and employment: Finland balances inflows and outflows of health
professionals
Hannamaria Kuusio, Meri Koivusalo, Marko Elovainio, Tarja Heponiemi, Anna-Mari Aalto, Ilmo Keskimäki
6.1 Introduction
Traditionally, there has been little international mobility of health-care professionals in Finland. Inflows of foreign health professionals have been very small and Finland acted as a source country until the late 1990s, particularly for nurses who migrated in low numbers to other European (for example, Germany or the United Kingdom) and Nordic countries. However, there have been some changes in mobility patterns over the last 20 years. The country now has a mixed mobility profile as the outflows of health professionals have decreased and become comparable to the inflows. Moreover, foreign medical doctors and dentists represent important shares of all new arrivals to the medical workforce.
This signals that the Finnish system could become dependent on the influx of health professionals from abroad – within a context of serious shortages, especially of general practitioners.
Migration policies in Finland have traditionally been formulated on humanitarian bases. However, in 2006 the government adopted a programme in which immigration was promoted in order to alleviate shortages in the
164 Health Professional Mobility and Health Systems
Finnish labour market. The changing policy environment and labour shortages in the health-care sector have created new grounds for international recruitment of health professionals. Since 2006, the recruitment programmes for foreign health professionals have gained more attention as a measure for tackling workforce shortages in the health sector, especially in primary health care.
Since 2000, Finland has granted increasing numbers of licences to practise to health-care professionals of foreign origin, particularly medical doctors and dentists. However, not all who received a licence have migrated to Finland and not all of those who did migrate are employed in the health-care sector. Further studies are needed to examine the reasons for this and to develop effective practices to recruit and employ these health-care professionals who have the potential to become part of the active workforce.
The aim of this study is to assess the cross-border mobility patterns of medical doctors, nurses and dentists in Finland. The specific aims are to (i) map the magnitude of professional mobility and identify critical data gaps and limitations, (ii) assess the contextual, health system and personal factors that influence professional mobility, and (iii) assess the impact of professional mobility. The overview of mobility among health professionals is based on a literature search, interviews and registers.
Five Finnish national databases were searched.1 In addition, senior experts on professional and workforce migration in government agencies were interviewed on the challenges and forthcoming actions regarding Finnish migration policies in the health sector. Data on the inflow and outflow of health professionals were obtained from the National Supervisory Authority for Welfare and Health (Valvira) and the employment statistics database maintained by Statistics Finland.
Limitations of the study
One limitation of this study concerns the data sets on health professional mobility that are available in Finland. Applications for residence permits in Finland do not include information on academic or vocational education.
However, those wishing to practise in the health professions in Finland must apply for a licence from Valvira and this information was available to the study. The Valvira register on licensed health professionals covers all health professionals who have completed their vocational education outside Finland and then been granted a licence to practise in Finland. The register does not allow identification of the limited number of native Finns who have studied abroad and subsequently returned to work in Finland or those foreign licensed
1 Using search terms for “mobility” or “immigration” or “emigration” AND “health care” AND “physician” or “registered nurse” or “dentist” or “public health nurse”. Publication years ranged from 1990 to 2009.
health professionals who have since left the country. Furthermore, the Valvira register covers only applications for licences and holds no information on those with a health-care education who do not apply for a licence to practise.
6.2 Mobility profile of Finland
Traditionally Finland has been a source country for workforce migration.
Nurses in particular have migrated from Finland to other Nordic countries such as Norway and Sweden. However, the direction of health professional mobility has changed and become more balanced over the last few years. Inflows of foreign-born health professionals have gradually increased (to some extent in line with the overall expansion of the health workforce) while outflows of Finnish-born health professionals have decreased. The country remains a source country, particularly for emigrating nurses, but has also become a destination for foreign medical doctors, nurses and dentists. In 2007, around 200 nurses and 50 medical doctors left the country; in 2008, 97 nurses and 135 medical doctors from abroad obtained a licence to practise in Finland. In 2006, foreign medical doctors, dentists and nurses represented between 2% and 7% of the total number of each profession in Finland, while around 5% of both medical doctors and nurses licensed in Finland worked abroad. The yearly inflows of medical doctors and dentists, in particular, represent important shares of total new arrivals to the medical workforce. This could indicate some dependency on migrating health professionals.
The term foreign-health professional is used to describe foreign-trained health professionals who have been granted a licence to practise their profession in Finland. They can be foreign nationals or foreign born with Finnish nationality.
Finnish nationality can be granted on the basis of application after living in Finland for at least five years.
6.2.1 Inflows of health professionals
While comparatively few health professionals have migrated to Finland, their relative importance in terms of new arrivals to the health workforce has been rising. Between 1980 and 2006, a total of 3499 foreign health professionals (1471 medical doctors, 228 dentists, 1800 nurses) obtained licences to practise in Finland (Statistics Finland unpublished data 2009). The number of foreign health professionals has remained small but has increased significantly since the late 1980s. In 1988, only one foreign medical doctor was licensed; 135 were licensed in 2008. Nine nurses and two dentists applied for licences in 1988;
in 2008 the corresponding numbers were 97 and 20 (Valvira unpublished data 2009). In 2006, 6.8% (1517) of medical doctors, 4% (232) of dentists and
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2.2% (1813) of nurses were foreign born,2 held a Finnish licence to practise and lived in Finland (Fig. 6.1) (Statistics Finland unpublished data 2009). Recent statistics (OECD 2010) on health professional mobility give other numbers for the foreign health workforce in Finland. However, these data are based on the Valvira registry data on numbers granted practising licences and include people of Finnish origin who studied abroad and foreign professionals who had already re-emigrated from Finland.
Dentists have formed the most significant foreign inflows to the health workforce, representing almost half of all those with new licences in the profession.
Licences were issued to 134 foreign-trained and 176 Finnish-trained dentists in 2006–2008 (Valvira unpublished data 2009). The number of newly licensed medical doctors of Finnish origin has been around 500 per year. In recent years, around 120 foreign medical doctors per year have obtained a licence to practise (Valvira unpublished data 2009), a quarter of the new medical workforce (Fig.
6.2). Foreign-trained nurses represent about 3% of new inflows to the nursing workforce – licences have been granted to about 75 foreign-trained and about 2500 Finnish-trained nurses per year (Valvira unpublished data 2009).
The majority of foreign health professionals have come from EU, EEA or the Russian Federation. The last is the most important source country for foreign medical doctors: around 70–80 per year in 2004–2008. Since 2006, Estonia has been a growing source country for all three professions. In 2006–2008, 266 medical doctors, 186 nurses and 53 dentists moved to Finland from Estonia
2 In 2006, total numbers were 22 191 medical doctors, 5989 dentists and 68 098 licensed nurses (Statistics Finland 2009).
Fig. 6.1 Total accumulated numbers of foreign-born health professionals with licence to practise in Finland, 2000–2006
2000 2001 2002 2003 2004 2005 2006
Medical doctors
(Valvira unpublished data 2009). Sweden and Germany, respectively, are the third and fourth most important source countries.
Foreign nurses migrating to Finland are predominantly female (81%); the mean age is 37 years for female and 34 years for male nurses. Nearly one half of foreign medical doctors are female. Of 228 foreign dentists in Finland, 67%
are female (Valvira unpublished data 2009).
6.2.2 Outflows of health professionals
About 4010 Finnish nurses and 840 Finnish medical doctors worked abroad in 2006 (Statistics Finland unpublished data 2009). These numbers correspond to 5.9% of the total number of licensed nurses (68 098) and 3.8% of all medical doctors (22 191). Outflows of health professionals have gradually decreased over the years; 595 nurses and 175 medical doctors emigrated in 2000 but only 215 nurses and 50 medical doctors left the country in 2007 (Fig. 6.3) (Statistics Finland unpublished data 2009). These numbers include foreign health professionals who have been granted a licence to practise as well as Finnish-born health professionals (Statistics Finland unpublished data 2009).
The most attractive destination countries were Sweden and Norway for nurses and Sweden and the United States for medical doctors.
It is interesting to note that a proportion of the outflow of Finnish health professionals is temporary. A register-based follow-up of those who had emigrated found that about 40% of nurses, 40% of medical doctors and around 30% of dentists had returned to Finland within two years. The study was based on an exercise linking data from the licence registries of the three health professions with population data on place of residence (Ailasmaa 2010).
Fig. 6.2 Inflows based on numbers of newly licensed Finnish and foreign-born medical doctors and dentists in Finland, 2006–2008
Source: Valvira unpublished data, 2009.
0 600 500 400 300
100
Finnish Foreign
Foreign born
born Finnish Foreign
born Finnish
2006 2007 2008
Medical doctors Dentists 200