Resource creation

Resource creation produces the manpower, skills and knowledge required by a health system. The education and training of the necessary health workforce forms an essential part of this, but mobility can shrink or expand the pool of human resources, skills and knowledge as health professionals come and go. From the perspective of countries that train health professionals who then leave, outmigration means no return on investment and possible disruption of planning efforts. For countries importing foreign-trained staff, immigration represents an additional workforce free of charge but has the potential to produce reliance on foreign health professionals.

According to estimates, Serbia and Montenegro have spent US$ 9–12 billion educating and training medical specialists who have left the country. Long-term migration may undermine the return on Serbia’s investment in education and training. Real but hidden financial losses are even higher in terms of lost profits and inadequate replacement of the departed experts. In an effort to offset such financial losses, programmes in Slovakia require compulsory postgraduate service or monetary compensation if graduates migrate. In other countries, foreign students may take up domestic training positions. Inflows of Dutch and French students to medical and health-related studies in Belgium disrupted health workforce planning efforts by bypassing the numerus clausus and because foreign students are likely to return home after graduation.

The volume of foreign nursing students could also aggravate nursing shortages in Belgium and there are similar concerns about the influx of Germans taking up medical student posts in Austria. In Spain, 36% of candidates sitting the entrance examination for specialist medical training were of foreign origin, mainly from Latin America.

For destination countries, mobility can expand resources. The United Kingdom and Spain have benefited greatly from importing knowledge and skills – the former’s case study notes the double benefit gained as foreign recruitment helped to free up senior staff and allow them to expand training. Conversely, a system that relies on inflows for resource creation can become dependent upon them (see sections 2.2 and 2.8) and was noted as one of the risks of mobility

during debates in the United Kingdom. Almost one-quarter of medical doctors and dentists in Slovenia are foreign but the slow-down of inflows from other former Yugoslav federal states led to shortages and staffing problems in the 1990s and 2000s. Such reliance is a particular issue in the context of forecasted domestic shortages, such as in Finland where foreign dentists represented almost half of all new dentist licences in 2006–2008 (134 foreign trained/176 Finnish trained) and foreign medical doctors obtaining a licence to practice represented a quarter of the new medical workforce in 2004–2008. In Spain, the number of foreign degrees in general medicine recognized (5383) was 40%

higher than the number of medical students (3841) graduating from Spanish universities in 2007. In the United Kingdom, 42% of newly registered medical doctors and 14% of newly registered nurses and midwives in 2008 were foreign trained. If reliance on foreign workforce grows as domestic shortages worsen, health systems will becoming increasingly susceptible to the directions and intensity of flows, which remain hard to predict. Hence, domestic production of a health workforce seems a more sustainable (and responsible) approach to resource creation.

2.6.3 Stewardship

The stewardship function contributes to health through planning, regulation and the provision of information and intelligence. Policy responses to health professional mobility are addressed in section 2.8 but the effects of health professional mobility on decision-makers’ ability to steer health systems are easily overlooked. Three interrelated aspects can be identified, concerning information, planning and regulation.

Firstly, there is a lack of information about which health professionals are leaving and which are entering the system. Without the capacity to track movements comprehensively, authorities’ ability to supervise (and react) is affected in Belgium, France, Germany, Hungary, Italy, Lithuania, Poland, Romania, Serbia, Slovakia, Spain, Turkey and the United Kingdom (specifically on the outflows of returnees). This situation is worsened when considering the illegal health workforce, which is not only invisible in official statistics but also constitutes crucial sources of care in countries such as Italy, Austria and Germany. The implication is that governments lose sight of the services delivered outside the regulated frameworks in the home and elderly care sectors. In Finland, more information is needed on the reasons for high unemployment among foreign health professionals in order to integrate this workforce in the system.

The lack of evidence on mobility and its unpredictable nature further hamper the planning function of health systems (see section 2.6.2) as workforce planning is not informed by the necessary data. Under Directive 2005/36/

52 Health Professional Mobility and Health Systems

EC on the recognition of professional qualifications, health professionals are not necessarily obliged to inform public authorities when entering or leaving a country. Moreover, the mutability of flows makes it difficult to factor them into planning and within projections (see section 2.8).

Mobility as enshrined in the acquis communautaire impacts on stewardship by undermining EU Member States’ ability to regulate. Governments have no legal instruments with which to limit or steer inflows and outflows between their own countries and other EU Member States. The United Kingdom faced this situation in 2006 when measures to rein in global migration could not be applied to EU citizens. Hungary has also had to adapt interventions on emigration to meet the EU prerogatives of free movement and, as part of the EU accession process, Turkey is debating radical reforms to its restrictive labour laws, which currently conflict with EU principles of labour mobility.

2.6.4 Financing

Financing a health system involves collecting and pooling revenues in order to purchase health services. Payment of health providers is a subfunction of purchasing services.

There have been few reported impacts on the financing function of health systems, with the exception of the payment conditions for medical doctors. Regardless of the limited evidence, health professional mobility is bound to have important impacts on payments systems, as demonstrated by income’s prominence as both a motivational factor (section 2.5) and a retention strategy (section 2.8).

For an important destination country such as Spain, foreign medical inflows from Latin America serve to keep salary levels in the public sector fiscally sustainable as the pool of providers grows. Conversely, countries of origin facing the threat of emigration are driven to consider increasing salaries in the same way as the Lithuanian Government and the Polish independent health care providers seeking to retain medical doctors. But such measures may not be sustainable in the long term and raise questions about redistribution within the system. Salary increases are dependent on a favourable economic situation and it is doubtful whether incentives can be maintained in the context of a financial crisis. While there is no evidence on how the financial downturn has impacted on health professional mobility, it will surely have repercussions in both sending and receiving countries (see also section 2.5).

2.7 Workforce context and relevance of health professional