Belgium as both source and host country
5.2 Mobility profile of Belgium
Belgium is both a source and a destination country. Cross-border flows are numerically relatively important in the investigated health professions and the most important exchanges have been found with neighbouring countries.
Recently, inflows seem to have increased in all professions. Anecdotal evidence suggests that Belgium is also a transit country for some medical doctors – having completed basic medical training in their home countries they undertake one or two years of specialization in Belgium before returning home or moving elsewhere (see section 5.5).
5.2.1 Outflows
Holders of a Belgian medical, dentistry or nursing diploma who intend to practise in another EU Member State can apply for a conformity certificate that assures compliance with the directive on the recognition of professional qualifications (European Parliament and Council of the European Union 2005). Health professional outflows are estimated from the numbers of conformity certificates requested, from the International Mobility Cell for the Health Professions of the Belgian Federal Public Service (FPS) Health, Food chain safety and Environment. This information is supplemented by inflow data from France (Le Breton-Lerouvillois 2007, 2009) and the Netherlands (Ministry of Health, Welfare and Sport unpublished data 2009).
The data on conformity certificates should be interpreted with caution.
Applicants do not always know or declare their destination – 10% of nurses and general practitioners, 11% of doctors with basic medical training, 14% of specialists and 22% of dentists did not. In addition, professionals may request these certificates but never leave Belgium to practise abroad, or may go to a country other than that declared. Some countries (such as the Netherlands) recognize Belgian diplomas without systematically requesting a conformity certificate; other countries (such as France) request a conformity certificate from every foreign-trained health professional who intends to immigrate. Aggregated conformity certificate statistics show that France and the Netherlands are the two most frequently declared destinations.
The outflow data take no account of the nationality of the person requesting the conformity certificate and thus do not distinguish between Belgian nationals and foreign nationals with a Belgian diploma. As a result, these data comprise important numbers of foreign nationals who came to study in Belgium and are applying for conformity certificates before returning to their home countries after graduation. Finally, the outflow statistics include a very small number of requests that were declined (less than 2% according to the competent civil servant). Data on the delivery of conformity certificates were available only for the last three years (2006–2008), making it difficult to analyse trends over time.
These data do not show any clear decreasing or increasing tendencies.
France is the destination of a large share of Belgium-trained migrating health professionals – specified for 57% (394) of specialists requesting conformity certificates (Table 5.1). It is often assumed that these migrating professionals include many French nationals who studied in Belgium (Roberfroid et al.
2008). However, data collected by the CNOM show important numbers of Belgian-national medical doctors practising in France (Le Breton-Lerouvillois 2007, 2009). In early 2009, a total of 1576 Belgian nationals were registered
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with the CNOM, 16.37% of all foreign medical doctors registered in France (Le Breton-Lerouvillois 2007). In 2007, Belgians accounted for 30% to 40% of all foreigners practising certain specialities in France.2 The Paris region and the regions bordering Belgium and Germany had the highest numbers of foreign medical doctors.
Belgian data on outflows of medical doctors and dentists show that the United Kingdom is the second most popular stated destination.
It should be noted that the Belgian data on conformity certificate requests underestimate actual outflows as the Dutch authorities do not systematically request conformity certificates from the holders of Belgian medicine, dentistry and nursing diplomas. Therefore, the Belgian data have been supplemented by Dutch Ministry of Health, Welfare and Sport statistics on the number of health professionals with Belgian diplomas newly registered in the Netherlands in 2006–2008 (Fig. 5.1). These data allow a more accurate picture of outflows to the Netherlands since it is compulsory for medical doctors, dentists and nurses to register with the Dutch authorities.
2 Radiotherapy, physical medicine and rehabilitation, nuclear medicine, occupational medicine, orthopaedic surgery and traumatology, urological surgery, vascular surgery; 11 of the 17 foreign neuropsychiatrists practising in France were Belgians (Le Breton-Lerouvillois 2007).
Table 5.1 Number of conformity certificates requested by specialists with Belgian diplomas, 2006–2008
United Kingdom 22 35 16 73 10.61
Unknown 38 45 18 101 14.68
Other EU-15a 7 10 7 24 3.49
EU-12b 0 0 0 0 0.00
Non-EU 9 31 6 46 6.68
Total per year 239 322 127 688 100
Source: FPS Health, Food chain safety and Environment unpublished data 2009.
Notes: a Austria, Denmark, Greece, Ireland, Italy, Spain, Sweden; b Bulgaria, Czech Republic, Cyprus, Estonia, Hungary, Latvia, Lithuania, Malta, Poland, Romania, Slovakia, Slovenia.
Dutch data show 373 doctors with basic training, general practitioners and specialists holding Belgian medical diplomas newly registered in the Netherlands between 2006 and 2008. The majority of those migrating doctors are likely Dutch nationals who studied medicine in the northern, Dutch-speaking part of Belgium (see section 5.6.3). During the same period, 81 nurses and 69 dentists with Belgian diplomas registered in the Netherlands (Fig. 5.1).
Dutch data suggest that outflows to the Netherlands by medical doctors, nurses and dentists with Belgian diplomas are numerically important and of a similar size to the outflows to France estimated from the Belgian data on conformity certificates.
The data on conformity certificate requests show that the emigrating specialists with Belgian diplomas represent a very high percentage of the total number of newly registered specialists in Belgium per year. Between 2006 and 2008, 3100 (foreign-trained and Belgium-trained) specialists registered in Belgium (see Table 5.4 below), while 688 specialists with Belgian diplomas requested conformity certificates during the same period (Table 5.1). This suggests that for every 10 specialists who enter the Belgian labour market nearly two (plan to) emigrate.
Fig. 5.1 Annual outflows to the Netherlands of health professionals with Belgian diplomas, comparison of Belgian and Dutch data, 2006–2008
Source: FPS Health, Food chain safety and Environment unpublished data 2009.
Notes: BE: Number of conformity certificates requested by Belgian doctors with basic training, general practitioners, specialists, nurses and dentists who declared Netherlands as destination. NL: Number of newly registered medical doctors, nurses and dentists holding Belgian diplomas in the Netherlands.
0
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5.2.2 Inflows
In Belgium, data on foreign health workforce are held at federal and community level. Inflows of foreign-trained health professionals to Belgium have been estimated from three different sources: (i) International Mobility Cell for the Health Professions’ data on EEA and non-EEA diplomas recognized or declared equivalent between 2001 and 2008; (ii) French Community statistics on non-EEA diplomas and EEA diplomas not conforming with the EC directive3 declared equivalent between 2003 and 2008; and (iii) the Federal Database of Health Care Professionals (Cadastre des professionels de soins de santé) (the register) comprising the number of registered general practitioners and specialists and the number of medical doctors, nurses and dentists newly licensed to practise (see section 5.8.2). Theoretically, the number of newly licensed medical doctors with foreign diplomas should coincide with the sum of equivalences and recognitions granted (although there might be a time lag) but this is not the case with the data provided. However, recognition data are more reliable than register statistics.4
Medical doctors with no general practice or specialist training
Inflow data provided by the International Mobility Cell for the Health Professions show that 1704 foreign basic medical diplomas were recognized or declared equivalent in Belgium between 2001 and 2008 (FPS Health, Food chain safety and Environment unpublished data 2009). These were mostly French (355) and Dutch (313). Before EU accession, no Romanian diplomas were declared equivalent. In 2007, Romania became the third most frequent country of origin (267 recognitions) overtaking both Germany (213) and Italy (187), which were the third and fourth source countries until 2006. The sharp increase in recognitions noticeable from 2007 (Fig. 5.2) is thus mostly attributable to inflows from Romania.
Belgian data on recognized foreign basic medical training include doctors with foreign general practitioner or specialist diplomas who might have further registered as a general practitioner or a specialist. Indeed, in Belgium, recognition of a foreign general practitioner or specialist diploma starts with the recognition of the applicant’s basic medical training.
The proportion of foreign-trained newly licensed doctors with only basic training has been increasing since 2005 and in 2008 reached just over 25% of
3 Only French Community (subnational) data on EEA diplomas not in conformity with the EC directive were used as the Flemish Community data lacked precision. The 2003–2008 data on equivalences of dentistry, bachelor-level nursing and basic medical diplomas and the 2007 and 2008 data on equivalences of secondary-level nursing diplomas were analysed.
Information on non-EEA diplomas was obtained from French Community data (2003–2008 for basic medicine, bachelor nursing and dentistry diplomas; 2007 and 2008 for secondary-level nursing diplomas) and 2004–2008 statistics on practice permits from the International Mobility Cell for the Health Professions.
4 Phone interview with the competent civil servant, Brussels, July 2009.
all newly licensed medical doctors with basic training (Table 5.2). A major part of this significant increase can be explained by the rise in Romanian diploma recognitions mentioned above.
Yearly inflows of Romanian doctors with basic medical training were comparable before Romania’s accession to the EU, but based on a different legal provision limiting their stay in Belgium (see section 5.8.3). In 2004–2006, some 682 medical doctors with third-country diplomas (mostly from Romania, Morocco and the Congo) arrived to do part of their specialization in Belgium on the basis of this specific legal provision (Table 5.3).
Table 5.2 Estimated numbers of foreign-trained medical doctors with basic training licensed in Belgium per year, 2005–2008
2005 2006 2007 2008
A: Foreign-trained newly licensed medical
doctors with basic training 199 258 417 459
B: Foreign-trained newly registered general
practitioners and specialists 75 110 105 148
C = (A − B): Foreign-trained doctors not registered as general practitioners or
specialistsa 124 148 312 311
D: Total of newly licensed doctors with basic
training 1082 1005 1157 1228
E = C/D 100 : % of foreign-trained within total newly registered medical doctors with
basic training 11.5% 14.7% 27.0% 25.3%
Source: Own calculations based on FPS Health, Food chain safety and Environment unpublished data 2009.
Note: a Category covers medical doctors who either have no general practitioner or specialist training or who did not register as general practitioners or specialists in Belgium.
Table 5.3 Medical doctors with non-EEA diplomas undertaking part of their specializations in Belgium under Royal Decree No. 78
Country of diploma 2004 2005 2006 Total per country
Congo 18 15 18 51
Morocco 27 40 26 93
Romania 51 114 113 278
Other 92 81 87 260
Total per year 188 250 244 682
Source: FOD Volksgezondheid 2007c.
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General practitioners and specialists
Table 5.4 shows the number of general practitioners and specialists with a foreign diploma newly registered in Belgium between 2005 and 2008 : non-Belgian diplomas were held by about 3%–8% of newly registered general practitioners and about 8%–12% of newly registered specialists.
The data on EEA diploma recognitions lead to similar conclusions to those drawn from the registration data – general practitioner inflows to Belgium appear to be rather insignificant while specialists migrate in larger numbers.
A total of 91 general practitioner diplomas were recognized between January 2001 and December 2008. Of these, 38 were French. Surprisingly, the United Kingdom (15 diplomas) and Spain (10 diplomas) were the second and third country of origin for general practitioners. The neighbouring Netherlands had only five recognitions. During the same period, Belgium recognized 348 specialist diplomas from within the EEA, mostly German (83), Dutch (68), French (55), Italian (40) or Romanian (34).
Over time, there has been a steady increase in the share of foreign nationals in the medical workforce. In 2003, foreign nationals counted for only 8% of all registered medical doctors. However, these data should be interpreted with caution as they include foreign nationals who lived and studied in Belgium already before enrolling in medicine in the country. Data from the OECD for 2008 show that 2989 medical doctors (6.7% of the total Belgian medical workforce) were foreign trained (OECD 2008). Stock data from the national database show that 10.5% of the 51 171 registered medical doctors in 2008 were not Belgian nationals: 2.3% were French, 2.6% Dutch, 0.8% German, 0.7% Italian, 0.5% Spanish and 0.5% Romanian (FPS Health, Food chain safety and Environment unpublished data 2009).
Table 5.4 General practitioners and specialists in Belgium, 2005–2008
2005 2006 2007 2008 Foreign-trained newly registered general practitioners 11 14 7 17 Total newly registered general practitioners 259 281 238 218 Percentage of foreign-trained general practitioners 4.2% 5% 2.9% 7.8%
Foreign-trained newly registered specialists 64 96 98 131
Total newly registered specialists 821 1056 973 1071
Percentage of foreign-trained specialists 7.8% 9.1% 10.1% 12.2%
Source: FPS Health, Food chain safety and Environment unpublished data 2009.
Fig. 5.2 EEA medical diplomas recognized in Belgium, 2001–2008
Source: Own calculations based on FPS Health, Food chain safety and Environment unpublished data 2009.
Note: a Values calculated by subtracting the number of recognized EEA general practitioner and specialist diplomas from the annual total of EEA basic medical training recognitions.
Inflow charts show a steady increase in recognitions of all types of foreign medical diploma. The sharp increase in specialist diploma recognitions in 2006 is mainly attributable to intensified inflows from France and the Netherlands (Fig. 5.2).
Nurses
Register, recognition and equivalence data suggest important inflows of foreign-trained nurses relative to total inflows to the profession. Register data for 2005–2008 show that the proportion of foreign-trained nurses within all newly licensed nurses varied between 5.8% and 13.5%, with a tendency to increase (Table 5.5).
Stock data show that 4.4% of the total of 175 111 registered nurses in 2008 were foreign nationals, mainly of French (2.5%), Italian (0.5%) and Dutch (0.4%) nationality (FPS Health, Food chain safety and Environment unpublished data 2009). Again, these data include second-generation immigrants who studied in Belgium. This is illustrated by the high proportion of Italians, as Belgium has
Table 5.5 Newly licensed nurses in Belgium, 2005–2008
2005 2006 2007 2008
Foreign-trained newly licensed nurses 205 268 330 565
Total of newly licensed nurses 3549 3798 4078 4170
Percentage of foreign-trained nurses 5.8% 7.1% 8.1% 13.5%
Source: FPS Health, Food chain safety and Environment unpublished data 2009.
0 350
200 150 100 50
2001 2008
250 300
2002 2003 2004 2005 2006 2007
Doctors with basic traininga Specialists
General practioners
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had a sizeable Italian population since the 1960s. OECD data for that same year show a share of only 1.5% of foreign nationals in the nursing population (OECD 2008). However, there are good reasons to question the validity of these OECD data as Belgian authorities stressed that nursing stock data for 2009 and older with an acceptable degree of reliability could be provided only for the last trimester of 2009. Prior to this, the database for nurses included those who were no longer active in the workforce.
Recognition data show that 40.5% of the 1152 foreign nursing diplomas recognized between 2004 and 2008 were French, mostly of post-secondary level. Dutch nursing diplomas ranked second, with 253 recognized diplomas balanced roughly between secondary and post-secondary level. German diplomas were the third most important group, with 111 exclusively secondary level diplomas.
For all the medical professions discussed in this chapter, community data demonstrate that non-EEA and EEA diplomas that do not conform to the EC directive are seldom declared equivalent. The noticeable exceptions are 153 Romanian secondary level nursing diplomas that the French Community declared equivalent in 2007–2008 (94% of all secondary level nursing diplomas declared equivalent during that period)5 and the 93 Lebanese post-secondary nursing diplomas declared equivalent in 2008 (80% of all post-secondary nursing diplomas declared equivalent by the French Community in that year).
The competent civil servant reported that the majority of the 169 diplomas declared equivalent between January and August 2009 were also Lebanese.6 Federal level data for 2008 on diplomas first declared equivalent by Community authorities (Table 5.6) do not reflect the 93 Lebanese nursing diplomas declared equivalent by the French Community in that year. This isprobably because of a time lag between the granting of equivalences and subsequent processing of the application. The 153 secondary level nursing diplomas from Romania that the French Community declared equivalent between 2007 and 2008 are not featured either because the federal data do not take account of EEA diplomas that fall beyond the scope of the EC directive (Table 5.6).
Federal data show that 59 of the 175 nurses with a non-EEA diploma granted a Royal Decree of Exercise between 2004 and 2008 had Congolese diplomas (Table 5.6). Moreover, the increase in recognitions noticeable from 2006 onwards is almost exclusively attributable to an increase in post-secondary diploma recognitions.
5 The French Community could provide data on nurses for 2007 and 2008 only; no statistics were received from the Flemish Community. This made it difficult to evaluate the inflows of EEA diplomas within the scope of the directive as these data are not covered by the FPS Health, Food chain safety and Environment statistics.
6 Phone conversation with civil servant from the Foreign University Diplomas Equivalences Unit, Ministry of the French Community of Belgium, 1 September 2009.
Dentists
Recognition statistics from the FPS Health, Food chain safety and Environment show that 181 foreign EEA dentistry diplomas were recognized between 2001 and 2008. Register data for 2005–2008 show the percentage of foreign-trained workforce among newly licensed dentists varied between 9.6% and 19.3%, with considerable fluctuations over the period (Table 5.7).
Stock data show that 6.1% of the 9 489 registered dentists in 2008 were not Belgian nationals – 2.3% were French, 0.8% Dutch and 0.5% Italian.
Summary
Federal data show that inflows of medical doctors, dentists and nurses have been increasing since 2001 (Fig. 5.3). Among medical doctors, this increase is
Table 5.6 Foreign nursing diplomas recognized or declared equivalent in Belgiuma
Country issuing diploma 2004 2005 2006 2007 2008 Total per country
France 79 66 93 96 133 467
Germany 37 18 14 28 14 111
Luxembourg 0 0 0 2 2 4
Netherlands 43 74 48 46 42 253
United Kingdom 6 3 2 3 3 17
Other EU-15 10 13 20 15 16 74
Romania 0 0 0 12 10 22
Other EU-12 2 1 4 7 14 28
Congo 1 5 16 14 23 59
Lebanon 0 6 1 7 35 49
Other non EU-27 24 12 13 9 9 67
Total per year 202 198 211 239 301 1 151
Source: FPS Health, Food chain safety and Environment unpublished data 2009.
Note: a Does not include EEA diplomas that do not conform to the EC directive but have been declared equivalent.
Table 5.7 Newly licensed dentists in Belgium, 2005–2008
2005 2006 2007 2008
Foreign-trained newly licensed dentists 11 28 21 37
Total newly licensed dentists 114 189 151 192
Percentage of foreign-trained dentists 9.6% 14.8% 13.9% 19.3%
Source: FPS Health, Food chain safety and Environment unpublished data 2009.
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Source: Own calculations based on FPS Health, Food chain safety and Environment unpublished data 2009.
Note: a Values calculated by summing up recognized EEA medical doctor diplomas (see Fig. 5.2).
less pronounced for general practitioners than it is for those with basic training and specialists (Fig. 5.2).
Stock data show a steady increase of foreign nationals in the total registered workforce for all these health professionals.
5.3 Vignettes on health professional mobility
Belgian health professional commuting to the Netherlands
HD is a 55-year-old Belgian living in Belgium and commuting daily to Maastricht. At 18, he started a work-integrated learning programme in nursing at the University Hospital of Maastricht (azM). In continuous employment, he gained permanent status after a year.
He graduated in 1975 and, while working in the same hospital, successively obtained post-secondary level diplomas as an operating theatre assistant (1976–1979), in management (1981–1982 and 1985–1986) and in law (1990–1997).
Since 1985, his duties have not included any contact with patients. His career developed both vertically and horizontally, in the following order – nurse, theatre assistant, deputy chief of theatres, chief coordinator of surgical care, administrator, manager, chief of the staff services department, education and labour market adviser.
He chose Maastricht because the employment structure seemed less hierarchical and less formal than that in the Belgian nursing schools he visited. Maastricht is very close to the Belgian border and, therefore, there was no need for him to move to the Netherlands. He is very satisfied with his choice of Maastricht and emphasizes that any Belgian nurse who takes up employment in the Netherlands, especially at azM, has no interest in being employed in Belgium.
Fig. 5.3 EEA diplomas for medicine, nursing and dentistry recognized in Belgium, 2001–2008
Romanian migrant doctor with plans to move on
AM is a 28-year-old Romanian who graduated in medicine in Romania and started a five-year specialization in internal medicine (neurology) at the University of Medicine in Iasi (Romania). After 18 months, he applied unsuccessfully for the exchange programme between his university and the Université catholique de Louvain (UCL) in Belgium. He signed a contract with a private agency that found him a position as assistant in a teaching hospital situated in a rural area in Belgium on a contract running
AM is a 28-year-old Romanian who graduated in medicine in Romania and started a five-year specialization in internal medicine (neurology) at the University of Medicine in Iasi (Romania). After 18 months, he applied unsuccessfully for the exchange programme between his university and the Université catholique de Louvain (UCL) in Belgium. He signed a contract with a private agency that found him a position as assistant in a teaching hospital situated in a rural area in Belgium on a contract running