Factors influencing health professional mobility .1 Facilitating factors

Language and geographical proximity appear as the crucial facilitating factors for any group of health professionals. In the case of outflows from Belgium, there is no language barrier for Dutch-speaking professionals migrating to the Netherlands or for French-speaking professionals willing to practise in France.

The relatively important inflows of Romanian professionals are facilitated because Romanian is a Romance language¹² and the country has traditional ties with the Francophonie. The latter is also true for Lebanon. The recent important inflow of Lebanese nurses with a post-secondary diploma, apparent in the French Community equivalence statistics, comprises graduates of a French-speaking nursing bachelor course organized in Lebanon (Geets 2008). It is suggested that French-speaking hospitals in Brussels turned to Lebanese nurses educated in French after Romanian nurses experienced language difficulties (Metro 2008).

12 Rocour (2006a) and interviews with Romanian specializing doctors working in Belgian hospitals.

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5.7.2 Activating factors

Standard activating factors include perceived opportunities of personal development, competence diversification, and horizontal and vertical career opportunities, which can be linked either to national differences in work styles or to particularities of the destination institution (van den Heuvel et al.

2007). Partner-like and less formal relations between nurses and doctors are commonly cited as activating factors for Belgian nurses seeking employment in the Netherlands (Nursing voor verpleegkundigen 2006).¹³ Employers also appeal to potential employees by offering in-service training¹⁴ or work in specialized care units (and thus opportunities for learning and higher income).

Romanian doctors specializing in Belgium underscore that Belgian hospitals provide specialized care for which there are no expertise centres in Romania (e.g. treatment of the neurovegetative state).¹⁵

Income and pension differentials remain among the key activating factors for Belgian nurses migrating to the Netherlands.¹⁶ However, Belgian health professionals working in the Netherlands often choose to live in Belgium and commute, whether for family reasons, lower housing prices or specific social benefits.¹⁷ Although it was not mentioned during the interviews, it is likely that financial motives are also significant for Romanian doctors coming to Belgium, particularly those recruited by private companies.¹⁸

5.7.3 Instigating factors

The surplus of specialists is cited as the main instigating factor encouraging Belgian specialists (mainly from the French Community) to migrate to France (Anrys 2009). Significant variation in the activity levels of specialists (Roberfroid et al. 2008) does suggest oversupply and this would impact on income as specialists are generally self-employed.

Literature cites potential instigating and activating factors for Belgian-trained general practitioners considering migration to the Netherlands: the past shortage of general practitioners in the Netherlands and the simultaneous surplus observed in Belgium (van den Heuvel et al. 2007); financial motivations;

differences in both status and working conditions; and work style or, more

13 Interview with Belgian nurse working in azM, Maastricht, 2 July 2009.

14 In-service training allows nurses with a secondary level certificate to obtain a bachelor diploma in nursing or to specialize. BBL (Beroeps Begeleidende Leerweg) programmes combine three or four days of practical employment with one or two days of paid theoretical courses per week, allowing the student to acquire a diploma mainly through experience.

15 Interview with Romanian medical doctor with basic training working in Belgium, July 2009.

16 Interview with Belgian nurse working in the azM, Maastricht, 2 July 2009.

17 Interview with Belgian nurse working in the azM, Maastricht, 2 July 2009.

18 Recruitment companies often promise Romanian candidates that they will be able to top up their income by working as on call physician as often as possible. Interview with Romanian doctor with basic training working in Belgium, July 2009.

generally, cultural differences.Despite these potential instigating/activating factors, and efforts to attract Flemish general practitioners to the Netherlands (van den Heuvel et al. 2007), inflow data from the Dutch authorities show that surprisingly few Belgian general practitioners migrated to the Netherlands (Ministry of Health, Welfare and Sport unpublished data 2009).This could indicate potential mitigating factors. Indeed, general practitioners tend to be more embedded in the local community, and this could explain the important difference between the low outflows of general practitioners and the much higher outflows of specialists (see section 5.2.1).

5.8 Policy, regulation and interventions

5.8.1 Policies and policy development on health professional mobility

No public policy at federal or regional level that specifically aims at encouraging or discouraging health professional migration has been reported.

5.8.2 Workforce planning and development

Belgium has had explicit health workforce planning policies since 1996, when the Committee for Medical Supply Planning (Commission de planification médicale) was established to advise the federal authorities on a quota system (Government of Belgium 1967).The committee comprises representatives of the public authorities, relevant health professions, experts and other stakeholders. Following the committee’s advice, in 1997 a quota for training places was introduced at federal level for medical doctors, further extended to dentists and physiotherapists (see section 5.6.3). The committee’s remit also covers nursing, midwifery and speech therapy.

A specific register to centralize data on health-care professionals was set up in 2003 in order to provide the Committee for Medical Supply Planning with necessary information on the current medical workforce (Government of Belgium 1967).The Federal Database of Health Care Professionals gathers information on professionals of all regulated health professions.

A mathematical model is used to forecast future supplies of medical doctors, dentists, physiotherapists and nurses (FOD Volksgezondheid 2009). This is intended to support the Committee for Medical Supply Planning in assessing the needs and sustainability of the system in order to determine health workforce planning policies. This stock-flow model should take account of the numbers, gender and age of foreign-trained health-care professionals migrating to Belgium as well as of the outflows of Belgium-trained graduates. However,

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the outflows have not been included in simulations to date as the Belgian authorities lack complete data on emigration (FOD Volksgezondheid 2009).

5.8.3 Cross-border regulatory frameworks and interventions Mutual recognition of diplomas in the European Community

Chapter 4 of the Belgian law on the exercise of the health professions specifies the means by which the EC mutual recognition directive was implemented in May 2005 (Government of Belgium 1967).The provisions of this chapter extend to third-country nationals with qualifications that conform to the directive. Professional qualifications that fall under the scope of the directive must be recognized by the health minister. Authorities can ask for a document certifying that the candidate’s qualifications are in compliance (a conformity certificate) and this is a systematic requirement for professionals from new Member States.¹⁹ Professions that are recognized automatically are granted recognition when the authenticity and conformity of the documents have been verified, up to three months after the complete file has been introduced.

For nurses, the recognition distinguishes between secondary level and post-secondary level diplomas.²⁰

The Belgian system distinguishes between nurses with secondary-level education,²¹ nurses with post-secondary/bachelor-level education²² and assistant nurses.²³ All three diplomas meet the criteria for nursing diplomas listed in the EC directive and holders of these three types of diploma are granted the same conformity certificates. Belgian law allows all three categories of nurses to perform the same functions, with two exceptions: (i) nursing assistants are not allowed to undertake work delegated by a doctor, and (ii) only nurses with post-secondary level diplomas can specialize. There are also de facto differences as hospitals generally prefer to hire nurses with bachelor-level diplomas and nursing homes are staffed predominantly by nurses with secondary-level diplomas.

For diplomas that fall outside the automatic recognition procedure, the FPS Health, Food chain safety and Environment additionally enquires whether the applicant complies with all the conditions on professional training and experience stipulated in the EC directive and defined in a Belgian Ministerial

19 Interview with competent civil servant, FPS Health, Food chain safety and Environment, Brussels, 7 July 2009.

20 Competent civil servant explains that authorities make this distinction because Belgian employers want to know whether a foreign diploma corresponds to secondary or post-secondary level. Furthermore, if no distinction was made, employers would recruit all foreign-trained candidates as if they held secondary-level diplomas and pay them (less) accordingly.

21 Infirmières brevetées/gebrevetterde verpleegkundigen.

22 Infirmières graduées/gegradueerde verpleegkundigen.

23 Aides-soignantes/verpleegassistenten.

Decree. TheFPS Health, Food chain safety and Environment have one month (two in exceptional cases) to inform the applicant about the results of the verification procedure. The professionals meeting the requirements are granted recognition within four months.Specialist medical doctor and specialist nursing diplomas that do not fall under the automatic recognition procedure must be recognized by the competent recognition commission (comprising representatives of the relevant profession).

As foreseen by the EC directive, EU nationals who are legally established in other EEA countries can provide health services in Belgium on a temporary and occasional basis without the recognition, licence to practice and registration.

However, they are required to apply for a provisional licence to practise (Fig.

5.4). Before the first provision of care, these professionals must give written notice informing the FPS Health, Food chain safety and Environment of their intentions and provide information on their professional liability insurance.

In practice, it appears that some health professionals do not apply for this provisional licence to practise.²⁴

Fig. 5.4 Recognition or equivalence route for medical doctors, dentists or nurses with EEA nationality

Source: Adapted from Duthoi 2007.

24 Interview with the competent civil servant, FPS Health, Food chain safety and Environment, Brussels, 7 July 2009^. Doctors, nurses, dentists, midwives, pharmacists, (paramedics)

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Bilateral agreements

A bilateral agreement signed with South Africa in 1965 in use for 40 years, established a system of mutual recognition of basic medical diplomas (Government of Belgium 1970).

Third-country health professionals

A qualification that does not conform to the EC directive must be declared equivalent by the French or the Flemish Community. Furthermore, third-country nationals with a non-EU diploma must obtain a Royal Decree before applying for a licence to practise and registering with the competent order.

Applications from doctors, dentists and pharmacists are also submitted to the competent Royal Academy (Fig. 5.5).

Doctors and nurses are granted equivalences only for the basic medical/nursing diploma. In addition, specializations must be recognized by the competent federal recognition commission. In practice, such recognitions are very rare.²⁵ Belgian law allows foreign-trained non-EEA medical graduates to undertake part of their specialization in Belgium. This is conditional upon a signed declaration of their commitment to return to their country of origin on completion of the assigned training period (Government of Belgium 1967).

Fig. 5.5 Recognition or equivalence route for medical doctors, dentists or nurses with non-EEA nationality

Source: adapted from Duthoi 2007.

25 Interview with competent civil servant, FPS Health, Food chain safety and Environment, Brussels, 7 July 2009.

Academic

the EC directive Diploma not in conformity with the EC directive Non-EEA nationals

Specific interventions and managerial tools

Some hospitals recruit nursing staff by setting up exchange programmes with foreign schools or by using the services of liaison or temporary work agencies that recruit abroad. Several Brussels hospitals have used this method to hire Romanian or Lebanese nurses (Metro 2008). In 2005, the University Hospital of Antwerp UZA hosted several Polish nursing students and, more recently, nurses from the Philippines (Vandaag.be 2009). Such private companies provide Belgian hospitals not only with nurses but also with specializing foreign medical doctors who are willing to work as assistants in Belgium (Anrys 2009, Geets 2008).²⁶

Private companies not only recruit in the country of origin but often also arrange travel, accommodation and administrative requirements (such as residence permit, diploma recognition/equivalence) for their recruits. Hospitals that have hosted or recruited foreign-trained nurses evaluate these experiences as overall positive or mixed, mentioning communication difficulties due to insufficient command of their hospital’s working language (Metro 2008).

A human resources manager at the Dutch azM reported that the hospital would not survive without recruiting nurses from Belgium – situated near the border, it employs 400 Belgian nurses (out of a total of 1100). Hence, the azM collaborates closely with the Flemish Public Employment and Vocational Training Service and publishes recruitment adverts in the Belgian Dutch-speaking local, national and specialized press.²⁷

Certain Belgian hospitals recruit foreign doctors with basic training for less-attractive tasks, mainly on-call duties (Geets 2008). Often, these duties are funded from the pooled income of a hospital’s medical doctors who, therefore, tend to choose lower paid trainee doctors over confirmed specialists. Some hospitals claim that they are not assigned enough Belgium-trained interns since the numerus clausus limits the number of doctors eligible to specialize (Rocour 2005; see section 5.8.4).

In 1990, the Belgian French-speaking Université Catnoligne de Louvain (UCL) and the Romanian University of Medicine and Pharmacy “Gr.T. Popa”

Iaşi signed an agreement allowing Romanian doctors with basic training to spend one year (potentially extendable to two years) of their specialization in one of UCL’s hospitals. Each year, this agreement brings around 70 third or fourth year Romanian medical students to Belgium. By 2009, some 450 Romanian interns had taken part in the programme.²⁸ Before Romania’s

26 Phone interview with specialist working in a rural hospital in southern Belgium, 14 July 2009.

27 Interview with Belgian nurse working in the azM, Maastricht, 2 July 2009.

28 Interview with Philippe Meert, Brussels, 13 July 2009.

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accession to the EU, participants could undertake part of their specialization in Belgium, under the responsibility of a qualified doctor, without obtaining equivalence of their diploma and a licence to practise (see section 5.8.3).²⁹ Some other hospitals signed similar cooperation agreements with foreign training institutions. For example, a university hospital in Liège signed such an agreement with a Vietnamese hospital (Janssens 2006) and the French-speaking Université libre de Bruxelles (ULB) runs the Fonds de Soutien à la Formation Médicale scholarship programme.³⁰

5.8.4 Political force field of regulating and managing health professional mobility

Professional associations in Belgium generally disapprove of the recruitment of foreign nurses and medical interns, rejecting hospitals’ shortage arguments (Vandaag.be 2009). They argue that migrant professionals accept less-favourable working conditions (Rocour 2006a, 2006b) that could potentially lead to social dumping. Hospitals experimenting with the recruitment of foreign professionals are much less sceptical and declare that they are well aware of the short-term character of such solutions (Rocour 2006a).³¹

Simultaneously with the decision to lift transition periods for the citizens of the eastern European Member States that joined the EU in 2004, the Belgian federal Minister for Migration and Asylum Policy evoked migration as a way of alleviating nurses’ shortages, probably in order to make the opening of the Belgian labour market more acceptable to the public (Turtelboom 2009).

Belgian medical associations cite the numerically significant outflows of specialists to France as an illustration of the oversupply of specialists in Belgium, especially in the French Community. These are used to refute arguments for an increase in the training places allowed by the quota system or even to push for stricter quotas (Anrys 2009). Several parliamentary questions have linked the recently increasing foreign inflows of medical doctors with basic training with the quotas preventing numerous graduates with a Belgian diploma from pursuing a specialization (Brotchi 2008, van Ermen 2009). Thus, the issue of foreign inflows is used to regenerate the debate on the quota system.

The linguistic capacities of the Romanian nurses and doctors with basic training recruited by bilingual hospitals in Brussels have also been the subject of parliamentary debate. At both federal and regional level, Flemish members of parliament have criticized the fact that these professionals are unable to

29 The legal basis for such practices was art. 49 ter, Royal Decree No.78.

30 http://www.ulb.ac.be/facs/medecine/fosfom/, accessed 15 July 2009.

31 See section on specific interventions and managerial tools.

speak Dutch (Vanackere 2006, van Linter 2006). The debate on professional mobility has thus become part of the Belgo-Belgian discussion. The generally insufficient Dutch language skills of health professionals (whether Belgian or foreign) working in Brussels’ bilingual hospitals have long been a very sensitive political issue (Gatz et al. 2005).

5.9 Conclusion

Based on the figures obtained for this study, it can be concluded that migration flows to and from Belgium are numerically significant in most health professions. However, mobility does not constitute a health workforce planning issue for the moment. The most important flows are observed to and from neighbouring countries, in particular France and the Netherlands. Inflows of foreign-trained health professionals in 2005–2008 represented 5% of all new general practitioner registrations, 10% of new specialist registrations, 9% of newly licensed nurses, 15% of newly licensed dentists and a remarkable 20%

of newly registered medical doctors with basic training. Outflows of specialists with Belgian diplomas, especially to France, are seriously exceeding inflows of specialists with foreign diplomas. This may be explained by an oversupply of specialists in the French Community. Stock data for 2008 show that 10.5% of medical doctors, 4.4% of nurses and 6.1% of dentists registered in Belgium were foreign nationals.

Inflows appear to be increasing in all professions over recent years, mainly through migration from neighbouring countries and from Romania. The increase in inflows from Romania is attributable mainly to the migration of medical doctors with basic training. The national quota system means that hospitals receive fewer specializing Belgian medical doctors and try to compensate for this by hiring foreign-trained doctors with basic training. It is too early to assess the stability of these inflows. Hospitals (mainly French-speaking) recruit foreign-trained nurses to alleviate shortages in nursing staff.

Recent inflows of Lebanese and Romanian nurses recorded by the French Community have been noticeably higher than in previous years but still appear negligible when estimated as a proportion of the average yearly number of nurses newly licensed to practise in Belgium.

The significant number of foreign (especially French) nursing students could aggravate the shortages in nursing staff, since most of these students are likely to return to their home country after graduation. The high proportion of foreigners studying medical and paramedical professions in Belgium calls for attention. Indeed, if these students choose to study in Belgium in order to avoid domestic enrolment quotas, it could potentially hurt the health workforce

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planning policies of their countries of origin. Furthermore, foreign candidates are not counted in the Belgian quotas that limit candidate specialists’ access to further training. This could have a negative impact on Belgian health workforce planning policies.

Overall, migration flows seem rather natural as Belgium is a country with generally high levels of individual and professional mobility – a country with permeable borders.³² However, recent developments indicate that health workforce flows require close monitoring.

References

Anrys H (2009). Numerus clausus. Le nombre de spécialistes qui quittent la Belgique correspond à un manque de postes.  Official note for the ABSyM-BVAS, Belgian Association of Medical Trade Unions, 16 January 2009.

Brotchi J (2008). Oral question No. 4-224 to the Federal Minister for Social Affairs and Public Health, Laurette Onkelinx. Annales No. 4-25. Brussels, Belgian Senate, 17 April 2008 (http://www.senate.be/www/?MIval=/publications/

viewPubDoc&TID =67110623&LANG=fr, accessed 20 December 2010).

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De Morgen (2007). Nederlanders lokken Belgische psychiaters met belastingvoordeel [The Dutch attract Belgian pyschiatrists with fiscal advantages]. De Morgen, 5 March 2007.