Mobility matters: key observations

Health professional mobility is clearly a phenomenon that cannot be ignored by policy-makers, health workforce planners, managers or researchers. Some important observations can be derived from the evidence presented in this volume, and this section puts forward six key observations formulated to highlight the most policy-relevant dimensions: (i) the significant but diverse magnitude of mobility, (ii) the lower than expected effects of EU enlargements, (iii) the worsening east–west asymmetries, (iv) money as a driver for mobility,

(v) the subtle but significant impacts of mobility, and (vi) the limited data available.

3.3.1 Magnitude of mobility: significant but diverse

The magnitude of health professional mobility is important in a number of countries in terms of reliance on the foreign workforce and of inflows.

Reliance shows the share of foreign health professionals within a country’s health workforce in a given year. As a share of total new entrants to the system, inflows show how migrants contribute to replenishing the workforce. There is considerable diversity in the magnitude of mobility across countries as well as within countries for different health professions.

Important reliance on foreign health professionals has been noted for the following countries. Foreign⁷ medical doctors amount to at least one in every ten medical doctors in Belgium, Portugal, Spain, Austria, Norway, Sweden, Switzerland, Slovenia, Ireland and the United Kingdom. Foreign-trained medical doctors made up 36.8% of all medical doctors in the United Kingdom in 2008. Overall, reliance on foreign nurses seems less pronounced but does exceed 10% of the nursing workforce in Italy, the United Kingdom, Austria and Ireland. One in every two nurses in Ireland is foreign trained.

All other countries in the study show low (around 5%) to negligible (<1%) reliance on the foreign health workforce.

The magnitude of flows also shows the importance of mobility. In Europe, flows have been increasing since the major geopolitical changes that began in the late 1980s. The limited number of time series data that are available indicate fluctuating inflows – increasing, decreasing or stable depending on the country.

Increases in outflows are suggested in more countries (observation (ii); section 3.3.2). In 2008, the proportion of foreign inflows within all new entrants⁸ to the health workforce was particularly high for foreign medical doctors in the United Kingdom (42.6%), Belgium⁹ (25.3%) and Austria (13.5%); for foreign nurses in Italy (28%), the United Kingdom (14.7%) and Belgium (13.5%); and for foreign dentists in Austria (40.8%), the United Kingdom (33.7%), Belgium (19.3%) and Hungary (9.7%). In Finland, 43.2% of newly licensed dentists in the period from 2006 to 2008 were foreign trained. Much lower shares were reported in Poland (around 3% for foreign medical doctors and dentists) and in Hungary (4.7% for foreign medical doctors and 2.4% for foreign nurses).

Data were not available for other countries.

7 Foreign born, foreign trained or foreign national.

8 Newly registered or newly licensed depending on country and profession.

9 In Belgium, these were medical doctors with basic medical diplomas (as opposed to general practitioner or specialist diplomas).

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3.3.2 Effects of EU enlargement: less than expected

The EU enlargements in 2004 and 2007 added 12 new countries to the free-movement area. Health professionals from eastern Europe joined the mobile workforce in Europe and mobility became a more diverse phenomenon.

The enlargements were associated with high expectations. Outflow intentions in Estonia, Hungary, Lithuania, Poland, Romania and Slovakia increased considerably at the time of accession but were lower than anticipated.

In many countries, annual outflow intentions hovered at around 3% of all health professionals but showed some peaks – reaching 6.5% of all medical doctors in Estonia in the last eight months of 2004 for example. In most countries, these outflow intentions subsequently decreased (between three and four times) but remained at higher overall levels than before enlargement. In Hungary, the outflow intentions of medical doctors have remained stable at around 2.5%

per year. By contrast, outflow intentions have remained low (<1%) in Slovenia.

Poland is an example of a country in which health professionals are reversing outflows by returning. Generally, outflows from the EU-12 have been lower than expected but are still higher than outflows from the EU-15.

It is important to note that intention-to-leave data are used as a proxy in the absence of data on actual outflows. However, these tend to overestimate emigration. Studies in Romania and Estonia showed that actual departures were two to three times lower than outflow intentions. Peaks such as the one recorded in Estonia in 2004 may be explained by retrospective applications for diploma certification from health professionals who migrated before accession.

Overall, the EU enlargements have led to increases in flows between EU countries but it is probably too soon to draw conclusions on the effects of EU enlargement. More recent (2009 or 2010) data from Estonia, Hungary and Romania point to a new surge in outflows, presumably related to the global economic downturn.

3.3.3 East–west asymmetries worsened

The analysis also reveals noticeable asymmetries between EU-12 and EU-15 countries. Flows are predominantly in one direction, from east to west, and most destination countries are in the EU-15 (observation (i), section 3.3.1).

All European countries are subject to outflows but most EU-15 countries show simultaneous inflows, unlike most EU-12 countries. EU-15 countries, therefore, have more possibilities to fill vacant positions with foreign health professionals.

These differences may signal the persisting importance of geopolitical contexts and economic incentives.  Lower income levels (observation (iv), section

3.3.4), working conditions and standards of living as well as unfinished health reforms in some EU-12 countries all add to the perception of less-promising perspectives. The lower inflows of foreign medical doctors and nurses as well as the lower levels of reliance on foreign health professionals in the EU-12 reflect and reinforce these asymmetries.

It should not be forgotten that outflows from eastern Europe started well before accession, following the political transitions that took place in various parts of the region. For example, high numbers of health professionals from Bosnia and Herzegovina, Croatia, and Serbia in Germany’s workforce stock in 2003 point to decades of outmigration from the former Yugoslav Republic. In some ways, it may still be too early to draw conclusions on the effects of enlargements.

Less than 10 years have passed and the right to free movement acquired with EU membership will continue to facilitate mobility even decades from now.

For the moment, mobility data show persisting differences between the EU-12 and the EU-15, albeit with variations within both groups.

3.3.4 Money: a main driver for mobility

Unsurprisingly, many of the country case studies show that money motivates mobility. This may seem obvious when an Estonian medical doctor can earn six times more in Finland and a Romanian general practitioner can earn ten times more in France. Income is the most cited factor in deciding whether or not to migrate, and influences leavers, returnees and those who remain. In Lithuania, annual salary increases of 20% for medical doctors and nurses in 2005–2008 likely helped to reverse high dropout rates from medical studies, as well as attrition and emigration. In Poland, better remuneration is reported to have diminished outflows and motivated returns. In Slovenia, increases in salaries arguably contributed to a smaller than expected loss of health professionals.

Conversely, a 25% cut in the salary of health professionals in Romania may have contributed to higher outflow numbers in 2009. It remains to be seen how the global economic downturn will affect flows, as mobility is dependent on what opportunities are (perceived to be) available in source and destination countries.

Money is an important motivator but only one among many factors that determine job satisfaction and willingness to stay or look for alternative options at home or abroad. The other most often mentioned motivation in the country case studies is working conditions. This includes the working environment, terms of employment, work relations and access to infrastructures. Low social recognition and/or low esteem were also mentioned relatively frequently.

Incomplete health reforms, unrealized objectives and disappointment among the workforce were mentioned in four EU-12 countries (Lithuania, Hungary, Romania and Slovakia).

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3.3.5 Subtle but significant impacts on the performance of health systems

One aim of this study was to assess mobility’s impact on health systems.

The perceived effects on shortages, training new workforces and financing sustainability have received much public attention in several countries. In spite of intense debates, there is surprisingly little evidence on the subject and there appear to have been no systematic studies. The country case studies address this gap by including some qualitative analysis based on expert interviews and authors’ observations.

The case studies indicate how mobility contributes to shortages concerning the size, skill-mix and geographical distribution of the health workforce in source countries. Inflows to destination countries can however help to compensate for inadequate workforce planning and to improve access. Foreign medical doctors, nurses, dentists and/or carers increase service capacity in the United Kingdom, Spain, Austria and Italy. Shortages in the less affluent eastern parts of Germany are increasingly filled by foreign medical doctors – their numbers tripled between 2000 and 2008. In France, medical doctors from non-EU countries fill gaps in public hospitals, particularly in socioeconomically disadvantaged areas.

There may be many reasons for shortages in source countries and it is hard to prove that emigration is the cause. However, several case studies mention that outflows can worsen service delivery. Losses become a particular problem if they involve large numbers, rare skills or occur in already undersupplied areas.

Slovakia lost a reported 3243 health professionals between January 2005 and December 2006, but the real numbers are likely to be substantially higher.

In Romania, rural areas with the lowest coverage of medical doctors report some of the highest emigration rates among medical doctors and nurses. Impacts are not always related to the size of flows. Hungary, Estonia and Lithuania noted that the departure of even a few specialists can upset service provision. Certain specialties appear to be more vulnerable. In Poland, most vacant posts concern anaesthetists and emergency doctors – specialists that show greatest intention to leave. In Belgium, the emigration of child psychiatrists has been reported as problematic given important shortages in the profession.

It is also important to recognize the accumulated effect of mobility. For instance, an annual outflow of 3% of total medical doctors may not appear to be significant but will leave a major mark on the size of the workforce if it continues over years. This implies that some impacts may take time to appear.

Training and financing are closely related in the mobility context. Mobility has implications for training owing to the huge cost and time needed to educate

and train health professionals. Several countries report (extremely) high foreign inflows in at least one health profession (cf. observation (i), section 3.3.1). In 2008, Spain recognized 8282 foreign degrees in general medicine – more than double the number of medical graduates produced that year. Whether or not this is a conscious strategy, the importation of health professionals expands knowledge and skills but at lower costs. As noted in the United Kingdom, foreign recruitment has the added benefit of freeing up senior staff to train a new workforce. Yet, while foreign inflows are substantial in many countries (observation (i)), they may come at the expense of reliance on a foreign workforce.

Conversely, Serbia and Montenegro have spent an estimated US$ 9–12 billion educating and training medical specialists who have since left the country.

This undermines returns on investment and possibly the necessary skill-mix of the country. Mobility of foreign students affects the availability of training positions, and foreign students are less likely to stay in a host country following graduation. Health workforce planning in Belgium is affected as inflows of Dutch and French students bypass the numerus clausus that applies to domestic students of medical and health-related studies. There are similar concerns about the influx of Germans taking up medical student posts in Austria.

In addition to the financial consequences of gaining or losing health professionals, there is also evidence that mobility can impact on salary levels.

Spain has reported that foreign inflows helped to keep salaries at sustainable levels within a context of high demand for health services. By comparison, the Lithuanian Government and Polish independent health-care providers increased salaries in order to retain medical doctors. Such incentives raise questions about long-term sustainability and redistribution within the system.

Impacts are subtle in the sense that they are often indirect, hard to discern and non-immediate. They may be insignificant at country level but substantial at regional or hospital level. As mentioned above, the analysis of impacts is also hampered by the difficulty of establishing causal effects. Moreover, the relative importance of mobility will depend on the domestic workforce issues facing planners and policy-makers in individual countries. These include shortages, unbalanced skill-mixes, geographical maldistribution, workforce and population ageing, attrition and/or underproduction of new health professionals. Within this context, mobility can be considered to be of high relevance in seven countries of this study (Austria, Hungary, Romania, Slovakia, Slovenia, Spain, United Kingdom), of medium relevance in six (Belgium, Finland, Germany, Italy, Poland, Serbia) and of lower relevance in comparison to other concerns in four (Estonia, France, Lithuania, Turkey).

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3.3.6 Data are still limited

In 13 of the 17 country case studies (Belgium, France, Germany, Hungary, Italy, Lithuania, Poland, Romania, Serbia, Slovakia, Spain, Turkey, United Kingdom) there was reported to be insufficient availability of updated and comprehensive data on migration. Decision-makers do not know exactly who is entering and who is leaving their systems and, therefore, it is harder to assess the implications for the workforce and for health system performance.

There are several aspects to the issue of data limitations. First, the absence of a proper definition of health professional mobility means that three indicators (foreign trained, foreign born, foreign national) are used to capture mobility.

Limitations in the validity of each indicator and their unsystematic use across Europe make it difficult to assess the scale and character of mobility. Countries such as Austria, Poland and Slovenia where more than one indicator is available show data values that differ significantly. With careful interpretation, these variations can provide a richer picture of mobility but they also raise questions about the validity of comparisons between indicators. Moreover, the inaccuracy of general stock indicators (for example, on licensed/active or full-time/part-time health professionals) makes it difficult to assess how mobility contributes to the health workforce. Data sources are also not able to capture certain types of mobility that may be on the rise in the EU such as returning migrants, short-term mobility, weekend work and dual practice, undocumented workers, commuting and training periods abroad.

Second, most countries find it very difficult to provide time series data, thereby hampering the ability to understand mobility trends and monitor fluctuations.

Changes in professional definitions, new collection methods and new data holders also led to discontinuity of data in EU-12 countries.

Third, data on nurses suffer from greater limitations and inaccuracies than data for medical doctors in most countries. Even where data are available, the professions and qualifications included vary widely between countries.

Finally, no country appears to have accurate outflow data. Intention-to-leave data are used to gauge emigration but, although an important signal, their validity is disputed. Health professionals may choose to leave without conformity certificates as they are not required by all employers; they may apply for certification retrospectively; or they may apply but never leave.

A study in Romania showed that only a third of medical doctors who requested certificates in 2007 actually emigrated; in Slovakia there is evidence that equivalence confirmations are severe underestimates of real outflows. Moreover, intention to leave may be susceptible to manipulation as health professionals can use requests for conformity certificates to pressurize governments and fuel

political debate. Countries can address this information gap by searching the registries of destination countries but this remains a cumbersome and little used procedure. Such studies have been carried out in Lithuania, Germany and Belgium.