Policy and regulatory interventions

What are the policy options for addressing health professional mobility issues?

Policy-makers aiming to tackle health professional mobility or to improve existing strategies will benefit from information on the use of policy and regulatory measures in other countries. Learning about the use of instruments individually and in conjunction with others may inspire solutions for their own country.

There is limited knowledge on policy development concerning health professional mobility and general workforce issues and there is no comprehensive overview.

Interest in workforce planning as a centrepiece of workforce policy has grown only recently (Dussault et al 2010). Buchan’s (2008) categorization of cross-border instruments and tools for managing health professional mobility (Table 1.1) provides a very useful starting point for further research but, apart from the research on bilateral agreements (Dhillon et al. 2010), knowledge remains patchy.

To address some of the knowledge gaps, case study authors were asked to search for explicit recruitment policies (international and self-sufficiency), international frameworks (see Table 1.1), workforce planning procedures and general workforce measures facilitating the retention of health professionals by improving working conditions and the working environment.

1.4 Methodology

This section will provide more details on the methodologies employed to research the evidence for this book, starting with a brief summary of the PROMeTHEUS project. This will be followed by a discussion of the challenges

that faced the project and some of the strategies used to address the challenges:

a good country sample, mechanisms to ensure comparability and a mix of research methodologies to develop analytically rich case studies.

Health PROMeTHEUS is a research project funded through the European Commission’s Seventh Framework Programme on research and innovation and run by a consortium of 11 partners, supported by seven country correspondents and a large number of country informants. Outputs of the project include several publications, conference workshops and policy dialogues. The acronym PROMeTHEUS was chosen because this titan of Greek mythology was a champion of mankind who stole fire from Zeus and gave it to mortals. Similarly, the aim of the project is to illuminate what would otherwise remain in the dark and compare the situation and trends of health mobility between countries in Europe.

The project has faced a number of daunting challenges. First, throughout the course of the project, the analytical work of country case study authors was hindered by the lack of a commonly agreed definition of health professional mobility. A definition was deemed necessary to define the scope of research and is also a starting point for future categorization of different types of health professional mobility. A second challenge was the selection of countries for the sample without losing key developments and trends. Time and resources would not allow the inclusion of all 31 countries from the European free-movement

Table 1.1 Cross-border instruments and tools for steering and managing health professional mobility

Instrument/tool Description

Twinning Links developed by health care organizations in source and destination countries based on staff exchanges, staff support and flow of resources to source country

Staff exchange Structured temporary move of staff to another organization, based on career and personal development opportunities or organizational development

Educational support Educators and/or educational resources and/or funding in temporary move from destination to source organization Compensation Destination country provides some type of compensation

to source country in recompense for the impact of active recruitment (much discussed but little evidence in practice) Training for international

recruitment Government or private sector makes explicit decision to develop a training infrastructure to train health professionals for employment in other countries in order to generate remittances or fees International code Code of ethics on international recruitment. The best known

codes are those from the United Kingdom (introduced 2001) and the WHO Global Code (adopted 2010).

Source: Adapted from Buchan 2008.

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area, let alone reaching out to the wider Europe. Third, how to ensure the comparability of research results? Variations between European countries (in institutional settings, types of health system and organizational peculiarities, for example) do not allow direct comparison. Also, diverse countries produce diverse stories. This may be appealing to the reader but offers limited scope for comparison if each case study emphasizes or omits different aspects. Fourth, how to ensure that the analytical quality of a country’s case study is not undermined by variations in the availability of data and research literature? International studies and international databases have shown wide differences in data availability and time trend data. Some countries have well-established research on health professional mobility that provides a robust basis for developing a country case study, but good literature is scarce in other countries. It is not claimed that such a multitude of challenges could be overcome completely but a set of strategies was employed to address these concerns.

To better define the focus of research and also to capture health professional mobility beyond the meaning of the trained, born and foreign-national indicators, an adequate definition of health professional mobility was discussed from the beginning of the project. This definition (Box 1.1) will also provide guidance for our future research by providing a starting point for the development of typologies of health professional mobility and assessing the validity of indicators.

A country sample was established with the intention of capturing the situation in Europe and covering the major trends without the need to include all 31 countries in the research. Four criteria were used to determine country selection.

First, the sample should be sufficiently diverse and represent every corner of the EU including larger and smaller countries, those with national health systems and those with social health insurance. Second, the sample should enable a particular focus on the 2004 and 2007 enlargement countries since their role in health professional mobility was underresearched. Third, the sample should include larger European labour markets in Europe since they have a high capacity to absorb large absolute numbers of mobile health professionals while showing relatively low reliance on foreign health professionals. Fourth, the sample should meet the need to build the bridge to a wider Europe and to understand mobility between countries within and outside the free-movement area (Table 1.2).

Box 1.1 Definition of health professional mobility emerging from the project Any intentional change of country after graduation with the purpose and effect of delivering health-related services, including during training periods.

The analytical framework discussed above was the centrepiece for ensuring comparability of results. All country authors were asked to respond to the questions raised in the analytical framework, which was supported by a resource package including a template, a conceptual background document.

A user guide provided detailed instructions on the coverage of professions, data types and data time points.

A mix of methodologies has been employed to research health professional mobility. The basic methodology is the country case study because impacts, inflows, outflows and policy responses are hugely influenced by country context. Case studies provide a systematic way of looking at health professional mobility, collecting data, analysing information and reporting the results.

All case study authors conducted a literature review on the basis of the analytical framework using international and national publications, different databases and the World Wide Web. Secondary data collections were collated from data on the reliance on foreign health professionals and on actual flows. The time trend data requested were chosen to reflect flows before and after the profound geopolitical changes of 1989. Authors of country case studies and country informants were asked to collect data for every year from 2000. Given the challenge of limited data and limited literature in some countries, interviews were conducted where necessary and appropriate: interviews with individual mobile health professionals to enable better understanding of the practicalities of health professional mobility and with experts in order to complement the existing literature and data. All country case study authors were asked to develop vignettes on health professional mobility to provide short summaries of individual experiences of health professional mobility.

Table 1.2 Country coverage Member States before

2004 Member States since

2004/2007 Countries having applied for EU membership

Austria Estonia Serbia

Belgium Hungary Turkey

Finland Lithuania

France Poland

Germany Romania

Italy Slovakia

Spain Slovenia

United Kingdom

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1.4.1 Limitations

The data on health professional mobility have imposed restrictions on the case studies as many have come with long disclaimers. Data analysis has been limited by the availability of indicators and of data and by the data collection methods.

Outflow data are disputed because they do not measure outflows directly and therefore impose serious limitations on the data analysis.

In addition, the time taken to develop a book of this magnitude and employ all the necessary quality measures means that some data collections were finalized a year before publication. Therefore, the impacts of the global financial crisis were not yet visible in many countries at the time when this research took place.

Country case studies provide the broad view and can put health professional mobility in context. This is essential for understanding the phenomenon but the reader is likely to want to know more about the details of the trends; the difficulties surrounding indicators, data, data collection and many other topics.

It is hoped that all these issues will be covered in much greater detail in the second volume.