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

No 18 ISSN 1997-8073 POLICY BRIEF 18 HEALTH SYSTEMS AND POLICY ANALYSIS 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 Keywords: 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. © World Health Organization 2015 (acting as the host organization for, and secretariat of, the European Observatory on Health Systems and Policies) Address requests about publications of the WHO Regional Office for Europe to: Publications WHO Regional Office for Europe UN City, Marmorvej 51 DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office web site (http://www.euro.who.int/pubrequest). All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The views expressed by authors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the World Health Organization. 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, WHORegionalOfficeforEurope,Denmark. Editors WHORegionalOffice forEuropeandEuropean ObservatoryonHealth SystemsandPolicies Editor GovinPermanand AssociateEditors ClaudiaStein JosepFigueras DavidMcDaid EliasMossialos ManagingEditors JonathanNorth CarolineWhite Theauthorsandeditorsare gratefultothereviewers whocommentedonthis publicationandcontributed theirexpertise.  PolicyBriefNo18 ISSN1997–8073 Howcancountriesaddresstheefficiencyandequity implicationsofhealthprofessionalmobilityinEurope? AdaptingpoliciesinthecontextoftheWHOCodeofPractice andEUfreedomofmovement Policy brief 2 How can countries address the efficiency and equity implications of health professional mobility in Europe? 3 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. Policy brief 4 How can countries address the efficiency and equity implications of health professional mobility in Europe? 5 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; Policy brief 6 • 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). How can countries address the efficiency and equity implications of health professional mobility in Europe? 7 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. Policy brief 8 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 Po rtu ga l Ita ly Tu rk ey Li th ua ni a Ro m an ia Po la nd Th e Ne th er la nd s Es to ni a Cz ec h Re pu bl ic Sl ov ak ia Au st ria De nm ar k Hu ng ar y Ge rm an y Fr an ce Sp ai n Be lg iu m Sl ov en ia M al ta Fi nl an d Sw ed en Sw itz er la nd Un ite d Ki ng do m Ire la nd No rw ay 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. How can countries address the efficiency and equity implications of health professional mobility in Europe? 9 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-hit systemsseekbetteropportunitiesandworkingconditions 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 2014201320122011201020052000 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. Policy brief 10 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 20 14 /1 5 20 13 /1 4 20 12 /1 3 20 11 /1 2 20 10 /1 1 20 09 /1 0 20 08 /9 20 07 /8 20 06 /7 20 05 /6 20 04 /5 20 03 /4 20 02 /3 20 01 /2 20 00 /1 19 99 /2 00 0 19 98 /9 19 97 /8 19 96 /7 19 95 /6 19 94 /5 19 93 /4 19 92 /3 19 91 /2 19 90 /1 Number of registrations Source:NMC/UKCCdata;Buchan,2015. How can countries address the efficiency and equity implications of health professional mobility in Europe? 11 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. Policy brief 12 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 – EU FromanEUlabourmarketperspective,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 How can countries address the efficiency and equity implications of health professional mobility in Europe? 13 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 – EU Freemobilitymayleadtoinefficienciesbecauseit(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 Policy brief 14 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. How can countries address the efficiency and equity implications of health professional mobility in Europe? 15 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. Policy brief 16 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. How can countries address the efficiency and equity implications of health professional mobility in Europe? 17 4.2 Policy options to manage mobility Policyoptionsinthiscategoryseektogetthebestoutof mobilityforallpartiesconcerned.Thisfollowsthelogicof theCodewhichadvocatesthatmigrationcancontribute tostrengtheninghealthsystemsif“properlymanaged” (Art3.2).Whilecertainmeasuresmightcontributeto reducingin-andoutflows(seeSection3),mobilityis likelytocontinuetogrowinimportanceanditsextent anddirectionsremainhardtopredict.Inthiscontext,no EUcountrycanignoremobility;destinationandsource countriesalikehaveanincentivetomanagemobility–at thenationalandinternationallevel–soastoreapits benefitsandminimizeitsnegativeeffects. Foursetsofpolicyoptionstomanageandsteermobility canbeidentified:ethicalrecruitmentpractices;country- to-countrycollaboration;integrationofforeign-trained professionalsinhostsystems;andfacilitatedreturnsinto sourcesystems(Table2).Thesewilloftenbeusedinparallel astheymanagemobilitybothbetweencountriesandby improvingthesituationofmobilehealthprofessionals withinacountry.Bilateralagreementscan,forexample, bundledetailsonrecruitment,induction,trainingandreturn dates.BoxEillustratessuchaprojectwhichincorporates aspectsofallfourpolicyoptionstoethicallyrecruitforeign- trainedhealthprofessionalsandhelpthemsettleinthe destinationcountry. 4.3 EU action to address the consequences and opportunities of free mobility Mutualrecognitionofdiplomasandfreedomofmovement meanthatEUhealthprofessionalsincreasinglyformone EUhealthworkforce.IndividualMemberStatesarenotin controlofin-andoutflows,noraretheyfullyequippedto dealwiththeefficiencyandequityconcernswhichmobility bringsabout,andyettheyhavecometodependoneach other’sworkforcesituations.Destinationcountriesmay “benefit”morefrommobilitybuttheyalsorelyonthe trainingcapacityofsourcecountries–whatwouldhappen ifRomaniastoppedtraininganaesthesiologists?–andon thesituationinotherdestinationcountriesastheycompete forinflows.Withlessindividualautonomy,jointpolicy responsesmakemoresense.ConcertedEUactionpresents addedvaluenotonlytodealwiththeconsequencesof mobilitybutalsotopromotetheopportunitiesitpresents forindividualswhoarefreetopursuetheiraspirationsand forhealthsystemswhichreceiveskillsthatarenotorcannot beproduceddomestically. Policyoptionswhichseektoaddresstheconsequences andopportunitiesofmobilityatEUlevelcanberegrouped accordingtofourpolicyobjectives:bettermobilitydata; jointplanningandworkforcedevelopment;protecting vulnerablehealthsystems;andprotecting/promotingfree mobilityasacitizens’right(Table2).BoxFgivesanexample ofhowtheEuropeanCommission’sstatisticalserviceis collaboratingwiththeOECDandtheWHORegionalOffice forEuropeintheareaofhealthcarestatisticstoimprove mobilitydata. Box E: Triple Win nurses – sustainable recruitment of nurses from four countries to Germany (2013–2016) Facedwithincreasingnursingshortages,Germanyhasmade bilateralagreementswithcountriessuchasBosniaand Herzegovina,SerbiaandthePhilippines,whicharereporting surpluses.TheFederalEmploymentAgency’sInternational PlacementServicesandtheGermanAgencyforInternational Developmentestablishedajointprojecttoplace2,000qualified nurseswithGermanhealthcareprovidersby2014.Theproject cooperateswiththeemploymentagenciesofthepartnercountries toselect,assess,prepareandplacethenurses,andprovidesthem withsupportintheircountryoforigin,uponarrivalinGermany andduringtheirstaythere.Thiscreatesatriple-winsituation bywhich: • Inthedestinationcountryshortagesareaddressed;heavy bureaucraticproceduresfortherecognitionofqualificationand workpermitsarereplacedbydirectagreements. • Inthesourcecountry,labourmarketpressureisalleviated, remittancescontributetonationalincomeandreturningnurses bringnewacquiredskills. • Thehealthprofessionalhasjobopportunitiesandiswelcomed inthehostcountry. Inapreviouspilotproject(2011–2012),around80nurses wereplacedwithGermanemployers.Projectmonitoringhas verifiedthatthesenursespossessedahighlevelofprofessional qualification.Employerswerehighlysatisfiedwiththe internationalnurses. Source:GIZ,DeutscheGesellschaftfürInternationale Zusammenarbeit,https://www.giz.de/en/worldwide/20322.html, accessed21/07/2015. Box F: European monitoring of health workforce mobility and migration: joint data collection on non-monetary healthcare statistics EUROSTAT,theOECDandtheWHORegionalOfficeforEurope areusingajointquestionnaireforcollectinghealthcarestatistics intheirMemberStates.In2014“healthworkforcemigration” wasintroducedforthefirsttimeintheJointQuestionnaireto improvethemonitoringofinternationalhealthworkforcemobility andmigrationthroughthecollectionofaminimumdatasetthat wouldberelevanttobothsourceanddestinationcountries,and feasibleformostEuropeanandnon-EuropeanOECDcountriesto reportdata.Thisdatacollectionrespondstoacurrentgapinthe OECD,EUROSTATandWHO-Europedatabases.Itwillalsoserveas partoftherequiredinputstotheNationalReportingInstrument, theself-assessmenttoolusedbytheWorldHealthOrganization tomonitortheimplementationoftheGlobalCodeofPracticeon theInternationalRecruitmentofHealthPersonnel(adoptedbythe WorldHealthAssemblyinMay2010),gatheringdatafortheupto 62countriesthatarereceivingtheJointQuestionnaire. Source:OECD,EUROSTAT&WHO-EUROPE,2014. Policy brief 18 5. IMPLEMENTATION CONSIDERATIONS Thissectionlooksatimplementationconsiderationsfor destinationcountries,forsourcecountriesandforthe policyoptionsatEUlevel.Beforeexaminingimplementation considerationsfromthesethreeperspectives,twogeneral observationsareworthmaking. Oneimportantobservationtomakeisthatcountriesoften willhavetoimplementseveralpolicyoptionsinparallel. Healthprofessionalmobilitycanaffectprofessionalgroups, specialtiesandregionsindifferentways.Thisalsoimpliesa needforpolicycoordinationwithincountriestoensurethat variousmeasuresbeingimplementedarecompatibleand, wherepossible,reinforceoneanother.Forimplementation tobesuccessful,coordinationeffortswillalsoneedto includestakeholderengagement.Decisions/actionson healthworkforceandmobilitypoliciesinvolveabroadrange ofactors. Second,implementingpolicyoptionsentailsinmanycases consensusbuildingandstronginter-sectoralgovernance. MostgovernmentsinEuropehavelimitedleverageover somekeyaspectsofworkforcedevelopment.University- basedtraining,forexample,isinmostcountriesnotin theremitoftheministryofhealthbutratherinthatof theministrycompetentforscienceandeducation.Asan additionalcomplication,medicalandnursingschoolsoften sitattheregionallevelwithsomeautonomyaccountableto regionalgovernments.Manyaspectsofhealthworkforce policyareperformedbyself-governingbodiesofthe professions.Clinicalguidelinedevelopment,licensing, registration,compliancewithprofessionalstandardsand mal-practiceproceduresareoftencontrolledbymedical societies,professionalchambersornursingandmedical councils.Working-andpay-conditionsarenegotiated betweenthesocialpartners.Mostcountrieshave coordinationmechanismsinplacetobringthesedifferent functionsintoalignment,butoftentheircapabilitytoresolve issuesislimitedbecauseofalackofagreementonpolicy priorities.Thereforepartoftheinter-sectoralgovernance istobuildconsensusonthehealthsystemreformsandthe workforcerole. 5.1 Countries experiencing inflows: implementing policies for health workforce sustainability and for managing mobility Fordestinationcountries,afirststepinthepolicyprocessis toidentifywhichneed,gaporshortcominginflowsmakeup forinthedomestichealthworkforce.Differentscenariosare possible,callingforspecificpolicyoptions(seealsoTable2): The health system replaces domestic by foreign health professionals:whereaforeign-trainedhealth workforceisneededbecausethesystemlosesdomestically- trainedhealthprofessionalstoemigrationorattrition,itis importanttounderstandwhyhealthprofessionalsleavethe country/healthsectorandtodesignandtargetretention anddomestic recruitmentpoliciesaccordingly.IntheIrish context,forexample,Humphriesandcolleagues(2013)note that“ashortagemaynotindicateashortageofsuitably skilledandqualifiedpeople,butrathertheunwillingness ofthoseskilledindividualstoworkundertheavailable conditions”.Improvedworkingandemploymentconditions willhelptoretainbothdomesticandforeign-trainedstaff, andtofacilitate returns.Measurestobetterintegrate foreign health professionalswillalsofavourretention,aswillethical recruitment practiceswhichincludeinformingpotential migrantsofwhattheycanexpectofthehostsystemprior toarrival. The health system does not produce the right type or number of health professionals:wheremobilehealth professionalsmakeupforinadequatedomesticproduction, thequestioniswhethertheshortcomingsareduetolimited studyplaces,unfilledstudyplaces(poortake-up),attrition duringstudies,orlackofspecializedtrainingposts.Inflows offoreign-trainednationalswhoreturnafterstudying abroadmay,forexample,signalexcessivelytighteducational quotas.Dependingonthecause(s),policyeffortsneedto focusonhealth workforce planningtoaligneducational andtrainingcapacitywithsystemandpopulationneeds, andontraining today’s and tomorrow’s workforcebearing inmindthetimerequiredforspecificmeasurestoproduce results.Giventhislag,country-to-country collaborationwith sourcesystemsmaybeparticularlyrelevantwhilewaiting fordomesticcapacitytocomeon-stream.Intermsofethical recruitment,transparency,forexampleonthedurationof contracts,willbeimportant. The health system faces regional mal-distribution of health professionals:whereasystemneedsforeignhealth professionalstofillgapsinunderservedareas,measures forabetter regional distributionneedtoattractandretain healthprofessionalsinareassuchasscarcelypopulated regionsordeprivedurbanzones.InFrance,measuresinclude bonusestoencourageyoungdoctorstosettledowninthese areas(Delamaire,2014).Country-to-country collaboration withsourcesystemsmayalsoofferwaystoencourage foreign-trainedhealthprofessionalstopractiseinspecific locations,althoughsuchmeasuresneedtobesupplemented bysolidintegration policiesgiventhedifficultiesinvolved withworkinginregionsorstructuressufferingfrom workforceshortagesandbyethical recruitment practices toensurethatforeignhealthprofessionalsareproperly informedofworkingconditionsaheadofmoving. Small countries:fiveoutofeightsmallcountriesin theWHOEuropeanRegionparticipateintheEuropean freemobilityzone,eitherasanEUMember(Cyprus, Luxembourg,Malta)orthroughtheEuropeanEconomic Area(Liechtenstein,Iceland).Smallcountriescanbe consideredadistincttypeofdestinationbecausethey cannotrealisticallyproducealltherequiredhealth professionalswithallspecializationsdomesticallyand thereforedependonhealthprofessionalmobilityfor workforcesustainability.Mobilityisindispensablebothto allownationalstobeeducatedand/ortrainedabroad,and toattractforeign-bornhealthprofessionals.Policyoptions insmallcountrieswillfocusonhowtomanage mobility; inparticular,country-to-country collaborationwithsource countriescanbeuseful,butalsowithcountrieswhichcan receiveandtreatpatientsrequiringhighlycomplexcarenot availableinsmallcountries. How can countries address the efficiency and equity implications of health professional mobility in Europe? 19 5.2 Countries experiencing outflows: implementing policies for health workforce sustainability and for managing mobility Forsourcecountries,thepolicyprocessstartswith identifyingwhyhealthprofessionalsleavethecountry,in ordertodeterminewhatpolicyoptionscanbepursued. Severalscenariosarepossible(seealsoTable2): Unsatisfactory working and employment conditions: insystemswhichsufferfromoutflowsduetounattractive oruncompetitiveconditions,better health workforce intelligencecanhelpdeterminewhichfactorsmotivate healthprofessionalstoleave.Asreasonscanvaryfrom, forexample,insufficientincometounmanageable workloads,jobinsecurityorpoorprospectsforcareer progression,retention measureswillhavetobefine- tunedtoaddressthe(perceived)shortcomings.Improving workingandemploymentconditionsalsobringsthe advantageofcontributingtofacilitate returns.TheIrish HealthService13has,forexample,launchedarecruitment campaigntoattractmigrantIrishnursestoreturnto Irelandbyofferingarelocationpackageandaseriesof benefitsincludingpermanentcontracts,CPDandflexible workingarrangements. Lack of training posts/study places:insystems wherehealthprofessionalsleavebecauseofinsufficient opportunitiestotrainorspecializeinthehomecountry, policyeffortsarelikelytoinvolvehealth workforce planning toassesstheworkforceneedsofthesystemandcoordinate trainingcapacityaccordingly,aswellasmeasurestotrain and develop the future health workforce.Giventhetime requiredto,forexample,setupnewtrainingfacilities, measurestofacilitate returnsandcountry-to-country collaborationwithdestinationscanbeinterestingto encouragecircularmobilityandknowledgetransfer. Unemployment:inasystemwhichisnotableto employthehealthprofessionalsittrains,itisimportantto establishwhetherthisisduetotheinabilitytomeetthe costsofemployinghealthprofessionals,orastructural overproductionofhealthprofessionals.Intheformercase, financialmeasuressuchaschannellingfundingtothehealth workforcebudgetmightbeasolution,whileinthelatter casehealth workforce planningcouldhelptobetteradjust educationalcapacitytotheneedsofthesystem.Country- to-country collaborationtoexploreoptionsfordestination systemstoco-fundmobilehealthprofessionals’education andtrainingcouldofferawaytopartlycompensateforthe costsofoutflows. Crisis-hit countries:theeconomicandfinancialcrisis whichhitEuropefrom2008/09hasaffectedhealthsystems andhealthworkforcemobilityconsiderably,although tovaryingdegrees(Dussault&Buchan,2014;Thomson etal.,2014).Thecountrieshithardestbythecrisisform asub-groupofsourcecountriesbecauseofadistinct constellationoffactors:theimplementationofausterity measureshaveworsenedtheemploymentandworking 13 http://www.hse.ie/eng/services/Campaigns/ nurserecruitment.787711.shortcut.html conditionsofthehealthworkforcewithknock-oneffects formobilityincentives;thegeneralsocial,economicand politicalcontextislikelytoencourageoutflows,including ofhealthprofessionals;thehealthsystemcannotaffordto hireorretainworkforce;andthecountryislikelytosuffer fromtheeffectsofstructuralunemploymentcausedalso by“inflows”ofhealthprofessionalspreviouslyemployedin theprivatesectorseekingtoreturntopublicsectorwork. Inthesecircumstances,policyoptionswillneedtofocus onlow-costretention measures.InHungary,forexample, taxrevenuesfrom“sinfoods”havebeenearmarkedto fundascholarshipprogrammewhichcommitsparticipating residentdoctorstoworkinthecountryafterspecializingfor adurationequivalenttothatofthebursary(Dózsa&Szigeti, 2015;EuropeanCommussion2015).InRomania,emergency measureshaveintroducedascholarshipforyoungdoctors whowereparticularlyaffectedbysalarycuts(European Commission2015a). 5.3 Implementing EU level policy options for addressing the consequences and opportunities of free mobility TheEUhasaspecialroleintheimplementation.Itcan addressallareasofUnionpolicies,suchastherecognition ofdiplomasandthefunctioningoftheEUlabourmarket. Butitcanalsohelptosetthepoliticalagendabyinitiating researchanddiscussionandcreatingplatformsforbest practiceexchangesbetweenMemberStates.Thiscapacityto instigatedebateandactionisofutmostimportancewhether implementationtakesplaceatEUorcountrylevel.Most activitiessofarhavebeenbundledundertheEuropean CommissionActionPlanfortheEUHealthWorkforce.14 TheActionPlanfocusesonfourtopics,including improvinghealthworkforceplanningandforecasting, betteranticipationofskillsneeds,stimulatingexchange onrecruitmentandretention,andsupportingethical recruitment.ToimplementtheActionPlan,theCommission sponsoredahostofprojects,firstandforemosttheJoint ActiononHealthWorkforcePlanningandForecastingwhich hasbecomeaEuropeanplatformofmorethan80members tosharegoodpracticeandtodevelopmethodologieson forecastinghealthworkforceandskillsneeds.Itsresults includeastudyontheapplicabilityoftheWHOCodeinthe contextoftheSingleMarket.15Toimprovethequalifications ofhealthcareassistants,withaparticularemphasisoncross- bordermobility,aprojectisresearchingthefeasibilityofa commontrainingframeworkforhealthcareassistantsunder theDirective2005/36/EUontherecognitionofprofessional qualifications,whilearecentEuropeanCommissionstudy reviewseffectiverecruitmentandretentionstrategiesto inspiresolutionsfororganizationsandcountriestoattract andretainhealthworkers(EuropeanCommission2015, 2015a).TheimplementationoftheActionPlanandgeneral healthworkforceissuesusesMemberStates’resources 14 CommissionStaffWorkingDocumentonanActionPlanforthe EUHealthWorkforce.SWD(2012)93final.http://ec.europa.eu/dgs/ health_consumer/docs/swd_ap_eu_healthcare_workforce_en.pdf 15 http://euhwforce.weebly.com/uploads/2/3/0/5/23054358/150609_ wp4_who_applicabilty_report.pdf Policy brief 20 andamultitudeofCommissioninstruments,derivedfrom arangeofprogrammesunderdifferentDirectorateGenerals (Greer,2014). Asecondpoint,whichshouldbetakenintoconsideration whenimplementingpolicyoptions,isthestrengtheningof intersectoralgovernanceatEuropeanlevel.Workingacross differentlevelswithMemberStatesischallenging.Butjust likeintheMemberStates,manyimportantpoliciesare outsidetheremitofDGSANTE,suchasthedirectiveon themutualrecognitionofprofessionalqualifications,which iswithDGGROWTHandworkingconditionswhichisthe responsibilityofDGEmployment.Ofgrowingimportance istheinfluenceoftheEuropeanSemesterwhich,in thecontextoffiscalgovernance,issuescountryspecific recommendations(CSR)includingonhealthcareandthe healthworkforce. Finally,whenchoosingamongpolicyoptions,afurther improvementofthedatasituationwouldbeofgreathelp. WHO,OECDandEUROSTAThaveincludedforthefirsttime in2014/2015intheirjointdatacollectionapartonhealth workforcemigration,includingdataonstockandflows offoreign-traineddoctorsandnurses.16Itwillbeofgreat importancethatthesedataaremadepubliclyavailablein atimelymannerandthattheinternationalagencieswork closelywithexpertsandMemberStatesinhelpingtoclose datagapsandimprovingthedataqualityandcomparability. 6. CONCLUSIONS Thisbriefanalysestheimpactoffreemobilityofhealth professionalsfordestinationcountries,sourcecountriesand theEUasawhole,andpresentsthepolicytoolsdecision- makerscanusetomitigatethenegativeandencouragethe positiveeffectsofmobility.Indoingso,theanalysisbuilds onanearlierbrief(Buchan,2008),andadaptsthescope ofanalysistofocusontheEU-specificcontextoffreedom ofmovementandtakeaccountoftheWHOGlobalCode ofPracticeontheInternationalRecruitmentofHealth Personneladoptedin2010. Theeffectsofhealthprofessionalmobilitydonotlend themselvestoeasyconclusions.Insourceanddestination countriesandatEUlevel,mobilityadvancesefficiency andequityinsomecontexts,butcreatesoraggravates inefficienciesandinequitiesinothers.Mobilitycanhelp balancethesupplyofanddemandforhealthworkforce, stimulateskillstransferandfillservicegaps,justasitmay contributetoworsenintra-EUdisparities,distractpolicy- makersfromtacklingunderlyinghealthworkforceissues,or bewastefuliftheskillsandqualificationsofincominghealth professionalsarenotusedtofullpotential. Healthprofessionalmobilityisnotinitself“good”or “bad”,buttargeted,well-conceivedpolicymeasurescan makeitworkbetter.InlinewiththeCode,whichcalls forstrengtheninghealthworkforcedevelopmentandfor 16 OECD,EUROSTAT,WHOJointDataCollectiononNon-Monetary HealthcareStatistics.JointQuestionnaire2015.http://www.oecd.org/ statistics/data-collection/Health%20Data%20-%20Guidelines%202.pdf “properlymanaged”migration,thebrieflistspolicyoptions whichaimatfosteringhealthworkforcesustainability andoptionswhichaimatmanagingmobility,butadds athirdlevel–EU-levelpolicyoptionsrespondingtothe consequencesandopportunitiesoffreemobility.Suchan approachrecognizesthecomplexityofmobilityandargues thatpolicyactionmustbecorrespondinglyclevertodeal withthemultiple,equivocal,overlappinganddynamic effectsofhealthprofessionalmobility.Thefirstsetofpolicy optionswillbeusefultoseektopreventsomemobilityby addressingtheshortcomingswhichleadhealthprofessionals tomigrate;thesecondsetofpolicyoptionsseekstogetthe bestoutofmobilityforsystemsandhealthprofessionals sinceEUflowsarelikelytoremainimportant;andthethird setofoptionsrecognizesthatintheEUfreemovement zone,whereindividualcountrieshavelessroomfor manoeuvre,collectivemeansandjointpolicyactionmight betheonlywaytofullyrespondtotherealitythatmobility createsalabourmarketwhereEUhealthprofessionals increasinglyformoneEUhealthworkforce. 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1. How can European health systems support investment in and the implementation of population health strategies? David McDaid, Michael Drummond, Marc Suhrcke 2. How can the impact of health technology assessments be enhanced? Corinna Sorenson, Michael Drummond, Finn Børlum Kristensen, Reinhard Busse 3. Where are the patients in decision-making about their own care? Angela Coulter, Suzanne Parsons, Janet Askham 4. How can the settings used to provide care to older people be balanced? Peter C. Coyte, Nick Goodwin, Audrey Laporte 5. When do vertical (stand-alone) programmes have a place in health systems? Rifat A. Atun, Sara Bennett, Antonio Duran 6. How can chronic disease management programmes operate across care settings and providers? Debbie Singh 7. How can the migration of health service professionals be managed so as to reduce any negative effects on supply? James Buchan 8. How can optimal skill mix be effectively implemented and why? Ivy Lynn Bourgeault, Ellen Kuhlmann, Elena Neiterman, Sirpa Wrede 9. Do lifelong learning and revalidation ensure that physicians are fit to practise? Sherry Merkur, Philipa Mladovsky, Elias Mossialos, Martin McKee 10. How can health systems respond to population ageing? Bernd Rechel, Yvonne Doyle, Emily Grundy, Martin McKee 11. How can European states design efficient, equitable and sustainable funding systems for long-term care for older people? José-Luis Fernández, Julien Forder, Birgit Trukeschitz, Martina Rokosová, David McDaid 12. How can gender equity be addressed through health systems? Sarah Payne 13. How can telehealth help in the provision of integrated care? Karl A. Stroetmann, Lutz Kubitschke, Simon Robinson, Veli Stroetmann, Kevin Cullen, David McDaid 14. How to create conditions for adapting physicians’ skills to new needs and lifelong learning Tanya Horsley, Jeremy Grimshaw, Craig Campbell 15. How to create an attractive and supportive working environment for health professionals Christiane Wiskow, Tit Albreht, Carlo de Pietro 16. How can knowledge brokering be better supported across European health systems? John N. Lavis, Govin Permanand, Cristina Catallo, BRIDGE Study Team 17. How can knowledge brokering be advanced in a country’s health system? John N. Lavis, Govin Permanand, Cristina Catallo, BRIDGE Study Team 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 and EU freedom of movement Irene A. Glinos, Matthias Wismar, James Buchan, Ivo Rakovac The European Observatory has an independent programme of policy briefs and summaries which are available here: http://www.euro.who.int/en/about-us/partners/ observatory/publications/policy-briefs-and-summaries Joint Policy Briefs World Health Organization Regional Office for Europe UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Tel.: +45 39 17 17 17 Fax: +45 39 17 18 18 E-mail: postmaster@euro.who.int web site: www.euro.who.int The European Observatory on Health Systems and Policies is a partnership that supports and promotes evidence-based health policy-making through comprehensive and rigorous analysis of health systems in the European Region. It brings together a wide range of policy-makers, academics and practitioners to analyse trends in health reform, drawing on experience from across Europe to illuminate policy issues. The Observatory’s products are available on its web site (http://www.healthobservatory.eu). The Division of Health Systems and Public Health of the WHO Regional Office for Europe supports the Member States in revitalizing their public health systems and transforming the delivery of care to better respond to the health challenges of the 21st century by: addressing human resource challenges, improving access to and quality of medicines, creating sustainable health financing arrangements and implementing effective governance tools for increased accountability. It assists Member States in answering critical questions. No 18 ISSN 1997-8073