Cross-border frameworks

Cross-border frameworks are used to steer and manage health professional mobility. They can be unilateral, bilateral or multilateral and may be led by national governments or local health care institutions.

There are many cross-border frameworks for steering and managing health professional mobility but uptake varies widely within and between countries, with a strong focus on bilateral agreements, staff exchange and educational support (Table 2.3). Austria and the United Kingdom use many of these instruments but most countries use only a few types of cross-border framework, although they may use them frequently. For example, France has three different kinds of bilateral agreement (conventions d’établissements, accord de réciprocité, and convention médicale transfrontalière) with at least 10 countries, the majority of which are in northern or sub-Saharan Africa.

In 2001, the United Kingdom introduced a code of conduct for international recruitment aiming to prevent recruitment from countries with workforce

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shortages. A regional code was introduced in Scotland. The effectiveness of such codes is the subject of scientific debate. The United Kingdom’s case study reports that further specifications and implementation measures were required before the code showed some effects. A national code was reported for Austria too, even though planning and recruitment takes place at regional and local levels; the effects of this code were not reported (see Table 2.3).

Bilateral agreements are the most commonly used cross-border framework.

Most country case studies do not cover these in depth but at least four types of bilateral agreements can be distinguished. Firstly, agreements can limit or exclude recruitment from countries with workforce shortages, as used in the United Kingdom in support of the international code. The Italian case study also reported on the implementation of a code to reduce immigration from third countries but it is not clear whether this applies only to health professionals. Secondly, agreements can aim to facilitate health professional mobility by establishing systems for mutual recognition of diplomas, such as the agreement established between Belgium and South Africa and those established as part of the free trade agreements in Nordic countries in the 1950s.

France has agreements with countries in north and central Africa, Monaco and Switzerland and has entered bilateral agreements on the establishment of health professionals (these include Monaco on the basis of its special relation to France). Thirdly, agreements can foster active recruitment, such as the bilateral agreement between Germany and Croatia concerning nurses. Between 2001 and 2005, the United Kingdom concluded bilateral agreements with Spain, Germany, Austria and Italy on the active recruitment of medical doctors.

Fourthly, bilateral agreements allowed temporary opening of the labour markets to accession countries until enlargement was finalized and full mobility established. Country case studies report agreements between Hungary and Norway and between the United Kingdom and Poland.

Policy changes can lead to the removal of bilateral agreements, as was the case for the United Kingdom agreements on reciprocal recognition of pharmacists from Australia and New Zealand. Slovenia has agreements inherited from the former Yugoslav Republic that are being phased out or becoming irrelevant.

Informal bilateral agreements between professional bodies assume similar functions in some cases, as shown by the examples between Tyrol in Austria and South Tyrol in Italy, or between Finland and Estonia.

Twinning aims to support the development of modern institutions in the beneficiary country. Some twinning activities have been reported from the United Kingdom, Italy and Austria, led by the Royal College of Physicians, the International Training Academy for Health Professionals and EU-funded projects.

Table 2.3 Cross-border frameworks for steering and managing health professional mobility International codeBilateral agreementTwinningStaff exchangeEducation supportCompensationTraining for export AustriaXXXXX BelgiumXX Estonia(X) FinlandX FranceX GermanyX HungaryXX ItalyXXX Lithuania PolandX RomaniaX SerbiaX SlovakiaX SloveniaX SpainX TurkeyX United KingdomXXXX Note: (X): informal agreement only.

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An abundance of initiatives focus on staff exchange and educational support but it is often difficult to distinguish between them because the same activity can cover both cross-border frameworks. These initiatives tend to be used more at regional or local level rather than nationally and often by professional bodies or health-care organizations. There are several examples in Belgium. In 1990, a Belgian university signed an agreement allowing Romanian third- or fourth-year medical students at a Romanian university to spend one to three fourth-years of their specialization in one its hospitals. By 2009, some 450 Romanian interns had taken part in the programme. A university hospital in Liège has signed an agreement with a Vietnamese hospital, and a university in Brussels runs a scholarship programme for medical doctors.

The Italian-led SkyNurse project has involved 180 candidates in a 14-month training programme that includes three months of distance learning between classrooms in Padua and the partners’ institutes in Bucharest and Pitesti. Other examples were reported for leading institutions from Austria, Turkey and the United Kingdom.

Authors of country case studies were also asked to report on compensation schemes. These aim to mitigate the loss of investment in human resources in source countries but, while discussed in the international literature, no compensation schemes were found.

Training for international recruitment takes place in Europe but the examples are not straightforward and do not necessarily involve high-level or governmental involvement. No intentional training for international recruitment was reported but the oversupply situation in Serbia is de facto training for unemployment.

Hungarian medical universities train foreign nationals for the European job market and have offered programmes in German since 1983 and in English since 1987. These courses are increasingly popular mainly among students from the Middle East, Nordic countries, Germany and the United States. Romanian doctors are offered the opportunity to undertake part of their specialist training in France. It is expected that most students will return to their countries on completion of their training.