the results
2.9 Summary of results
The case studies show the diversity within Europe, with large intercountry variations in terms of flows, impacts, motivations, relevance and responses.
Reliance on foreign health professionals is characterized by large differences across Europe and indications of an east–west asymmetry. Reliance levels gradually decrease towards the eastern part of Europe (ranging between <1% and 2% for both professions in most 2004 and 2007 accession countries). Reliance on foreign medical doctors is negligible in Turkey, Estonia, Slovakia and Poland (0.02–0.7%); relatively low in Hungary, Italy and France (>5%); moderate
62 Health Professional Mobility and Health Systems
in Germany (5.2%) and Finland (6.2%); high in Belgium, Portugal, Spain, Austria, Canada, Norway and Sweden; and very high in Switzerland, Slovenia, Ireland and the United Kingdom (22.5–36.8%). Fewer countries provide data on foreign nurses yet evidence shows lower reliance than for medical doctors.
At 1.3%, Hungary shows the highest reliance on foreign nurses among the EU-12 countries but this is in sharp contrast with Ireland (47%). Reliance on foreign nurses is negligible in Turkey and Slovakia; relatively low in Spain, Hungary, France, Finland, Sweden, Germany, the United States, Portugal and Belgium;
moderate in Canada and Italy; high in the United Kingdom and Austria (10–
20%); and very high in Ireland. Analysis of the reliance on foreign dentists is limited by the lack of data and no conclusions could be drawn across Europe.
Flow analysis quantifies the numbers of health professionals leaving and entering a country. Despite differences in the availability and quality of data for medical doctors, nurses and dentists, the evidence suggests that foreign inflows for all three professions in 2008 rate higher in absolute and relative terms in the EU-15 than in the EU-12. For most EU-15 countries, the growth of inflows of foreign medical doctors and nurses appears to have peaked and has been followed by lower inflows. Austria, Finland, France, Germany, Hungary, Lithuania, Poland, Slovenia, Spain and the United Kingdom provided data on inflows of newly registered foreign medical doctors. These show that, in absolute numbers, the largest inflows were reported in Spain (8282), the United Kingdom (5022) and Germany (1583); the lowest were in Lithuania (11). Data on inflows of foreign nurses were available in Austria, Belgium, Finland, France, Hungary, Italy and the United Kingdom. The highest numbers were in Italy (9168) and the United Kingdom (3724); the smallest reported number was in Finland (97). Austria, Belgium, Finland, Hungary, Poland, Slovenia and Spain provide data on inflows of foreign dentists. These show the highest absolute numbers in Spain (421) and Austria (100) and the lowest in Hungary (18).
The case studies show that mobility has also increased over time in terms of outflows although substantial data limitations on emigration imply that outflow data are rather approximate. Outflows and/or outflow intentions increased substantially in Estonia, Hungary, Poland, Romania, Slovakia and Slovenia at the time of EU enlargements. This was also true in Austria, Germany, Italy and the United Kingdom. Health workforce losses are occurring in EU-12 and EU-15 countries, but it appears that many EU-15 countries are concomitantly receiving health professionals although poor data do not allow firm conclusions to be drawn.
Three geographical patterns can be identified in the case studies: (i) mobility within the European free-movement area, (ii) neighbourhood movements, and (iii) the EU enlargements of 2004 and 2007.
In terms of the geographical source of mobile health professionals, Austria, Belgium, France, Germany and Italy receive their foreign health professionals predominantly from the European free-movement area with (at least) 50% of the foreign medical workforce from EU countries. In Italy, this also holds true for nurses. Slovenia is the only country receiving foreign health professionals predominantly from the wider Europe – 22.5% of all active medical doctors in 2008 were primarily from Croatia, Bosnia and Herzegovina, and Serbia.
The United Kingdom and Spain receive their foreign health professionals predominantly from third countries, the former from the Commonwealth and the latter from Latin America (for medical doctors) although the trend is slowing in the United Kingdom.
Mobility between neighbouring countries occurs across Europe as either reciprocal or one-way flows. This occurs mainly in densely populated border regions and is facilitated by shared languages and cultures. Prime examples include France–Belgium–Netherlands, Austria–Germany, Austria–Italy–Hungary–
Slovenia–Slovakia and Finland–Sweden–Estonia–Russian Federation.
Although health professionals were already moving from eastern to western European countries, the EU enlargements opened the borders for health professionals from ten new Member States in 2004 and two in 2007. These had significant influence on migratory flows, although the magnitude of outflows of health professionals (measured by intention to leave) was not as large as anticipated. In countries with data available, outflows rarely exceeded 3% of the domestic workforce.
Estonia, Hungary, Poland, Slovakia and Romania faced initial strong outflows followed by a slow-down or more contained development. The highest numbers of mutual recognition of diploma certificates were issued in the year of accession or the following year. In Estonia, the number of certificates issued peaked in 2004, with 283 for medical doctors, 118 for nurses and 29 for dentists. Numbers dropped in the following years but increased slightly in 2009. Hungary showed the highest numbers in 2004, and Poland15 and Slovakia in 2005. High outflow intentions among Romanian medical doctors seem to be continuing – certificates were issued to more than 300 per month in 2010, although the data have to be interpreted with care. The mobility of medical doctors and dentists appears to have increased on a higher scale than for nurses after EU enlargement, although the real scale of flows may be underestimated due to the lack of good-quality data on nurses (including those in Poland, Romania and Slovakia).
15 Numbers for 2005 may be cumulative.
64 Health Professional Mobility and Health Systems
The net winners of EU enlargements have been predominantly those in the EU-15. The numbers of newly registered EU-12 medical doctors, nurses and dentists increased modestly in destination countries such as Austria, Belgium, Finland, France and Italy around 2004–2007. France experienced a higher increase in the number of Romanian medical doctors, from 174 in 2007 to 1160 in January 2009. In Austria, nursing inflows seem to follow enlargement as no nurses from future enlargement countries had applied for diploma validation in 2000 but 278 did so in 2008. Spain and the United Kingdom reported important inflows of medical doctors from Poland and Romania, partly linked to the active roles of recruitment agencies targeting these countries.
Contrary to estimates and expectations the 2004 and 2007 EU enlargements did not lead to “swamping” in the EU-15 countries or to massive brain drains of health professionals from the then accession states (EU-12). Enlargement did considerably reinforce pre-existing flows from eastern and central EU Member States towards western parts of the EU. Labour market restrictions in several EU-15 Member States in the transition periods, and better salaries and working conditions in some eastern European countries, may help to explain why mobility was less than expected.
In terms of the motivational factors which influence health professionals in their decision on whether to migrate, the case studies confirm existing knowledge and add new insights from the EU-12 Member States. Key findings are the importance of income-related incentives in all 17 countries studied, good working conditions and the perception of better earnings and/or better opportunities.
The case studies show how health professional mobility’s impacts on health systems are seldom immediately or easily discernible and rarely produce visible effects on health outcomes. Information was of a qualitative, unsystematic and often anecdotal nature from a limited number of countries, but the reported observations confirm the stark differences between sending and receiving countries in terms of the impacts. The evidence suggests that health professional mobility affects service delivery by alleviating or worsening pre-existing workforce issues of skill mix, shortages and geographical distribution.
It also affects resource creation by cancelling returns on investment and disrupting planning efforts in countries which educate and train workforces for international recruitment (but involving savings for destination countries) and by the potential to induce reliance on a foreign workforce. Stewardship is affected as countries lack information about health professionals leaving and entering the system, which in turn hampers workforce planning. Countries are also restricted in their ability to regulate mobility within the EU free-movement area. Financing may be affected in terms of payment of providers.
Mobility appears to have helped to keep salary levels under control in at least one destination country but has probably contributed to salary increases in source countries. Overall, the impacts of outflows often exacerbate pre-existing challenges in the health systems of source countries and are not necessarily related to the volumes of flows.
To understand health professional mobility’s role in broader contexts and to identify the need for policy interventions, qualitative material was collected to assess its relevance in comparison to domestic workforce issues such as the maldistribution of health workers, workforce shortages, attrition, demographic transition and problems with the training pipeline. Geographical maldistribution of the health workforce is endemic in virtually all 17 countries in terms of undersupplied and underserved areas. Workforce shortages were reported among public-sector general practitioner posts in Finland; for family medicine, anaesthetics, psychiatry, pathology and gynaecology in Estonia;
and among nurses in Hungary and Italy. France and Belgium reported some nursing shortages especially in urban areas. Good data on attrition are widely missing, but in Estonia this is reported to more problematic than outmigration and it has contributed to an observed decline in workforce numbers in Poland.
Ageing of the workforce is a major concern across countries, as projections show that retirement from the health workforce will outpace the replacement of health professionals in some places. This is exacerbated as educational systems are facing severe difficulties producing and training sufficient numbers of health professionals in countries such Hungary, Germany, France, Romania and Turkey. Based on these findings, countries have been ranked according to the relative importance of health professional mobility: high relevance for seven countries (Austria, Hungary, Romania, Slovakia, Slovenia, Spain, United Kingdom), of some relevance in six (Belgium, Finland, Germany, Italy, Poland, Serbia) and of relatively lower relevance in four (Estonia, France, Lithuania, Turkey).
Four different types of policy and regulatory intervention were identified in the case studies: (i) international and domestic recruitment policies, (ii) workforce planning, (iii) cross-border frameworks, and (iv) general workforce measures. Recruitment policies have been developed by the United Kingdom, Slovakia and Slovenia. Growing interest in workforce planning and the application of sophisticated forecasting methodologies is documented by the case studies from Belgium, Estonia, Finland, Lithuania, Spain and the United Kingdom. A host of cross-border frameworks have been established to steer and manage health professional mobility but the uptake of these instruments varies widely, with a strong focus on bilateral agreements (11 countries), staff exchanges (7 countries) and educational support (4 countries).
66 Health Professional Mobility and Health Systems
Overall activity levels concerning policy and regulatory interventions vary substantially. Some countries have unfolded a range of interventions; others have been rather inactive although no less affected by health professional mobility. The United Kingdom is the only country that is responding to health professional mobility by developing activities in all four areas covered.
Countries that are developing a variety of activities include Austria, Belgium, Slovenia and Slovakia. Poland, Romania and Hungary have been less active.
References
Cash R, Ulmann (2008). Projet OCDE sur la migration des professionels de santé: le cas de la France. Paris, Organisation for Economic Co-operation and Development (OECD Health Working Paper No. 36.
Dragomiristeanu A et al. (2008). Migratia medicilor din Romania [The migration of medical doctors from Romania]. Revista Medica, 17 March 2008 (http://www.medicalnet.ro/content/view/498/31/, accessed 27 April 2011).
OECD (2010). International migration outlook 2010. Paris, Organisation for Economic Co-operation and Development.
WHO (2000). The world health report 2000. Health systems: improving performance. Geneva, World Health Organization.