and

Serbia (Djikanovic 2006). Case studies on the United States (Cooper 2008),

Canada (Dumont et al. 2008) and New Zealand (Zurn & Dumont 2008)

are also o value since these are destination countries or European health

proessionals. Te case studies provide very important analysis but show wide

variations in thematic ocus, coverage o proessions and analytical depth and

it is dicult (i not impossible) to draw comparisons. Tere is insucient

coverage o EU enlargement and some countries have introduced major health

policy reorms and changes to their workorce policies since publication o their

case studies.

We address some o the knowledge gaps on the scale and characteristics o

health proessional mobility by analysing the levels o reliance on oreign healthproessionals and the scale o actual inows and outows, complemented by

analysis o the geographical patterns o mobility and the source regions o the

mobile workorce. Te analysis will be based on a secondary data collection

retrieved rom dierent sources in the individual countries. o ensure

comparability, the coverage o the proessions and the data will apply across all

countries included in the volume.

1.3.2 Role o EU enlargement

What have been the eects o EU enlargement on proessional mobility?

Analysis o the role o enlargement is important not only because o the

impetus it has provided or the volume and diversity o health proessional

mobility in Europe but also or policy debate. Te latter covers the concerns o

the prospective EU-12 countries regarding expected brain drain and concerns

in some EU-12 countries about disruptive impacts on their health system

stemming rom excessively high inows. Te question is also important orconsideration o the likely eects o liting remaining labour market restrictions

and o uture enlargements.

Tere is still no comprehensive analysis o mobility trends during the course

o enlargement (OECD 2008, Wiskow 2006). A ew o the reports and case

studies mentioned in section 1.3.1 provide some insights but the Romanian

case study was published beore accession (Galan 2006). Other reports and

case studies include only the frst 12 to 18 months o EU accession in Estonia

(Buchan & Peflieva 2006) and Lithuania (Buchan 2006b). Data and analysispublished on Polish nurses include the frst quarter o 2007 (Leniowska 2007,

2008).


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We will respond to the question on the role o enlargement and address the

knowledge gaps by analysing the outows rom the seven EU-12 countries

included in this study and identiying these health proessionals in the statistics

o the destination countries. We will also assess the time trends notwithstanding

the lack o data in many countries. Intention-to-leave data will be used to fll

data gaps when quantiying outows.

1.3.3 Motivation o the mobile workorce

What are the motivations o the mobile workorce? Why do some health

proessionals leave their country but others stay or return? Understanding o

these motivations is an essential precondition or policy-makers seeking to

develop adequate recruitment and retention policies.

Some existing studies in Europe provide some insights into motivations but

huge gaps remain. Te OECD (2008) has looked into these motivations and

some studies ocus on migrants rom third countries (Nichols & Campbell

2010a, 2010b). In Lithuania, studies were conducted on intentions to leave

among physicians and medical residents (Stankunas et al. 2004), nurses

(Matuleviciute 2007) and pharmacists (Smigelskas 2007). Related to this

research, the ramework o the European NEX-Study6 has included extensive

research on intention to leave the proession and another study has explored

young doctors willingness to work in rural areas (Girasek et al. 2010).

We have asked authors to address the motivations o the mobile workorce by

researching specifc motivational actors within their country based on surveys,

qualitative interviews, ocus groups, grey literature and expert observations.

Specifcally, we have asked the authors to consider instigating, activating and

acilitating actors and encouraged them to identiy research into the particular

motivations driving health proessionals intending to leave, to stay or to return.

1.3.4 Impacts on perormance

What are the (positive or negative) impacts on the perormance o health

systems that result rom mobility ows?

A central concern o our research and, thereore, o this volume is to analyse

the impacts o health proessional mobility on the perormance o health

systems. Tese are the lynchpin o the policy debate on health proessionalmobility. It is important to see whether both hopes and worries concerning

health proessional mobility are supported by the evidence reported rom the

countries. Also, there is a need or urther examination o the distribution o

eects between source and destination countries.

6 Nurses Early Exit Study (http://www.next.uni-wuppertal.de/EN/index.php?next-study, accessed 13 March 2011).
http://www.next.uni-wuppertal.de/EN/index.php?next-studyhttp://www.next.uni-wuppertal.de/EN/index.php?next-study


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But what is known already about the impacts? Overall, there have been only a

ew attempts to identiy impacts in Europe (Peeters et al. 2010), covering only a

handul o countries including the United Kingdom (Ballard et al. 2004, Jinks

et al. 2000), Germany (Hyde 2005), the Czech Republic (Mareckova 2006)

and Poland (Leniowska 2007). Some o the impacts relate to regional or local

shortages, others to the training pipeline. Tere have also been reports on the

impact on workorce planning. Another example is the concerns about impacts

on health system perormance raised by the inormal network o competent

authorities or the recognition o qualifcations or doctors. Tese concerns

ocused on the quality o care and patient saety linked to the proessionalskills and language knowledge o migrant doctors and to their integration

within the host countrys health system (Inormal Network CompetentAuthorities or Doctors 2010).

In this study we pick up on the observation discussed above: that impacts

may aect health system perormance indirectly through complex chains o

causality. In conceptual terms, we are analysing not only direct impacts on

perormance but also impacts on the unctions contributing to the objectives o

a health system. o this end we have adopted a broad health systems approach

based on the WHO health systems model depicted in Fig. 1.1.

1.3.5 Policy relevance

What is the policy relevance o these impacts vis--vis other workorce

challenges? In other words, should policy-makers address health proessional

mobility as a priority?

Creating resources

(investment and training)

Deliveringservices

(provision)

Fair (financial)contribution

Health

Stewardship(oversight)

Financing(collecting, pooling

and purchasing)

Responsiveness(to peoples non-medical

expectations)

Functions the system performs Objectives of the system

Fig. 1.1 Categorizing the impacts of health professional mobility according to the

functions and objectives of the health system

Source: WHO 2000.


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It is important to place health proessional mobility within the context o other

workorce issues in order to prioritize policy action. Te results o such an

examination can provide an overview to determine whether this is a pressing

issue across Europe. It can also indicate whether health proessional mobility

requires specifc policies or should be tackled in the context o other workorce

measures.

In order to respond to these questions, we have asked authors to qualitatively

assess the relevance o health proessional mobility in comparison with domestic

workorce issues including the maldistribution o health workers over the

territory, workorce shortages, attrition, demographic transition and problems

with the training pipeline. In comparative terms, we will classiy countries in

dierent levels o policy relevance.

1.3.6 Policy and regulatory interventions

What are the policy options or addressing health proessional mobility issues?

Policy-makers aiming to tackle health proessional mobility or to improve existing

strategies will beneft rom inormation on the use o policy and regulatory

measures in other countries. Learning about the use o instruments individually

and in conjunction with others may inspire solutions or their own country.Tere is limited knowledge on policy development concerning health proessional

mobility and general workorce issues and there is no comprehensive overview.

Interest in workorce planning as a centrepiece o workorce policy has grown

only recently (Dussault et al 2010). Buchans (2008) categorization o cross-

border instruments and tools or managing health proessional mobility (able

1.1) provides a very useul starting point or urther research but, apart rom

the research on bilateral agreements (Dhillon et al. 2010), knowledge remains

patchy.

o address some o the knowledge gaps, case study authors were asked to

search or explicit recruitment policies (international and sel-suciency),

international rameworks (see able 1.1), workorce planning procedures and

general workorce measures acilitating the retention o health proessionals by

improving working conditions and the working environment.

1.4 Methodology

Tis section will provide more details on the methodologies employed to

research the evidence or this book, starting with a brie summary o the

PROMeHEUS project. Tis will be ollowed by a discussion o the challenges


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that aced the project and some o the strategies used to address the challenges:a good country sample, mechanisms to ensure comparability and a mix o

research methodologies to develop analytically rich case studies.

Health PROMeHEUS is a research project unded through the European

Commissions Seventh Framework Programme on research and innovation and

run by a consortium o 11 partners, supported by seven country correspondents

and a large number o country inormants. Outputs o the project include

several publications, conerence workshops and policy dialogues. Te acronym

PROMeHEUS was chosen because this titan o Greek mythology was achampion o mankind who stole fre rom Zeus and gave it to mortals. Similarly,

the aim o the project is to illuminate what would otherwise remain in the dark

and compare the situation and trends o health mobility between countries in

Europe.

Te project has aced a number o daunting challenges. First, throughout the

course o the project, the analytical work o country case study authors was

hindered by the lack o a commonly agreed defnition o health proessionalmobility. A defnition was deemed necessary to defne the scope o research

and is also a starting point or uture categorization o dierent types o health

proessional mobility. A second challenge was the selection o countries or the

sample without losing key developments and trends. ime and resources would

not allow the inclusion o all 31 countries rom the European ree-movement

Table 1.1 Cross-border instruments and tools for steering and managing health

professional mobility

Instrument/tool Description

Twinning Links developed by health care organizations in source anddestination countries based on staff exchanges, staff support

and ow of resources to source country

Staff exchange Structured temporary move of staff to another organization,

based on career and personal development opportunities or

organizational development

Educational support Educators and/or educational resources and/or funding in

temporary move from destination to source organization

Compensation Destination country provides some type of compensation

to source country in recompense for the impact of active

recruitment (much discussed but little evidence in practice)

Training for international

recruitment

Government or private sector makes explicit decision to develop a

training infrastructure to train health professionals for employment

in other countries in order to generate remittances or fees

International code Code of ethics on international recruitment. The best known

codes are those from the United Kingdom (introduced 2001) and

the WHO Global Code (adopted 2010).

Source: Adapted rom Buchan 2008.


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area, let alone reaching out to the wider Europe. Tird, how to ensure the

comparability o research results? Variations between European countries (in

institutional settings, types o health system and organizational peculiarities,

or example) do not allow direct comparison. Also, diverse countries produce

diverse stories. Tis may be appealing to the reader but oers limited scope or

comparison i each case study emphasizes or omits dierent aspects. Fourth, how

to ensure that the analytical quality o a countrys case study is not undermined

by variations in the availability o data and research literature? International

studies and international databases have shown wide dierences in data

availability and time trend data. Some countries have well-established research

on health proessional mobility that provides a robust basis or developing a

country case study, but good literature is scarce in other countries. It is not

claimed that such a multitude o challenges could be overcome completely but

a set o strategies was employed to address these concerns.

o better defne the ocus o research and also to capture health proessional

mobility beyond the meaning o the oreign-trained, oreign-born and oreign-

national indicators, an adequate defnition o health proessional mobility was

discussed rom the beginning o the project. Tis defnition (Box 1.1) will also

provide guidance or our uture research by providing a starting point or the

development o typologies o health proessional mobility and assessing thevalidity o indicators.

A country sample was established with the intention o capturing the situation

in Europe and covering the major trends without the need to include all 31

countries in the research. Four criteria were used to determine country selection.

First, the sample should be suciently diverse and represent every corner o the

EU including larger and smaller countries, those with national health systems

and those with social health insurance. Second, the sample should enable

a particular ocus on the 2004 and 2007 enlargement countries since theirrole in health proessional mobility was underresearched. Tird, the sample

should include larger European labour markets in Europe since they have a

high capacity to absorb large absolute numbers o mobile health proessionals

while showing relatively low reliance on oreign health proessionals. Fourth,

the sample should meet the need to build the bridge to a wider Europe and to

understand mobility between countries within and outside the ree-movement

area (able 1.2).

Box 1.1 Denition of health professional mobility emerging from the project

Any intentional change of country after graduation with the purpose and effect of

health professionals and health sistems _migratie

Documents