No 18
POLICY BRIEF 18
How can countries address the
efficiency and equity implications of health professional mobility
in Europe?
Adapting policies in the context of the WHO Code of Practice and EU freedom of movement
Irene A Glinos
Matthias Wismar
James Buchan
Ivo Rakovac
EMIGRATION AND IMMIGRATION – trends
FOREIGN PROFESSIONAL PERSONNEL – supply and distribution
HEALTH PERSONNEL – trends HEALTH MANPOWER – ethics HEALTH MANPOWER – trends EUROPE
This policy brief is one of a new series to meet the needs of policy-makers and health system managers. The aim is to develop key messages to support evidence-informed policy-making and the editors will continue to strengthen the series by working with authors to improve the consideration given to policy options and implementation.
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Contents
page
Key messages 3
Executive summary 5
Policy brief 5
1. Introducing the Efficiency-Equity Conundrum 6 2. Trends in Mobility: A New Map of Europe? 9 3. Unpacking the Efficiency-Equity
Conundrum: A Matrix 11
4. Policy Options: How to make mobility
work better 15
5. Implementation Considerations 18
6. Conclusions 20
Acknowledgements 20
References 20
Authors
IreneA.Glinos,SeniorResearcher,European ObservatoryonHealthSystemsandPolicies, Belgium.
MatthiasWismar,SeniorHealthPolicyAnalyst, EuropeanObservatoryonHealthSystems
andPolicies,Belgium.
JamesBuchan,Professor,SchoolofHealth, QueenMargaretUniversity,Scotland.
IvoRakovac,ProgrammeManagera.i.,Division ofInformation,Evidence,ResearchandInnovation,
Editors
WHORegionalOffice forEuropeandEuropean ObservatoryonHealth SystemsandPolicies Editor
GovinPermanand AssociateEditors ClaudiaStein JosepFigueras DavidMcDaid EliasMossialos ManagingEditors JonathanNorth CarolineWhite
Theauthorsandeditorsare gratefultothereviewers whocommentedonthis publicationandcontributed theirexpertise.
PolicyBriefNo18
andEUfreedomofmovement
The theme of this policy brief has been developed and discussed in the context of a workshop organized jointly by the Swiss Federal Office of Public Health and the European Observatory on Health Systems and Policies in October 2014 at the European Health Forum in Gastein.
The policy brief builds on work presented at the Informal Meeting of Ministers of Health in Gödöllö on 4–5 April 2011 under the Hungarian EU Presidency.
This policy brief was presented jointly with the World Health Organization report entitled “Making Progress on Health Workforce Sustainability in the WHO European Region”. They were launched at the 65th session of the WHO Regional Committee for Europe, September 2015, in Vilnius, Lithuania.
KEY MESSAGES
• HealthworkersintheEuropeanUnion(EU)arefreeto seekemploymentinanotherMemberStateasguaranteed byEUlaw.Thismobilityofhealthprofessionalschanges thecompositionofthehealthworkforceinsourceand destinationcountriesandmayaggravateormitigate existingproblemssuchasshortages,mal-distribution andskill-mismatchesofhealthprofessionals.
• Tomitigateunwantedeffectsandstrengthenpositive ones,theMemberStatesoftheWorldHealth
OrganizationhaveadoptedtheGlobalCodeofPractice ontheInternationalRecruitmentofHealthPersonnel.The Code,however,needstobecontextualizedforEurope, takingintoaccountthefreedomofmovementintheEU.
• Mitigatingunwantedeffectsandstrengtheningpositive onesishighlyrelevantintheEUassomeMemberStates relytoalargeextentonforeignhealthprofessionalswhile othersexperienceimportantoutflows.IntheEUfree mobilityarea,flowsofhealthprofessionalsaredynamic, oftenchangingdirectionandmagnitude,andaffect allcountries.
• Countriesarefacedwiththeconstantlychanging conundrumofefficiencyandequity,thatis,between thefreemobilityofhealthprofessionalsinthe
Europeanlabourmarketononehand,andtheplanning requirementsofhealthsystemsensuringuniversalhealth coverageontheotherhand.Itisnecessarytodisentangle theconundrumandmakeitaccessibletopolicy-makers andstakeholdersashealthprofessionalmobility:
o hascleareffectsonefficiencyandequity;
o isacomplexphenomenon,neitherpositivenor negativeper se,butimplyingmeritsanddrawbacks forbothsourceanddestinationcountries;and o affectstheEUasawholeanddestinationandsource
countriessimultaneously.
• Threesetsofpolicyoptionscanbeusedtoaddress theconsequencesofhealthprofessionalmobilityon efficiencyandequityatEUandcountrylevel:
o policyoptionstofosterhealth workforcesustainability;
o policyoptionstomanagemobility;and o EUactiontoaddresstheconsequencesand
opportunitiesoffreemobility.
• Countriescanchoosefromawiderangeofpolicy optionsthatcorrespondbestwiththeirneeds(Table2).
Implementingpolicyoptionswilloftenrequirestrong intersectoralgovernanceandconsensusbuildingacross governmentdepartmentsandstakeholders.
EXECUTIVE SUMMARY What’s the problem?
Thehealthworkforceisakeycontributortothe
performanceofhealthsystems.Shortages,mal-distribution andskill-mismatchesofhealthprofessionalsarehowever widespreadproblemswhichcanresultindelayedandunsafe treatments,lowqualityofcareoutcomesandnegative patientexperiences.Workforceissueshaveimmediate consequencesfortheefficiencyandequityofhealth systems.Themobilityandmigrationofhealthprofessionals changethecompositionofthehealthworkforceinboth sourceanddestinationcountries.Theymayimproveor aggravatehealthworkforceproblems.
Tomitigateunwantedeffectsandstrengthenpositiveones, theMemberStatesoftheWorldHealthOrganizationhave adoptedtheGlobalCodeofPracticeontheInternational RecruitmentofHealthPersonnel.AccordingtotheCode, recruitmentshalltakeintoaccounttherights,obligations andexpectationsofsourcecountries,destinationcountries andmigranthealthpersonnel.TheCode,however,needs tobecontextualizedwithregardstothefree-mobilityzone oftheEuropeanUnion(EU).ThemobilityforeseeninEU legislationis,atbest,indifferentwithregardstohealth systemsinsourceanddestinationcountriesasitfocuseson theindividual(health)workersandtheirrights.Theyarefree toseekemploymentinanotherMemberState.Countries maytrytorecruitethicallybutitisthehealthworkersthat makethedecisiontomovetoanotherMemberSate.The TreatyonEuropeanUniondoesnotforeseethathealth workerscanbeexpectedtoconsidertherights,obligations andexpectationsofsourceanddestinationcountries.
TheissueishighlyrelevantforEuropeassomeEUMember Statesrelytoagreatextentonforeignhealthprofessionals whileotherEUcountriesexperiencesignificantoutflowsof healthworkforce.Healthprofessionalmobilityisdynamic andrespondtoeventssuchastheEUEnlargementsin2004 and2007andeconomicandfinancialcrisis.Destination countriesbecomesourcecountriesandviceversa,the magnitudeofin-andoutflowsalterssubstantiallywithout warningandflowshaveknock-oneffectsontheequityand efficiencyofhealthsystems.
How do we unpack the policy conundrum?
Healthprofessionalmobility,anditsconsequencesfor equityandefficiency,isacomplexphenomenonbecause per se itisneitherpositivenornegativeforsourceand destinationcountries;itseffectsarechangingovertime, equivocal,overlapping,hardtopindownanddependon thecontextandgovernanceofmobility.Tounpackthis conundrumwehavedetailedthemeritsanddrawbacksof healthprofessionalmobilityontheequityandefficiencyin destinationandsourcecountriesandfortheEUingeneral.
• The merits of free mobility on efficiency:abetter balancebetweenhealthworkforcesupplyanddemand acrossEurope;aneasy,cheapandfastwaytoclose workforcegapsindestinationcountries,including
staffingunderservedareas;bringingnewskillsand culturalexperiencestocountries;insourcecountries, remittanceofmigrantworkerswillcreatenational income,andoutflowsmayalsoprovidepoliticalstimulus totackleworkforceissues.
• The merits of free mobility on equity:theequityof opportunitiesforhealthworkers;improvedaccessfor patientsindestinationcountrieswheninflowsfillgaps.
• The drawbacks of free mobility on efficiency:
fundsfortraininginsourcecountriesareredistributedto destinationcountries;planningtheworkforcebecomes moredifficult;skillsofmobilehealthprofessionalsin destinationcountriesareoftennotusedtotheirfull potential.Fordestinationcountries,relyingonforeign healthworkerscanbeanunstablewaytoreplenishthe workforce;newarrivalsrequiretime,capacityandmoney forinductioncourses,languagetrainingandmentoring;
mobilitymayimpedetheaddressingofunderlying workforceissues.Insourcecountries,healthprofessionals mayleavealreadyunderservedareas;mobilitymay leadtoincreasedworkloadforthosethatstaybehind;
youngleaversdonotpaybacktothesystem;andthe lossofthe“bestandbrightest”affectsthecapacityto addressshortcomings.
• The drawbacks of free mobility on equity:existing inequitiesbetweencountriescanbereinforcedwhen healthprofessionalsleaveresource-strainedhealth systemstoworkinmoreadvantagedMemberStates;
indestinationcountries,foreignhealthprofessionals mayfacediscrimination,andcapsonthenumbersof medicalstudentsmightbeunfairwhenthesystemrelies onforeigninflows.Insourcecountries,notallhealth professionalshavethesameopportunitiestomoveif familyobligationsorlivingcircumstancesdonotallow themtoexercisefreedomofmovementandoutflows canworsenregionaldisparities.
What are the key policy options?
Policy options to foster health workforce sustainabilityFordestinationandsourcecountries alike,healthprofessionalmobilityisoftenasymptomof underlyinghealthworkforceissues.Healthprofessionals comeandgobecausethehostsystemdoesnothave sufficientworkforceorlackscertainskills,andbecause thehomesystemisnotperceivedasprovidingsufficient rewardsandopportunities.Giventhechallengeswhichfree mobilitygivesriseto,countrieshaveaninterestinfostering asustainablehealthworkforce–destinationcountriesby addressingthereasonswhythesystemreliesonforeign inflowstoreplenishthehealthworkforce,sourcecountries bytacklingthefactorswhichleadhealthprofessionals toleave.Policyoptionswhichimprovehealthworkforce sustainabilityinclude(seeTable2):
• betterhealthworkforceintelligenceandplanning;
• trainingandadaptingtoday’sworkforce;
• trainingtomorrow’sworkforce;
• domesticrecruitment;
• betterregionaldistribution;and
• retention.
Policy options to manage mobilityThesepolicyoptions aredevelopedtogetthebestoutofmobilityforallparties concerned.Thisfollowsthelogicthathealthprofessional mobilitycancontributetostrengtheninghealthsystems if“properlymanaged”.Whilecertainmeasuresmight contributetoreducingin-andoutflows,mobilityislikelyto continuetogrowinimportanceanditsextentanddirections remainhardtopredict.Inthiscontext,noEUcountrycan ignoremobility;destinationandsourcecountriesalike haveanincentivetomanagemobility–atthenationaland internationallevel–soastoreapitsbenefitsandminimize negativeeffects.Policyoptionswhichseektomanage mobilityinclude(Table2):
• ethicalrecruitmentpractices;
• country-to-countrycollaboration;
• integrationofforeign-trained/bornprofessionals;and
• facilitatedreturns.
EU action to address the consequences and opportunities of free mobilityMutualrecognitionof diplomasandfreedomofmovementmeanthatEUhealth professionalsincreasinglyformoneEUhealthworkforce.
IndividualMemberStatesarenotincontrolofin-and outflows,noraretheyfullyequippedtodealwiththe efficiencyandequityconcernswhichmobilitybringsabout, andyettheyhavecometodependononeanother’s workforcesituations.Policyoptionswhichseektoaddress theconsequencesandopportunitiesofmobilityatEU levelcanberegroupedaccordingtofourpolicyobjectives (Table2):
• bettermobilitydata;
• jointplanningandworkforcedevelopment;
• protectingvulnerablesystems;and
• protecting/promotingfreemobilityasacitizens’right.
What to consider when implementing?
Countrieswilloftenhavetoimplementseveralpolicyoptions inparallel.Thechoiceofpolicyoptionsforimplementation willneedtomatchthedestinationand/orsourceprofile ofthecountry.Healthprofessionalmobilityoftenaffects professions,specialtiesandregionsindifferentways.
Thisimpliesaneedforpolicycoordinationtoensurethat measuresbeingimplementedarecompatibleand,where possible,reinforceoneanother.
MostministriesofhealthinEuropehavelimitedleverage overkeyaspectsofworkforcedevelopment.Implementing policyoptionswillthereforeentailinmanycasesconsensus buildingandstrongintersectoralgovernance.
1. INTRODUCING THE EFFICIENCY-EQUITY CONUNDRUM
Freedomofmovementisacitizens’rightwithinthe EuropeanUnionandoneofthecornerstonesofEU
integration.ItimpliesthatEUhealthprofessionalsarefreeto seekworkinanyMemberStateandtomovefreelybetween EUcountries.Byvirtueofthemutualrecognitionof
diplomasandfreemobility,thedoctors,nurses,midwives, dentistsandpharmacistsof32Europeancountries1canbe consideredtoformoneEUhealthworkforce:justasthe regionsofacountry,sodothemembercountriesofthefree mobilityzoneexperiencein-andoutflows,exchangesand commutinghealthprofessionals.
Themobilityofhealthprofessionalsraisesseveralquestions.
Atthegloballevel,awarenesshasdevelopedintoconcern asthescaleofqualifiedhealthprofessionalsleaving developingcountriescausesshortages,mal-distribution andotherworkforceproblemstoworsenalready
vulnerablehealthsystems(Meija,Pizurki&Royston,1979;
WHO,2006).TheWHOGlobalCodeofPracticeonthe InternationalRecruitmentofHealthPersonnel(“theCode”) officiallyrecognizestheethicalimplicationsthathealth professionalmigrationcanhavefortheindividualsand countriesinvolved.TheMemberStatesoftheWorldHealth Organization,includingallEUMemberStates,adoptedthe Codein2010,therebyagreeingtoavoidactivelyrecruiting healthprofessionalsfromfragilesystems,tofavour sustainablehealthworkforcedevelopment,andtowork togetherforthebenefitofsourceanddestinationcountries, allwhilerespectinghealthprofessionals’freedomtomigrate (WHO,2010).
1 Directive2004/38/EContherightofcitizensoftheUnionandtheir familymemberstomoveandresidefreelywithintheterritoryof theMemberStatesappliestothe28EUMemberStatesandthe threeEFTAEEA(Iceland,LiechtensteinandNorway).Switzerland isnotaMemberStateoftheEuropeanUnionbuthasabilateral agreementonthefreemovementofpersonswiththeEU.The analysisoffreemobilityintheEUthereforeextendstoIceland, Liechtenstein,NorwayandSwitzerlandinthesamemannerasto EUMemberStates.Forreasonsofsimplicity,thetermEUwillbe usedtocoverthese32countriesinthisbrief.
Box A: The guiding principles of the WHO Code
TheCodeisavoluntaryinstrument;withoutinanywaybanning migrationorinternationalrecruitment,itseekstopromote principlesandpracticesthat“mitigatethenegativeeffects andmaximizethepositiveeffectsofmigration”(Art3.4,p.2), especiallyfordevelopingcountries,countrieswitheconomies intransitionandsmallislandstates.Amongitsguidingprinciples figuresthat“internationalmigrationofhealthpersonnelcanmake asoundcontributiontothedevelopmentandstrengtheningof healthsystems”(Art3.2,p.2)(WHO,2010).
InsidetheEU,themovementofEUhealthprofessionals isnotmigrationbutmobility:whereascitizensfrom thirdcountriesaresubjecttonationalimmigrationlaws, lengthyrecognitionproceduresandlabourmarketpolicies whenseekingtoenteracountry,anextensivebodyof EUlegislationprotectsandpromotesthefreedomof movementofEUcitizens.Specifically,Directive2005/36/
ECfacilitatestheautomaticrecognitionofqualificationsof doctors,nurses,midwifes,dentistsandpharmacistswith anEUcountryandtheTreatyonEuropeanUnionentitles EUcitizenstoseekemployment,workandsettledownin anyMemberState.Freemobilityislegallybindingandmay notbehinderedbygovernmentsorotheractors.Thanks toauniformregulatoryframework,themutualrecognition ofqualifications,relativelyshortdistancesbetweenEU countries,andculturalandlinguisticproximitysharedby manyEuropeancountries,mobilityiseasier,cheaperand fasterthanmigration.
Healthprofessionalmobilitybecameanissueasthe Unionpreparedtoexpanditsmembership,andhencethe freemobilityzone,to12newMemberStatesinthefirst decadeofthe2000s.2Withsubstantialdifferencesinliving standardsbetweenthe“old”and“new”MemberStates, itwasexpectedthatEnlargementwouldleadtomassive movements.Fearfulofthepotentialeffects,countries suchasAustria,Denmark,GermanyandSwitzerland reactedbyrestrictingaccesstotheirlabourmarketsfor
2 10countriesenteredtheEUon1May2004:Cyprus,theCzech Republic,Estonia,Hungary,Latvia,Lithuania,Malta,Poland,Slovakia andSlovenia.In2007BulgariaandRomaniabecameEUmembers.
CroatiajoinedtheUnionin2013.
allcategoriesofworkersduringtransitionalperiods;others (e.g.Ireland,SwedenandtheUK3)didnotraisebarriers totheinfluxofforeignworkforce,includingtofillservice gapsandvacanciesinthehealthsystem(Ognyanovaetal., 2014;Young,Humphrey&Rafferty,2014).Whilehealth professionalmobilitydidnotreachthepredictedlevels (Maieretal.,2011;Ognyanovaetal.,2014),intra-EUflows ofhealthprofessionalsaresubstantialandgrowing,and highlightthatsomehealthsystemsareconsiderablybetter offthanothers(Glinos,Buchan&Wismar,2014).Data ontheshareofforeigndoctorsandnursesinEuropean countriesshowconsiderabledifferencesbetweencountries andtheextenttowhichtheyrelyonforeignhealth workforce(Figure1).HealthcaredeliveryinNorwayand Ireland,reliesmorethan35%onforeigndoctors.The UnitedKingdom,Switzerland,SwedenandFinlandhave 20%ormoreofforeigndoctorsintheworkforce.Spain, GermanyandFrance,countrieswithlargelabourmarkets, havecloseto10%foreigndoctorsinthehealthworkforce.
WiththeexceptionofSwitzerlandandtheUnitedKingdom, relianceonforeignnursesappearstobelesspronounced althoughthenumericalimportanceofthenursingworkforce shouldbekeptinmind.
Ontheeveofthe2004Enlargement,theEuropean Commissionnotedthatpotentiallyinadequatenumbers andskillsintheworkforcerepresentedaseriousriskfor healthsystems“withtheimpactbeingfelthardestinthe poorestMemberStates”andthatitis“difficultforanyone countrytoinvestintraininghealthprofessionalswithout knowingthatothercountrieswilldolikewise”.4Forsource countries,5thefearisthatmobilitywilldrainthesystem of“vitalskills,professionalknowledge,andmanagement capacity”,impedingitsperformance(Kingma,2007).But destinationcountriesalsorecognizethatrelyingonforeign inflowstoreplenishtheworkforcecanbeinefficientand unethical–flowsaredifficulttopredictandtofactor intohealthworkforceplanning,andmaysignaldeeper underlyinghealthworkforceissues(Buchan&Seccombe, 2012;Humphriesetal.,2014).Switzerland,forexample, strivestoreducerelianceonforeignhealthprofessionals andincreasedomestictraining(FederalOfficeofPublic Health,2013).England,Scotland,Ireland,theNetherlands andNorwayhaveintroducednationalguidelinesto promoteethicalrecruitment.In2008theseeffortswere supplementedbyacodeofconductonethicalcross-border recruitmentandretentioninthehospitalsectorsignedby theEuropeanFederationofPublicServiceUnionsandthe EuropeanHospital&HealthcareEmployers’Associationin theirfunctionasrecognizedsocialpartnersinthehealth sectoratEUlevel(Merkur,2014).InareviewofthisCode,
3 IrelandandtheUKdidnotimposelabourmarketrestrictionson nationalsfromthe2004waveofaccessions,butdidonnationals fromBulgariaandRomania.
4 EuropeanCommission,CommunicationfromtheCommission, Follow-uptothehighlevelreflectionprocessonpatientmobility andhealthcaredevelopmentsintheEuropeanUnion,20.04.2004 COM(2004)301final.
5 ThetermssourceanddestinationcountriesaredefinedinSection3.
Box B: Contextualizing the WHO global code for the EU free-mobility zone
Internationalrecruitment,accordingtotheCode,shalltake intoaccounttherights,obligationsandexpectationsofsource countries,destinationcountriesandmigranthealthpersonnel.
Internationalrecruitmentishealthsystemspecificandimplies somecoordinationorplanningwithinandbetweencountries.
ThemobilityforeseenintheTreatyontheFunctioningofthe EuropeanUnionis,atbest,indifferentwithregardstohealth systemsinsourceanddestinationcountriesasitfocuseson theindividual(health)workersandtheirrights.Thefreedomof workersshallbesecuredwithintheUnion(TFEU,Art45para1).
Itshallentailtheright[…]toacceptoffersofemployment actuallymade;tomovefreelywithintheterritoryofMember Statesforthispurpose;tostayinaMemberStateforthepurpose ofemployment[…];toremainintheterritoryofaMember StateafterhavingbeenemployedinthatState[…](TFEU, Art45para3).MemberStatesshall,withintheframeworkof ajointprogramme,encouragetheexchangeofyoungworkers (TFEU,Art47).
Countriesmaytrytorecruitethicallybutitisthehealthworkers thatmakethedecision,andtheTreatydoesnotforeseethat healthworkerscanbeexpectedtoconsiderrights,obligations andexpectationsofsourceanddestinationcountries.
Therefore,toberelevantandeffective,theCodeneedstobe adaptedtotheconditionsofthefree-mobilityzone.
socialpartnersineightEUcountriesreportedhavingusedor tobeusingtheCode(EPSU-HOSPEEM,2012).
ThedebateisevolvingintheEU.Recognizingtheshared challengesandtheinterdependenceofMemberStates,a 2008Commissionpaper6andconclusionsfromtheCouncil in20107laidthefoundationsfortheActionPlanforthe EUHealthWorkforceandforclosercooperation,including onhealthworkforceplanningandforecasting.8ThePlan estimatesthattheEUcouldhaveanestimatedshortfallof 1millionhealthprofessionals(2millionincludinglong-term carestaff)by2020ifappropriatemeasuresarenottaken
6 OntheEuropeanWorkforceforHealth:http://eur-lex.europa.eu/
legal-content/EN/TXT/PDF/?uri=CELEX:52008DC0725&from=EN
7 https://www.consilium.europa.eu/uedocs/cms_data/docs/pressdata/
en/lsa/118280.pdf
8 http://euhwforce.weebly.com/
(EuropeanCommission,2012).9TheEU2014–2020Health Programmemakeshealthworkforcesustainabilityapriority andproposesto“monitormobility(withintheUnion)and migrationofhealthprofessionals,[and]fosterefficient recruitmentandretentionstrategies”(EURegulation 282/2014).
Thedevelopmentsatcountry,EUandgloballevelssignal thathealthworkforcemobilityisfirmlyonthepolicy agenda.Freemobilitybetweendissimilaranddiverse systemsgivesrisetoequityaswellasefficiencyconcerns, trade-offsanddilemmas.Destinationcountries,source countriesandtheEUasawholeareaffectedintheshort aswellaslongterm,inobviousandinambiguousways.So whilemobilityiseasier,cheaperandfasterthanmigration, thequestioniswhetheritisalsobetterforthehealth professionalsandthecountriesinvolved.
9 http://ec.europa.eu/dgs/health_consumer/docs/swd_ap_eu_
healthcare_workforce_en.pdf
Figure 1: Share of foreign-trained doctors and nurses in selected European countries, 2014 or latest year available 1
0 5 10 15 20 25 30 35 40
% foreign nurses
% foreign doctors
Portugal
Italy
Turkey
Lithuania
Romania
Poland
The Netherlands
Estonia
Czech Republic
Slovakia
Austria
Denmark
Hungary
Germany
France
Spain
Belgium
Slovenia
Malta
Finland
Sweden
Switzerland
United Kingdom
Ireland
Norway
Source:OECDdata(Mercay,Dumont&Lafortune,2015).
1 Dataondoctors:from2013forFrance,Germany,HungaryRomaniaandTurkey;from2012forDenmark,Finland,Poland,Swedenand Switzerland;andfrom2011fortheNetherlands,SlovakiaandSpain.Alldataondoctorsrepresentsforeign-trainedprofessionalsexcept forGermany.UnitedKingdomdatadoesnotincludeNorthernIreland.
Dataonnurses:from2013forHungary,Portugal,Romania,SloveniaandTurkey;from2012forDenmark,Finland,Poland,Swedenand Switzerland;from2011forTheNetherlandsandSpain;andfrom2010forGermany.Danishnursingdataonlyincludesprofessionalnurses andexcludesassociateprofessionalnurses.Finnishnursingdatarefersonlytogeneralnurses.Germannursingdatatocitizensbornabroad, notGermanbybirth(exceptethnicGermanrepatriates)andthehighestdegreeinnursingacquiredinaforeigncountry.
Dataondoctorsandnurses,whoseplaceoftrainingisunknown,havebeenexcludedfromthecalculationoftheparentageofforeign- traineddoctors.
Thispolicybriefarguesthatwhilefreemobilityisan undisputedachievement,itcanleadtoinefficienciesand inequitiesifnotproperlygoverned.Tohelpcountries mitigateunwantedeffectsandstrengthenpositiveones, thebriefproposesaframeworktounderstandtheequity/
efficiencyconundrumandpolicyoptionsformanaging healthprofessionalmobilityintheevolvingEuropeanreality.
Thebriefsetsoutbyoutliningthemostimportanttrends whichmakeuptoday’smobilitycontext(Section2).Section 3goesontounpacktheefficiency-equityconundrumby analysingtheimplicationsofhealthprofessionalmobilityfor thoseconcerned–countries,healthprofessionalsandthe EU.Theseinsightsinformthepolicyoptionsputforward bythebrieftohelpactorsmitigatetheundesirableeffects ofhealthprofessionalmobility(Section4),aswellasthe implementationconsiderations(Section5)whichallowfor thevariationsacrossEuropeintermsofpolicycontexts, governance,healthsystemdevelopment,etc.
2. TRENDS IN MOBILITY: A NEW MAP OF EUROPE?
2.1 Mobility in the context of EU enlargements and the economic crisis: changing directions
Healthprofessionalmobilityrespondstoimportantevents takingplaceinEurope.Theeast-to-westflowsbrought aboutbyEUenlargementshavebeenjoinedbynew south-to-northflowsashealthprofessionalsfromcrisis-hitsystemsseekbetteropportunitiesandworkingconditions abroad.Datasuggestthattheeconomiccrisisandausterity measuresmighthaveagreaterandmoreenduringimpact onEuropeanmobilitypatternsthanEnlargementhashad, orthatthecrisisiscontributingtoa“delayed”Enlargement effect(Mercay,Dumont&Lafortune,2015).Totheflows fromEasternandCentralEuropeancountriesshouldbe addedthemobilityofhealthprofessionalsparticularly affectedbythecrisisfrom“old”MemberStates.InGreece, anoversupplyofdoctorsmeansthatmainlydoctorsleave:
stockdatafromGermanyshowthatnumbersofGreek doctorsgrewby50%in2010–2014(comparedto37%
in2005–2009),andthestockgrowthofdoctorsfrom RomaniaandHungaryalsorosemarkedlyfromaround2011 (Figure2).InSpain,PortugalandIreland,nurseshavebeen particularlyaffectedbydifficultiesinfindingemployment.
Inalargedestinationcountry,suchastheUnitedKingdom, nursestrainedinthesethreecountrieshaveconstituted around90%ofapplicationsforrecognitionofqualifications since2009(Buchan,2015)(Figure3).InFrance,numbersof foreign-traineddentistsfromRomania,SpainandPortugal haveincreasedmarkedlyinrecentyears,representing83%
ofnewforeign-trainedregistrationsin2014(ONCD,2015).
Theeconomiccrisishasmadeclearthatthedirectionof flowscanchangewithoutwarning.Inthespanoftwo decades,countriessuchasIrelandandSpainhavegone frombeingsourcecountriesinthe1990stoattracting foreign-trainedhealthprofessionalsaroundthemid-2000s asdemandwasincreasing,toagainexperiencingoutflows Figure 2: Stock growth of foreign medical doctors in Germany, selected nationalities, 2000–2014
0 500 1000 1500 2000 2500 3000 3500 4000
Hungary
Spain Slovakia Romania
Lithuania Italy Greece
Bulgaria
2014 2013
2012 2011
2010 2005
2000
Source:Ärztestatistik,Bundesärztekammer(ArbeitsgemeinschaftderdeutschenÄrztekammern),accessedthroughGermanFederal HealthReportingPortal:https://www.gbe-bund.de/oowa921-install/servlet/oowa/aw92/WS0100/_XWD_FORMPROC?TARGET=&PAGE=_
XWD_304&OPINDEX=3&HANDLER=XS_ROTATE_ADVANCED&DATACUBE=_XWD_332&D.000=ACROSS&D.342=DOWN&D.001=PAGE&D.928=PA GE#SOURCES,accessed17/07/2015.
ofdoctorsand/ornursessincearound2010,whenthe effectsofthecrisishit(López-Valcárcel,Pérez&Quintana, 2011;Buchan&Seccombe,2012).Astheeconomicstrength andrelativeattractivenessofdomestichealthsystemsof EUMemberStatesarechanging,sodothedirectionsof mobility.Theeconomicandpoliticaluncertaintywhich severalEUMemberStatesarefacingwilllikelycontinue tocontributetothevolatilityofflows,makingitdifficult forbothdestinationandsourcecountriestopredictwhich healthprofessionalswillcomeandgo.Thisisallthemore importantgiventhegrowingweightofintra-EUflows.
2.2 Intra-EU flows: changing policy options
Severalfactorscontributetoincreasingthescaleand relativeimportanceofmobilitybetweenMemberStates comparedtomigrationbetweentheEUandthirdcountries.Fordestinationcountries,intra-EUmobilitycanbeeasier, cheaperandfasterthanrecruitingfromnon-EUcountries, whilethesuccessivewavesofEUenlargementsin2004, 2007and2013haveseenthenumberofEUcountriesgrow from15to28today.
IntheUnitedKingdom,forexample,thenumberof EU-trainednursesovertookthenumberofnursesfrom non-EUcountriesadmittedtotheUKnursingregisterin 2008/9forthefirsttimeandhasbecomethemainsource ofrecruitsinrecentyears,supplantingthe“traditional”
sourcecountriesofEnglish-speakingAustralia,Indiaand thePhilippines(Figure3),andasimilartrendisvisiblein
Ireland(Mercay,Dumont&Lafortune,2015).InGermany, thenumberofdoctorswithEUnationalitygreweight-fold between1991and2014,fasterthanforeignstocksfromany otherregion.AsimilartrendisvisibleinFrance(Delamaire
&Schweyer,2011).In“new”MemberStates,expatriation ratesfornursesgrewconsiderablyinthedecadebetween 2000/01and2010/11inBulgaria(from2.6%to4.4%), Hungary(from2.4%to4.3%),Poland(from4.6%to 7.7%)andRomania(from4.9%to8.6%)(Mercay,Dumont
&Lafortune,2015).Thesetrendsarelikelytocontinue sincethelastlabourmarketrestrictionsimposedonthe nationalsfromaccedingMemberStatesexpiredinlate2013 (Ognyanovaetal.,2014).
Otherfactorsinfluencingintra-EUflowsincludethe economicandfinancialcrisiswhichevidencesuggestsis causinganetincreaseinEUhealthprofessionalmobility (Dussault&Buchan,2014).Astheeffectsofthecrisisare farfromover,thistrendislikelytocontinue.Thegrowing numberofhealthprofessionalstudentsforexamplefrom Sweden,France,PortugalandGermanywhoseekuniversity andtrainingpostsinotherEUcountriesalsocontributesto intra-EUmobility(Ribeiroetal.,2013;Safuta&Baeten2011;
Offermanns,Malle&Jusic,2011;Socialstyrelsen,2013):they move“ontheirwayout”tothedestinationcountryand manyofthemarelikelytoreturnhomeas“foreign-trained”
aftertheirstudies.
TheCode,aswellascountry-levelcommitmentstoethical recruitment,mightalsoleadEuropeancountriestorecruit Figure 3: Trends in “inflow” of nurses to the UK, as measured by annual registration of EU and non-EU international nurses, 1990–2015
0 2000 4000 6000 8000 10000 12000 14000 16000 18000
EU Non-EU
2014/15
2013/14
2012/13
2011/12
2010/11
2009/10
2008/9
2007/8
2006/7
2005/6
2004/5
2003/4
2002/3
2001/2
2000/1
1999/2000
1998/9
1997/8
1996/7
1995/6
1994/5
1993/4
1992/3
1991/2
1990/1
Number of registrations
Source:NMC/UKCCdata;Buchan,2015.
lessfromdevelopingcountriesandtoreplacenon-EU inflowswithEUhealthprofessionals.
Thegrowingimportanceofintra-EUflowsmattersfor policy-makingbecausecountriesinthefreemobilityzone havelesscontroloverEUmobilitythanovermigration toandfromtheEU.Whereascountriescancontrolthe inflowsofthird-countrynationalsviaimmigrationlawsand professionalregulatoryrequirements,mobilitydependson factorssuchastherelativeattractivenessofhealthsystems, marketforcesandbroaderhealthworkforcepoliciesinboth homeandhostcountry,factorswhichareonlypartially withintheremitofpolicy-makers.Freemobilitycanalso underminetheobjectivesofnationaleducationquotas–
countriescannotstopinflows,includingoftheirown nationalswhoreturnafterstudyingabroad.
Freemobilitymeansthatintra-EUflowsarerelatively
“unmanaged”and“unmanageable”–theyaredifficultto steerindirectionandinlengthofstay(Buchan&Seccombe, 2012).Moreover,countriesmayhavelessprecisedataon mobilitybecauseoflessstrictregistrationrequirements forEUnationals.Inthiscontextcountriescaninfluence mobilitybyadoptingbroaderpolicyresponses,forexample todomesticallytrainortoretainhealthprofessionals.Thisis especiallytrueforsourcecountriesforwhichitisevenmore difficulttosteerorpredictoutflowstootherEUMember States.Increasingintra-EUflowsmeansthattheirefforts shouldfocuson“prevention”–i.e.retentionmeasures.
2.3 Demand, demography and interdependence: growing mobility
Globaldemandforhealthworkforceisincreasingbutis notbeingmatchedbyasimilargrowthinsupply.Onthe demandside,pressuresstemmainlyfromagrowingworld population(Campbelletal.,2013).Withinthenexttwo decades(2035),theworldispredictedtofaceashortage of12.9millionhealthprofessionals,accordingtoWHO estimates(ibid).
Demographicfactorsalsoplayanimportantrole.The populationofEuropeisageingandsoisitsworkforce.The EuropeanCommissiontalksaboutthe“retirementbulge”:
aroundone-thirdofmedicaldoctorsintheEUwereover 55in2009,andby20203.2%ofallEuropeandoctorsare expectedtoretireannually(EuropeanCommission,2012).
Thesituationmightbeevenmorealarmingfornurses (Buchan,O’May&Dussault,2013).AsEurope’sactive workforceisshrinking,notonlywillcountriesbecompeting forhealthworkforcebutalsodifferentsectorsofthe economywillbecompetingtoattractsufficientrecruits.
Whencountriesdonotproducesufficientnumbersof healthprofessionalsbuthavetheresourcestoemploy more,mobilitycanbecomeawaytofillvacantposts.Policy decisionsandpolicychangesoninternationalrecruitment, especiallyincountrieswithattractiveworkingconditions andlabourmarketsthathavethecapacitytoabsorblarge numbersofmigranthealthprofessionals,mayhavealmost instantknock-oneffectsoncountrieswithlessfavourable conditions.Globalcompetitionforqualifiedhealth professionalsislikelytoincreaseagainstthisbackdropof
projectedshortagesandastheskillsandcompetencesof healthprofessionalsbecomeincreasinglyportable.Mobility makescountriesinterdependent.Theresultisthatcountries cannolongerviewtheirhealthworkforcepoliciesin isolationfromdevelopmentsinothercountries.
3. UNPACKING THE EFFICIENCY-EQUITY CONUNDRUM: A MATRIX
Countriesarefacedwiththeconstantlychanging conundrumofefficiencyandequity,thatis,betweenthe freemobilityofhealthprofessionalsintheEuropeanlabour marketononehand,andtheplanningrequirementsof healthsystemsensuringuniversalhealthcoverageonthe otherhand.Mobilityisacomplexphenomenonbecause per se itisneitherpositivenornegativeforsourceand destinationcountries;itseffectsarechangingovertime, equivocal,overlapping,hardtopindown,anddepend onthecontextandgovernanceofmobility.Thematrix proposedservestounpackthisconundrum.Countriescan usethematrixasatooltoanalysetheirspecificsituation andclarifyhowhealthprofessionalmobilityinfluences efficiencyandequityintheirhealthsystem,othersystems andEurope-wide.
Inwhatfollows,theefficiencyandequityimplicationsof freemobilityareexaminedfromtheperspectivesoftheEU, ofdestinationcountriesandofsourcecountries.Table1 givesavisualrepresentationofthematrix.Buildingonearlier worklookingattheopportunitiesandcosts/challenges broughtaboutbyhealthprofessionalmobility(Buchan, 2007;Buchan,2015),thematrixregroupsimplicationsas merits,thatis,whenhealthprofessionalmobilitycontributes toefficiencyorequityintheEU,acountryorahealth system,anddrawbacks,thatis,whenmobilitycreatesor
Box C: Why focus on efficiency and equity when addressing mobility?
Efficiencyhasbecomethecentre-pieceofEUhealthpolicy.
TheCommissionerforhealthandfoodsafetywasmandated in2014todevelopexpertiseonperformanceassessmentsof healthsystems,“[…]whichcaninformpoliciesatnationaland Europeanlevel”.1Thisexpertiseisalsomeanttoinformthework oftheEuropeansemesterofeconomicpolicycoordination.Inthis context,country-specificrecommendationonhealthsystemreform focusesspecificallyonefficiency(Greeretal.,2014).TheCodealso promotesefficiencybecausethe“[s]hortageofhealthpersonnel constitutesamajorthreattotheperformanceofhealthsystems”
(WHO,2010).
EquitybetweencountriesiscentraltotheCode.Itisdeemed unethicaltoincreaseinequitiesbyrecruitinghealthprofessionals fromcountriesalreadysufferingfromshortages.Equitywithin countriesplaysanimportantroletoo.In2006thethen25health ministersoftheEUofficiallyendorsedequityasoneofthe overarchingvaluesinhealthsystems.Equitywasdefinedinterms ofequalaccessaccordingtoneed,regardlessofethnicity,gender, age,socialstatusorabilitytopay(Council,2006).
1 http://ec.europa.eu/commission/sites/cwt/files/commissioner_
mission_letters/andriukaitis_en.pdf,accessed12/08/2015.
aggravatesinefficiencyorinequityatEU,countryorsystem level(seealsoGlinos,2015).Eachofthetwelvepossible combinationsisdescribedbelowwithconcreteexamples fromacrosstheEU.Anexceptionhasbeenmadetoequity improvementsintheEU,destinationsandsourceswhichare lookedattogetherduetothescarcityofevidence.
Thetermssourcecountryanddestinationcountrydeserve someexplanation.Whiletheycanbedefinedrespectively asacountryfromwhichhealthprofessionalsleaveanda countrytowhichhealthprofessionalsmigrate,inreality theconceptsaremoreblurred.Most,ifnotall,countries experiencebothinflowsandoutflows;Italy,forexample, experiencesoutflowsofmedicaldoctorsbutinflowsof nurses,whileinIrelandinflowsofforeign-traineddoctors replaceoutflowsofdomesticallytraineddoctors.Countries usuallyhavea“doubleprofile”,beingsimultaneouslysources anddestinationseveniftovaryingdegrees.Intermsof policyanalysis,thismeansthatmostcountriescannotignore eitherperspectivebutareconcernedbytheimplicationsof mobilitybothasadestinationandasasource.
Weshouldalsonotethatthematrixwasprimarilydeveloped formobilitythatresultsinextendedstaysabroad.Other formsofmobilitywhicharecommonintheEUsuchas temporaryflowsandcross-bordercommutingwilllikely havedifferent,moremoderateimpactsforcountries andindividuals.
Table 1. The effect of free mobility in terms of efficiency and equity in the EU, destination countries and source countries
Implications/
Level EU Destination Source
Merits:
• Efficiency A B C
• Equity D E F
Drawbacks:
• Inefficiency G H I
• Inequity J K L
Source:Theauthors,seealsoGlinos,2015.
3.1 Merits of free mobility
A: Efficiency – EUFromanEUlabourmarketperspective,freemobilityhas thepromiseofenablingabetterbalancebetweensupply anddemand.Unemploymentandunderemploymenthave, forexample,ledmedicaldoctorsfromItaly,Spain,Greece andRomaniatoseekworkelsewhereintheEU.Asurvey ofEuropeannursingassociationsshowedthatrising unemploymentfornurseswasaconcerninoverhalfofthe 34countries(EuropeanFederationofNursesAssociations, 2012).Insteadoflettingskillsandcompetencesgo unused,itismoreefficientfromanEUperspective–and arguablymorerewardingfortheindividuals–iftheskills ofmobilehealthprofessionalsareusedtofullpotentialin destinationcountries.
B: Efficiency – destination
Becausemobilityiseasier,cheaperandfasterthan migration,itcanmeanconsiderableefficiencygainsfor destinationcountries,forexamplewhenforeign-trained healthprofessionalsfillservicesgapsandworkforce shortages.InSwitzerland,oneinthreenursesandonethird ofdoctorsareforeign-trained,10mainlyfromneighbouring countries(Hostettlera&Kraft,2015);inSpainandGermany, foreigndoctorsalleviateregionalshortagesastheysettle downinregionsconsideredlessattractivebynationals;in France40%ofnewlyregisteredanaesthetistsand20%of newlyregisteredpaediatricianswereEU-nationals,mainly fromRomania,in2007(Wismaretal.,2011),whileonein threenewlyregistereddentistswastrainedinanotherEU countryin2014(ONCD,2015).
Butbenefitsgobeyondservicedelivery.IntheUK,a governmentreviewintothebalanceofcompetences betweentheUKandtheEUintheareaofhealthconcludes thattheEUSingleMarketaddsvalueinthehealthsector.
ThereviewquotedtheRoyalCollegeofNursing:“Nursing intheUKhasbenefitedenormouslyfromtheUK’s
membershipoftheEU,fromfreemovementofprofessionals andfromagreedminimumemploymentandworking conditionsinEurope”(HMGovernment,2013).11 Foreignhealthprofessionalscanalsoaddtothecultural diversityoftheworkforce,bringinnewskillsand competences,andreducetheaverageageofthehealth workforce,andtheextrasupplymaykeepshortage- drivenwageincreasesincheck(López-Valcárcel,Pérez
&Quintana,2011).Othersavingsincludeseniorstaff havingtimetoexpanddomestictrainingthanksto foreignhealthprofessionalsalleviatingworkloads(Young, 2011),aswellasthevastamountsofmoney,timeand organizationalcapacityrequiredtoeducateandtrainhealth professionalsdomestically.
C: Efficiency – source
Freemobilitycanpresentefficiencyadvantagesforthe sourcecountryondifferentlevels.Oneisthatofmobile healthprofessionalssendingorbringingremittancesback home,asdo,forexample,nursesfromeasternEuropean countriesworkinginGermany(Ognyanovaetal.,2014).
Returninghealthprofessionalsmayincreaseexpertise inthehomesystemwhentheyimprovetheirskillsand qualificationsabroad(see,forexample,Galan,Olsavszky
&Vladescu,2011),suchasinthecaseofexchange programmes(Wismaretal.,2011).Mobilitycanalsobe apolicystimulustotackleworkforceissuesasthethreat ofexitmakesgovernmentsmoreresponsive.In2010 some3800publiclyemployedCzechdoctorsjoinedthe protestmovement“Thankyou,we’releaving”,threatening tocollectivelyresignandsubsequentlyobtainingsalary increasesandimprovementstotheeducationalsystem (Alexaetal.,2015).AlsoinLithuania,HungaryandSlovakia
10 http://www.bfs.admin.ch/bfs/portal/en/index.html
11 https://www.gov.uk/government/uploads/system/uploads/
attachment_data/file/224715/2901083_EU-Health_acc.pdf
protestsand/ornegotiationshavebeenassociatedwith emigrationintentionsandconcessionsbygovernments.
D, E, F: Equity
Thereislittleevidenceonhowfreemobilitymayimprove equityatEUandcountrylevel.Thisisnottosaythatsuch improvementsdonottakeplace.Oneofthegreatest achievementsoftheEUistogive500millionpeoplethe righttofreelymove,workandliveanywhereintheUnion.
Freemobilitycontributesto“equityofopportunities”.EU citizensshareopportunitiesinallMemberStates.Working inanattractive,rewardinghealthsystemisnotonlyan optionforthenationalsofthatcountrybutforallhealth professionals:Finnishdoctorsseekcareeradvancement abroad,Belgiannursesareattractedbyflatterwork hierarchiesintheNetherlands,Slovakdoctorscanaccess betterequipmentabroad,whileAustrianandRomanian (junior)doctorsdotheirspecializationinGermanyand Belgiumrespectively(Wismaretal.,2011).Indestination countries,mobilitymayimproveequityofaccessforpatients whenforeignhealthprofessionalsalleviatehealthworkforce shortages,asnoted,forexample,inSpainandintheUK (López-Valcárcel,Pérez&Quintana,2011;Young,2011).
3.2 Drawbacks of free mobility
G: Inefficiency – EUFreemobilitymayleadtoinefficienciesbecauseit(re) distributeshealthprofessionalsandfundingwithinthe EU.Freemobilitychallengesdomesticplanning,which seeksapredictable,stableandneeds-basedsupplyof healthprofessionals.Whilemigrationcanbecontrolled (seeSection2.2)andmaybeanexplicitcomponentwithin overallnationalplanningincountrieswithidentified shortfallsinhealthprofessionalsduetoalowlevelof domestictraining,freemobilityfollowsthechoicesofhealth professionalsanddoesnotalwaysalignwithhealthsystem prioritiesandtherequirementsofuniversalhealthcoverage.
Toprotecttheirsystemsfromexpectedinflows,17European countries12restrictedfreemovementoflabourfrom
accedingMemberStatesin2004(Ognyanovaetal.,2014).
WhilstnotallEUcountriesfundthetrainingofalltheir healthprofessionals,giventhelargeshareofgovernment fundinggoingintomedicalandnursingeducation,mobility redistributesmillionsofEurosoftax-payers’moneybetween EUcountries.Thelackoftransparencyontheexact
extentanddirectionofin-andoutflows,andabsenceof compensationmechanismstooffsetcountries’gainsand losses,arguablyaggravateinefficienciesinhowmobility distributeshealthworkforceandfunding.
Anunbalanceddistributionofhealthworkforceacrossthe EUterritorycouldpotentiallyposeapublichealthriskif shortagesreachcriticallevels.Itisnotefficientorsafeif thelackofqualifiedhealthprofessionalsmeansthathealth
12 AllEU15countries,excludingIreland,SwedenandtheUK,plus Iceland,Malta,Norway,LiechtensteinandSwitzerland.Countries graduallystartedliftingrestrictionsfrom2006onwards.
systemsareunabletoprovideadequatecare,including containingpropagation.
Finally,freemobilitycanleadtoinefficiencywhenthe skillsofmobilehealthprofessionalsarenotusedtofull potentialinthedestinationcountry.TheEstoniannurse whodivideshertimebetweenEstonia,wheresheworks inemergencycare,andNorway,wheresheworksina nursinghome,isbutoneexampleofhowmobilitycan bewastefulforcountriesandhealthprofessionalswhen (specialized)skillsgounused(Saar&Habicht,2011).In Switzerland,anestimated4000foreign-traineddoctors workashospitalassistants,andothersimilarexamplesof mobilehealthprofessionalsnotbeingabletousetheirskills andqualificationsaboundacrossEurope(Bertinatoetal., 2011;DelamaireandSchweyer,2011;Mercay,Dumont&
Lafortune,2015;Ognyanovaetal.,2014).
H: Inefficiency – destination
Fordestinationcountriesoneformofinefficiencyisthat foreigninflowscanbeanunstablesourceofworkforce replenishment;thismightbeparticularlypronouncedfor inflowsofEUhealthprofessionalsforwhomitisgenerally easier,cheaperandfastertomovewithintheEUthanitis fornon-EUhealthprofessionals.Foreign-nationaldoctors inGermanyarefourtimesmorelikelythanGerman- nationaldoctorstomoveabroad(Ognyanovaetal.,2014).
IrelandandtheUKareknowntobe“steppingstones”for onwardmobility,whilereportsshowFinnish,Romanian andSpanishmigrantdoctorsreversingmobilitybyreturning home.EmployersinPolandarereportedtoheadhuntPolish doctorsabroadtoreturn(Kautsch&Czabanowska,2011;
Kuusioetal.,2011;López-Valcárcel,Pérez&Quintana, 2011;Galan,personalcommunication,2014).EUflows arealsolessmanageablethannon-EUflows.AsEUlaw bansdiscrimination,destinationcountriescanonlyguide EUhealthprofessionalstospecificareasusingthesame mechanismsasfordomesticallytrainedstaff,andhave nomechanismsforlimitingtheirstay.Bycomparison,in Germany,forexample,immigrationproceduresgivenon-EU doctorsaccesstotheGermanlabourmarketiftheytakeup workinunderservedregions(Ognyanova&Busse,2011), whilemigrationschemescandefinethedurationofnon-EU healthprofessionals’stay(Safuta&Baeten,2011;Buchan&
Seccombe,2012).
Anotheraspecttoconsideristheimportanceofintegrating foreignhealthprofessionalsintothenewsystemandthe time,capacityandmoneyittakestoorganizeinduction courses,languagetraining,mentoring,etc.Receiving inflowscanbebothdemandingandcostly,absorbing capacityofexperiencedhealthprofessionals,andcan causeinefficienciesifpatientsafetyiscompromiseddueto improperlanguageassessmentandinduction(Braeseke, 2014;Ognyanovaetal.,2014;Young,Humphrey&Rafferty, 2014).
Finally,mobilitymayimpedenecessarypolicychangeto addressunderlyingworkforceissues.InIreland,forexample, inflowsofforeign-traineddoctorsreplacetheoutflows ofIrish-traineddoctorsbutdistractdecision-makersfrom
tacklingretentionproblems(Humphriesetal.,2014).
AccordingtoBuchanandAiken(2008),“ashortagemaynot indicateashortageofsuitablyskilledandqualifiedpeople, butrathertheunwillingnessofthoseskilledindividualsto workundertheavailableconditions”.
I: Inefficiency – source
Insourcecountriesinefficienciescanarisewhenhealth professionalsleaveunderservedregions(Galan,Olsavszky
&Vladescu,2011;2013)orwhenshortagesmakemedical specialtiesparticularlyvulnerabletooutflows,asforexample inBelgium,Estonia,Hungary,Lithuania,PolandandSlovakia (Maieretal.,2011).Between2004and201418%of Polishdoctorswhospecializedinanaestheticsandcertain categoriesofsurgeryappliedforcertificatestoleavethe country,comparedtoanaverageof7%amongalldoctors (Mercay,Dumont&Lafortune,2015).Inthesecasesitis highlyprobablethatpatientcareisaffected.
Mobilityalsoimpactsonremainingstaffwhofacegreater burdensandlowerworksatisfaction,forexamplewhen postsareleftvacantorcloseddownduetorecruitment stops,withadverseconsequencesforqualityofcare
(Kingma,2007;Galan,Olsavszky&Vladescu,2013;Bruyneel etal.,2014).Thelossofworkforcecanbeallthemore problematicfortheorganizationofpatientcareasoutflows occursuddenlyandarerarelyplannedfor.
Butlossesgobeyondservicedelivery.Outflowsundermine returnsoninvestmentswherecountriespayforthe educationofhealthprofessionals.Whenthehealth professionalswholeavearepredominantlyyoung–asis thecasein,forexample,Estonia,Hungary,Italy,Poland, Portugal,RomaniaandSlovakia(Wismaretal.,2011;Ribeiro etal.,2013)–theyhavehadlittletimeto“giveback”to theirhomecountrysystemandmightbemorelikelyto stayinthedestinationcountryastheyseemtoadaptmore easilytolivingandworkingabroad(Young,Humphrey&
Rafferty,2014;Galan,personalcommunication,2014).
Whilemigrantsoftenintendonreturninghomeatthe momentofleaving,returntothehomecountryisless likelyonceprofessionalandpersonaltiesareestablished inthedestination.
Whenhealthprofessionalsleave,sourcesystemsalsolose thosewiththecapacitytoshapetoday’sandtomorrow’s workforce.Whetheritisexperiencedhealthprofessionals workingasteamleadersandeducatorsorthosewiththe drivetoimproveandreformthesystemwholeave,the departureoftalentandpotentialinstitution-builderscan leadtoaviciouscirclewhereshortcomingsinthesystem triggermobility,andtheabsenceof“thebestandthe brightest”meansthatshortcomingsarenotaddressed (Kapur&McHale,2005).
J: Inequity – EU
Thedifferencesinworkingconditions,salarylevels,status ofhealthsystemsandlivingstandardsacrosstheEUmean thatsomeMemberStateshaveanadvantageintermsof attractingandretaininghealthprofessionals,whileother countriesthatarenotappealingorcompetitiveenough
toattractinflowsrelyontheirownmeansandinvest considerablyindomesticproduction,healthworkforce developmentandretention.Thesituationcanleadto inequityandself-reinforcingdisparities:MemberStates which,inadditiontonotreceivinginflows,experience outflows,endupsubsidizingpartofthehealthworkforce ofmoreadvantageddestinationcountrieswithno
“compensation”.Second,mobilitypatternsreinforceexisting disparitiesasEUMemberStateswithfewerresourcestend tolosehealthworkforce,whilethosewithmoretend toreceiveworkforce.Third,totheextentthateconomic hardshipandausteritymeasurestriggeroutflowsand aggravatehealthproblems,thesystemsandpopulations withthegreatestneedsmightendupwithless.
Theseconcernsarepresentwhenagenciesandemployers fromwealthierdestinationcountriesorganizerecruitment fairsandpromotionalevents,forexamplearounduniversity campusesinsourcecountries,orcontactfinalyearstudents torecruitthemabroadbeforetheyhaveevenqualified.
Whilethisisentirelylegal,thequestionfromanEU
perspectiveiswhetherthese(aggressive)techniquesarefair.
SourcecountriessuchasEstonia,Greece,Hungary,Italyand Romaniacanhardlycompetewhencertaindestinationsoffer salariesfivetotentimeshigherthanwhatnewlytrained healthprofessionalscanexpecttoearnathome(see,for example,Fujisawa&Lafortune,2008;Wismaretal.,2011).
K: Inequity – destination
Atcountrylevel,inequityoftenrelatestothedifferences betweenthemobileandthenon-mobileworkforce.
Indestinationcountries,freemobilitycanresultin discriminationwhenforeignhealthprofessionals (systematically)facelessfavourableworkingconditions thandomesticallytrainedstaff.StudiesinBelgium,France, IrelandandSwedensuggestthatforeign-traineddoctors aremorelikelytoexperiencestalledcareerprogressionand lowerpay,workbelowtheirskilllevel,andperformless attractivechoresandshifts,attimescombinedwithworking inisolated,remoteregions(Delamaire&Schweyer,2011;
Safuta&Baeten,2011;WolanikBoström&Öhlander,2012;
Humphriesetal.,2013;2014).AstudyofeightEuropean destinationcountriesshowsthatforeign-trainednursesare morelikelytoperformtasksbelowtheirskillslevelthan thosedomesticallytrainednurses(Bruyneeletal.,2014).
Anotheraspectofinequityconcernseducationalquotas.
CountriessuchasBelgium,IrelandandSwitzerlandcap thenumberofuniversityplacesandhealth-relatedtraining poststocontrolworkforcenumbersbutshowadegreeof relianceonforeigninflows(Safuta&Baeten,2011;deHaller, 2014;Humphriesetal.,2014;Mercay,Dumont&Lafortune, 2015).Whilethisraisesequityissuesintermsofeffectsfor sourcecountries,italsoraisesthequestionofwhetherit isfairthatsuitablyqualifiedyoungpeopleareprevented fromenteringhealthprofessionaleducationintheircountry becauseofacontinuedrelianceoninternationalrecruits.In theUK,forexample,thenumberofapplicantsfornursing studiesonanannualbasisistwotothreetimesthelevelof thoseaccepted.
L: Inequity – source
Insourcecountries,mobilitybringsequityconcernsfor thehealthprofessionalsstayingbehindandforpatients.
Whilemobilityisfarfromalwaysaneasyexperienceforthe migrant(Glinos,Buchan&Wismar,2014),italsoaffects thosewhoremaininwhatareoftenalreadydisadvantaged systems(Kingma,2007).Socialequityaswellasthe diversityanddynamismoftheworkforceareatstakeif certainprofilesofhealthprofessional,suchasthosewith familyobligations,olderhealthprofessionalsandthose withnoforeignlanguagecompetencies,arelessableor likelytoexercisetheirrighttofreemobility.Outflowsmight alsoexacerbate(territorial)inequityintermsofregional workforceimbalancesandproblemswithaccesstocare.
InRomania,poorerruralregionshavelowcoverageof medicaldoctorsandexperienceimportantoutflows(Galan, Olsavszky&Vladescu,2011;2013),whileperipheralor smallerhospitalshaveproblemsinattractingandretaining medicalaswellasnursingstaff,asituationwhichismade worsebyemigration(Galan,Olsavszky&Vladescu,2013).
InBulgaria,lackofspecialistsmeansthatpatientsinrural areashavetotravellongerdistancestoaccessspecialized services(Mercay,Dumont&Lafortune,2015).
4. POLICY OPTIONS: HOW TO MAKE MOBILITY WORK BETTER
Intheprecedingsectionwehaveunpackedtheefficiency- equityconundrumsurroundinghealthprofessional mobility.Wehavestartedbyclarifyingtheoverlapping andcontrastingeffectsmobilitycanhavefortheEU,for destinationsandforsources.Freemobilityleadstoboth synergiesandtrade-offsasitimpactsonefficiencyand equityinmultipleways.Thechallengeforobserversand policy-makersistoobtainascomprehensiveapicture aspossibleofhowhealthprofessionalmobilityaffects healthsystems.
Thissectionexamineswhichoptionspolicy-makersin countriesandatEUlevelhavetomakemobility“better”, thatis,toaddressitsnegativeeffectsandpromoteits positiveeffects.Thisisanongoingactivitywithnosingle orsimpleanswertoit.Anarrayofpolicyoptionsispossible andpolicy-makerswillhavetodecideonthemixofoptions whichsuitstheirpurpose,currentprioritiesandcontext.To facilitatethetask,thebriefcataloguesanddescribesthe variouspolicyoptionsaccordingtothreebroadcategories:
policiesatcountrylevelwhichseektostrengthenhealth workforcesustainability;policiesatcountrylevelwhichseek tomanagemobilitywhenitdoestakeplace;andpolicies atEUlevelwhichseektoaddresstheconsequencesof freemobility.
Inwhatfollowsthethreecategoriesofpolicyoptionswillbe brieflysummarizedandexampleswillbeprovidedforeach category.Table2liststheexactpolicyobjectivesandpolicy measuresofeachcategory.Thevarietyofmeasuresincluded inthelistrangesfromwell-knownpolicyoptionswhich havebeentriedincountriestooptionsasyetuntestedbut withpotentialrelevance.Intheabsenceofanypanaceaor
ready-madesolutions,theaimoftheoverviewistobeas comprehensiveaspossibleandinformpolicy-makersabout optionsattheirdisposal.
4.1 Policy options to foster health workforce sustainability
Fordestinationandsourcecountriesalike,health professionalmobilityisoftenasymptomofunderlying healthworkforceissues.Healthprofessionalscomeandgo becausethehostsystemdoesnothavesufficientworkforce orlackscertainskills,andbecausethehomesystemisnot perceivedasprovidingsufficientrewardsandopportunities.
Giventhechallengeswhichfreemobilitygivesriseto (cf.Section3),countrieshaveaninterestinfosteringa sustainablehealthworkforce–destinationcountriesby addressingthereasonswhythesystemreliesonforeign inflowstoreplenishthehealthworkforce,sourcecountries bytacklingthefactorswhichleadhealthprofessionalsto leave.ThisisalsooneofthemaintenetsoftheCode–to strengthenhealthworkforcedevelopmentasanalternative tointernationalrecruitmentandmigration.Ensuringa sustainablehealthworkforcecanbeawayto“prevent”
mobilityanditspotentiallyundesirableeffects,byreducing thedriversformobility.
Policyoptionswhichseektoincreasehealthworkforce sustainabilitycanberegroupedintosixpolicyobjectives:
betterhealthworkforceplanning;trainingandadapting today’sworkforce;trainingtomorrow’sworkforce;domestic recruitment;betterregionaldistribution;andretention (Table2).Eachobjectivepresentsarangeofpolicymeasures tochoosefrom.BoxDdescribesaconcreteexampleof howpolicy-makers,togetherwithproviderandprofessional organizations,mayprioritizeattractingyoungpeopleinto certainhealthprofessionsasawaytocountershortages andtrainthefutureworkforce.
Box D: Attracting young people to nursing, radiography and medical laboratory technology studies in Denmark Athree-yearrecruitmentcampaign,calledtheHvidZone Campaign(inEnglish:WhiteZoneCampaign),wasdesigned andimplementedinDenmarktoincreasethenumberofpeople enteringtraininginthefieldsofnursing,radiographyand medicallaboratorytechnologyandtoraiseawarenessofthe careeropportunitiesinthesefields.Thecampaign,whichran from2009to2011,emphasizeddigitalmedia,includingsocial media,andwasincludedintheexistingwebsitesforprogrammes andactivitiesofprofessionalschools.Ledandfinancedbythe MinistriesofEducationandofHealth,DanishRegions,Danish municipalities,professionalorganizationsanduniversitycolleges, thecampaigntargeteda44%increaseinthenumberofpeople enteringtraininginthethreeconcernedfields.By2011the increaseinuptakeofthethreeprogrammesfarexceededthe target.
Source:EuropeanCommission,2015.
Table 2: Policy options to make mobility work better Policy options to foster health workforce sustainability
Objectives Measures
Betterhealthworkforceintelligenceandplanning Measuresincludeinvestinginhealthworkforceintelligence(incl.onstock,composition, flows,regionaldistribution,vacancies,motivations),indemographicscenariomodelling, andinmobilitydata;coordinatingplanningwithtraininginstitutionsandprovider organizations.
Trainingandadaptingtoday’sworkforce Measuresincludecontinuousprofessionaldevelopment;re-skilling;redefiningskillsin linewithpopulationneeds;life-longlearning.
Trainingtomorrow’sworkforce Measuresincludeattracting(young)peopletohealthcare;steeringstudentsto shortageprofessions;investingineducationalcapacity;allocatingseniorstafftimeto teaching;adaptingcurriculatodemographyanddiseaseprofiles;liftingorre-evaluating educationalquotas.
Domesticrecruitment Includeentrystagemeasurestoattractnewgraduates/recruitstodomesticjobs bycreatingopportunitiesforemployment,professionaldevelopmentandcareer progression,aswellasmeasurestoencouragereturntopracticewithfinancial incentives,retrainingcourses,andmentoring.
Betterregionaldistributionwithinthecountry Measuresincludepromotingnetworksandextendedteamwork;settingupcontact points;guaranteedemployment;housingandsocialbenefits;regionalinvestment.
Retention Measuresincludecreatingsupportiveandsafeworkplaces;flexibleworkinghours;
professionalautonomy;expansionofroles;remuneration;grantsinexchangefor workinginthesystemafterspecialization;careerprogression.
Policy options to manage mobility
Ethicalrecruitmentpractices Introductionandimplementationofguidelinesandcodesatnationalorinternational levels,suchastheCode,toencourageespeciallyemployerstorecruitand
employethically.
Country-to-countrycollaboration Measuresincludebilateralagreementsbetweendestinationandsourcecountries withmechanismstosharetrainingcosts,promotecircularmobility,provideadditional trainingpriortoreturn,definethetypeandnumberofhealthprofessionalstobe trainedforinternationalrecruitmentand/orencourageprofessionalstosettledown inparticularlocations.
Integrationofforeign-trained/bornprofessionals Measuresindestinationcountriesincludeinductionandlanguagecourses;mentoring;
practicalhelptosettledowninhostsystem;legalframeworkstofacilitaterecognition andauthorizationtopractiseprocesses;preventingdiscrimination.
Facilitatedreturns Measuresinorbysourcecountriestoencouragereturnsandtoallowreturninghealth professionalstouseskillsacquiredabroadandreintegratetheworkforce,e.g.by offeringconcreteemploymentopportunities.
EU action to address the consequences and opportunities of free mobility
Bettermobilitydata Investinginmobility“R&D”includingupdatedflowdata;mappingexercisesofnational policiestoaddressmobility;dataonmigrantitinerariesandmotivations;evaluationof instruments,e.g.bilateralagreementsandcodesofpracticeincludingtheCodeand theirimplementationatnationalandorganizationallevels;mobilityimpactassessments.
Jointplanningandworkforcedevelopment MeasuresincludeinvestinginEuropeanhealthworkforceintelligenceandregional forecastingmodels;introducingEU-wideCPDprogrammes;coordinatingtraining capacityandhealthworkforceproduction.
Protectingvulnerablehealthsystems MeasuresincludeanEUcompensationfundtocompensatefortrainingcostsinsource countries;EUstructuralandcohesionfundingandtechnicalsupporttostrengthen vulnerablehealthsystemsinsourcecountries.
Protecting/promotingmobility Measuresincludemonitoringadherencetofreedomofmovementandanti- discrimination;EU-fundedscholarshipstargetingspecificdisciplines/regions;
mechanismsforknowledgeandskilltransfersbetweenMemberStates.
Source:Authors’compilation,adaptedfromBuchan,2007;Wiskow,Albreht&dePietro,2010;Wismaretal.,2011;Delamaire,2014;
Mercay,Dumont&Lafortune,2015;Plotnikova,2014;EuropeanCommission,2015.
