Relevance of cross-border health professional mobility .1 Inflows and outflows

The Belgian health workforce is characterized by oversupply in most professions, including dentists, specialists and physiotherapists. There are difficulties in the recruitment of nurses, especially in urban centres, and shortages of general practitioners are expected in the coming years. Attrition rates seem to be important in both nursing and general practice medicine. Furthermore, there is a reduction of the available labour volume as the health workforce is ageing and undergoing feminization. The professional mobility of general practitioners is negligible and consequently has little impact on the available workforce. Inflows and outflows of nurses are more important – recent active recruitment of nurses from Romania and Lebanon aims at alleviating existing shortages.

5.6.2 Distributional issues influencing the composition of the health workforce

Oversupply in most specializations has led to the introduction of a quota that limits access to general practitioner, specialist and dentistry training (see section 5.6.3). However, general practitioner density has decreased in a short period of time and shortages are expected in the coming years, especially in the Dutch-speaking north of the country (Roberfroid et al. 2008). A federal programme offers financial incentives to general practitioners willing to settle in sparsely populated areas or in urban positive action zones (NIHDI 2010).

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

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Regional variations in the density of practitioners are more marked for specialists (8.4–24.0 per 10  000 inhabitants) than for general practitioners (9.8–14.4 per 10 000 inhabitants). Given the discrepancies in general practitioner and specialist coverage between the better-served French-speaking south and the medically less well-served Dutch-speaking north, it is likely that the quota system will result in lower numbers of French-speaking medical graduates being able to specialize or to train as general practitioners (Roberfroid et al. 2008).

Shortages of nurses are more acute in urban areas such as Antwerp or Brussels and in nursing homes more than in hospitals (Geets 2008). It is argued that increasing the involvement of auxiliary nurses by redefining the functions of nurses and auxiliary nurses and changing nursing home regulations could have a smoothing effect on the shortages (Geets 2008, Jacobs 2007).

5.6.3 Factors within the system influencing the size and composition of the health workforce

Educational system

Oversupply resulted in the introduction of the numerus clausus: quotas which set the maximum number of graduates allowed to start general practitioner, specialist and dentistry training each year (see section 8.2). For 2008–2011, the quota allows 757 medical graduates to pursue general practitioner or specialist training (Government of Belgium 2008c).The number of dentistry graduates allowed to practise was limited to 140 per year until 2010 (Government of Belgium 2008b).

In the Flemish Community, almost 10% of those who passed the entrance examination for medical/dentistry studies in 2007 had Dutch nationality (Janssen 2007).¹⁰ Similarly, during the 2007–2008 academic year, around 7%

of medical and 19.5% of dentistry students in the French Community were French nationals with a non-Belgian secondary education diploma (Cref 2008, FOD Volksgezondheid 2007a).

The number of students with foreign basic medical diplomas who submit training plans in Belgium increases every year in both the French and the Flemish Communities. In 2007, foreign-trained graduates started medical internships amounting to 10% of all internships initiated that year, in comparison with only 6.6% of all training plans submitted in Belgium between 2004 and 2006 (SPF Santé publique 2007). Holders of foreign diplomas are not subject to the numerus clausus and thus not included in the federal quotas (FOD Volksgezondheid 2007b). Foreign students apply almost exclusively for

10 The number of Dutch medicine and dentistry students in Flemish universities decreased by one-third between 1996 and 2005, presumably due to the introduction of the quota system in Belgium (Nuffic 2007).

specialization rather than general practitioner training (SPF Santé publique 2007).

There are no restrictions in access to nursing training, which can be studied at secondary level or at post-secondary/bachelor level. During the 2007–2008 academic year, 16% of all enrolled post-secondary nursing students and 40%

of all enrolled secondary level nursing students in the French Community were not registered as Belgian residents (Service statistique de l’ETNIC unpublished data 2009). French nationals accounted for 95% and 98%, respectively, of those non-resident students (Service statistique de l’ETNIC unpublished data 2009).

It is likely that most of the French nationals who study in Belgium without being officially registered as residents practise in France after graduation.

Quotas limit the number of physiotherapists registered with the statutory health insurance (SHI) system, but only for outpatient practice. The number of physiotherapists working in nursing homes and hospitals is not subject to limitations.¹¹ Unlike doctors, candidate physiotherapists with a recognized or equivalent foreign diploma are included in the physiotherapists’ quota.

Similar to the situation for nurses, there are extremely high proportions of French-national physiotherapy and paramedical students in the French Community. In 2006, 74.4% of physiotherapy students in higher education institutions and 78.1% of those studying physiotherapy at the university were students officially residing abroad, mainly in France. The same was true for 68.2% of podiatry, 59.5% of speech therapy and 63.2% of midwifery students (Simonet 2006a). This is due to the educational quotas in France (Simonet 2006a, 2006b) and relatively low registration fees in Belgium (France 3.fr 2009).In 2006, this caused the French Community to introduce a 30% quota for non-residents enrolling for the first time on certain medical and paramedical curricula in a higher education institution within its territory (Ministère de la Communauté française 2006, Simonet 2006a). The introduction of this quota has been justified by the possibility of shortages in some professions (Simonet 2006a, 2006b).

The impact on the education budget of such significant numbers of non-resident foreigners studying in Belgium probably also played a role in the introduction of these quotas. The European Commission challenged the quota measure in an infringement procedure that was subsequently suspended.

The Commission accepted that, without an appropriate safeguard measure, the French Community would not be able to maintain a sufficient level of territorial coverage and quality in its public health-care system (Europa 2007).

In case C-73/08, the European Court of Justice ruled that such legislation is

11 Interview with Henk Vandenbroele, civil servant from the FPS Health, Food chain safety and Environment, Brussels, November 2009.

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precluded by the Treaties “unless the referring court … finds that it is justified in the light of the objective of protection of public health” (Court of Justice of the European Union 2010).

Demographics

Medical and dental professionals are ageing rapidly. In 2005, 47.7% of practising general practitioners and 46.2% of practising specialists were aged over 50 years. Activity levels (expressed as the number of patient contacts per year) decrease gradually from 50 years onwards for general practitioners and from 60 years onwards for specialists (Roberfroid et al. 2008). The 42–56 age group is heavily overrepresented among active dentists. Many dentists stop practising from the age of 55 onwards, and activity levels decrease among those who remain active (Gobert et al. 2007). Most medical doctors and dentists are self-employed and, therefore, have no legal retirement age.

Women make up 30% of the current medical workforce and 60% of new graduates (Roberfroid et al. 2008). Among female doctors over 30, both general practitioners and specialists have significantly lower activity levels than their male counterparts. Women make up 43% of active dentists and the majority of newly qualified dentists. The activity rate of female dentists is about 75% of that of their male peers (Gobert et al. 2007). The gender ratio of immigrating medical doctors appears close to one and they are markedly younger than the average age of domestic medical doctors (FOD Volksgezondheid 2009).

The ageing and feminization of the medical workforce could reinforce the expected shortages of general practitioners. No such problems are forecasted for the other medical professionals discussed in this chapter, given their current oversupply.

Nursing is considered to be a heavy activity profession and, therefore, most nurses have the right to take early retirement from the age of 58. This results in nurses over 60 years forming less than 1% of the total nursing workforce (Pacolet & Merckx 2006a). Furthermore, nurses aged 45 years or more have the right to reduce their working hours progressively by up to 15%.

The Federal Database of Health Care Professionals showed that, as of 31 December 2008, holders of a license to practise nursing were, in the majority, women (87%) with a median age of 44 years. Nurses have high attrition rates, especially those aged 50 and over (Geets 2008). The fact that the profession is highly feminized impacts strongly on the labour volume, as reduced working time, career breaks, parental leaves are more common among female professionals (Pacolet & Merckx 2006b). It is estimated that nurses work an average of 75% of a full-time working schedule (Pacolet & Merckx 2006b).

Health professionals leaving or returning to the profession

Only 53.3% of registered general practitioners practise medicine and only an estimated 5500 (43%) of these work full-time as general practitioners (Meeus 2009). Between 65.4% and 87.4% of registered specialists work full-time, with activity levels varying between specialities. The rest of registered medical doctors work in non-curative sectors (Roberfroid et al. 2008). The number of practising general practitioners decreased from 12 531 to 11 626 between 2002 and 2005, possibly due to significant professional attrition rates. Suggested factors include long working schedules and/or low earnings (Roberfroid et al.

2008).

5.6.4 What does cross-border mobility mean for Belgium?

While migration flows in some health professions are not negligible, most appear to be the initiative of individuals looking for opportunities elsewhere.

Intentional recruitment of foreign-trained health professionals by Belgian hospitals has been observed for nurses and for medical doctors with basic training (see section 5.8.3). There are no elements to assert that the Belgian health system is dependent on migratory flows and no indication of any negative effects of workforce losses due to migration.

5.7 Factors influencing health professional mobility