Mobility of Health Professionals

Final Report Summary - MOHPROF (Mobility of Health Professionals)

Executive Summary:
Worldwide mobility of trained health professionals is a growing phenomenon, seriously impacting on the health care systems of receiving, transit and sending countries in terms of losses and gains of human resources. EU Member States are increasingly affected by these developments which can occur simultaneously within the same country and comprise effects of migration streams both within the EU mainly from the new Eastern member states to the old Western ones and between the EU and third countries (East European as well as further worldwide sending and destination countries). There is an urgent need to develop strategies and policies at European level to adequately address these issues and to deal with the causes and effects of migration on national health care systems in the long run. But at the same time, reliable and differentiated knowledge as a basis for the development of such approaches are hardly available or only very incomplete since a coherent monitoring-system of international mobility of health professionals is widely lacking.

Mobility of Health Professionals (MoHProf) was a global research project funded by the European Commission as a medium-scale collaborative project within the Seventh Framework Programme, over a three-year period starting from November 2008. Scientific institutes conducted comparable investigations and have been working together with worldwide active international organisations which have global links to research and policy development on international mobility of health workers. Lead partner was the Scientific Institute of the Medical Association of German Doctors (WIAD), Germany. A Research Steering Group supervised studies conducted by Regional Research Partners with the support of national consultants in 25 countries on all continents.

The general objective of MoHProf was to analyse current trends of mobility of health professionals, physicians and nurses in particular within the EU, from third countries to the EU and vice versa. Studies on macro and micro level took place with comparable methodological approaches in sending and destination countries within and outside the EU to determine quantitative and qualitative impacts of several types of mobility on the respective national health care systems. The essential methodological feature of MoHProf was a mainly qualitative approach which analysed quantities and qualities of migration flows. Beyond the analysis of existing statistics, the collection and analysis of comparable, specified and qualified data and information was conducted to determine in more detail general qualitative features of worldwide mobility of health workers as well as distinctive particularities.

The countries under investigation were: Austria, Bulgaria, France, Germany, Ireland, Lithuania, the Netherlands, Poland, Portugal, Romania, Sweden and the United Kingdom, Russia and Ukraine, Angola, Egypt, Ghana, India, Kenya, Morocco, South Africa and the Philippines, Australia, Canada and USA.

The policy dimension of the project comprised the development of recommendations on human resource policies in European and third countries. Thus, the project gathered evidence about basic questions and knowledge gaps relating to international migration of health workers, which implied analysis of migration flows, evaluation of policies addressing migration and the development of recommendations concerning these policies.

The final results of MoHProf are presented in different but related formats.
a) National Reports: detailed country specific reports integrating all macro and micro data
b) National Profiles: short version of the main outcomes at national level
c) Final Summary Report: provides a comparative and comprehensive summary of the project based on the national data and updated information on the global context to present the state of research achieved by MoHProf
d) Recommendations: general recommendations for Europe and third countries based on the research activities and input from stakeholders during a final international conference included in the summary report

All information and reports are available at the project webpage www.mohprof.eu.

Project Context and Objectives:
According to the WHO the world was lacking at least 4.2 million health workers in 2006. But the WHO calculated shortages on minimalist densities of 2.28 doctors, nurses and midwives combined per 1000 population, implying that actual shortages could be much bigger. This is reflected by prognoses for the United States as well as for the EU: both expect a shortage of a million health workers by 2020. Such data do not reflect the WHO calculations.

These shortages, with widely varying spread of health workers and health spending across the EU imply major imbalances resulting in a breeding ground for migratory wave of health workers. Thus the EU plays a role in the global process of migration, and - in this context - of migration of health workers. This has been enhanced by the process of expansion as of 2004, when ten, and in 2007 a further two, countries joined the EU15 and when its internal market gradually opened up for health workers from these EU12 to the EU15.

Shortages of health workers have widespread effects as they may deplete areas of much needed resources. As education and training of health workers is costly and time-consuming and as major parts of their education and training may be financed by their country of qualification, their migration, although a personal freedom, can also represent a loss of investment for the country in question. These contexts shape the relevance of the MoHProf project.

Mobility of Health Professionals (MoHProf) was a global research project funded by the European Commission as a medium-scale collaborative project within the Seventh Framework Programme, over a three-year period starting from November 2008. Scientific institutes conducted comparable investigations and have been working together with worldwide active international organisations which have global links to research and policy development on international mobility of health workers. Lead partner was the Scientific Institute of the Medical Association of German Doctors (WIAD), Germany. A Research Steering Group supervised studies conducted by Regional Research Partners with the support of national consultants in 25 countries on all continents.

Worldwide mobility of trained health professionals is a growing phenomenon, seriously impacting on the health care systems of receiving, transit and sending countries in terms of losses and gains of human resources. EU Member States are increasingly affected by these developments which can occur simultaneously within the same country and comprise effects of migration streams both within the EU mainly from the new Eastern member states to the old Western ones and between the EU and third countries (East European as well as further worldwide sending and destination countries).

In the light of increasing mobility rates, there is an urgent need to develop strategies and policies at European level to adequately address these issues and to deal with the causes and effects of migration on national health care systems in the long run. But at the same time, reliable and differentiated knowledge as a basis for the development of such approaches are hardly available or only very incomplete since a coherent monitoring-system of international mobility of health professionals is widely lacking. The MoHProf project contributes to improving this knowledge base and provides substantial background to facilitate European guidelines and policies on human resource planning in the health care sector.

WIAD was the coordinator and as well as regional research partner. The following research institutes have been regional partners and thus each responsible for the implementation of studies in several countries.

Scientific Institute of the Medical Association of German Doctors (WIAD), Germany
Centre of Migration Research of the Warsaw University (CMR), Poland
Medical University of Varna (MUV), Bulgaria
Institute of Health Policy and Development Studies of the University of the Philippines
Public Health Institute (PHI), USA
International Organization for Migration (IOM), Mission with Regional Functions South Africa

The research institutes closely worked together with the following professional organisations:
International Hospital Federation (IHF), France
International Organization for Migration (IOM) Brussels, Belgium
International Council of Nurses (ICN), Switzerland
World Medical Association (WMA), France
European Medical Association (EMA), Belgium
Global Health Workforce Alliance (GHWA), Switzerland

The general objective of MoHProf was to research and analyse current trends of mobility of health professionals, physicians and nurses in particular within the European Union, from third countries to the EU and vice versa. Studies took place with comparable methodological approaches in sending as well as destination countries within and outside the European Union, but the focus was on EU member states. Comparative studies on macro and micro level were conducted in a theoretically selected sample in different countries to determine quantitative as well as qualitative impacts of several types of mobility on the respective national health care systems.

The countries under investigation were: Austria, Bulgaria, France, Germany, Ireland, Lithuania, the Netherlands, Poland, Portugal, Romania, Sweden and the United Kingdom, Russia and Ukraine, Angola, Egypt, Ghana, India, Kenya, Morocco, South Africa and the Philippines, Australia, Canada and USA.

The essential methodological feature of MoHProf was a mainly qualitative approach which analysed quantities and qualities of migration flows. Beyond the analysis of existing statistics, the collection and analysis of comparable, specified and qualified data and information was conducted in order to determine in more detail general qualitative features of worldwide mobility of health workers as well as distinctive particularities. By means of qualitative interviews such analysis aims at differentiations according to professions and specific sub-groups and addresses also motives to migrate, circumstances and social contexts as well as push and pull or stick and stay factors.

While the general objective of the project was to investigate and analyse current trends in the mobility of health professionals to, from and within the EU, including return and circular migration, its policy dimension comprised the development of recommendations on human resource policies in European and third countries. Thus, the project aimed to gather evidence about basic questions and knowledge gaps relating to international migration of health workers, which implied analysis of migration flows, evaluation of policies addressing migration and the development of recommendations concerning these policies.

In order to analyse flows and stocks of health workers it was necessary to not only gather such data, but also to put them into the perspective of countrys specificities and health system, including the possible specific European context. Moreover the concept policies addressing migration was operationally defined widely as policies that can enhance or restrict migration.

To be able to analyse and determine the extent and relevance of migration flows, the health workforce and health system of a country in general had to be taken into consideration not only for a point in time but for a period of time. In this sense, the project aimed for a historical perspective as well, amongst others by acquiring time series data, including the international mobility of foreign and the respective native health professionals, where possible, specified according to different professions, sectors and departments. Data on general migration processes could furthermore help identify the particularities in the health system while demographical and epidemiological data concerning needs and planning of provision, together with additional information that indicate structures and processes in the health system contributed to the evaluation of migration flows. Factors like general effects on the health system (remaining staff, health care services, health outcomes) social impacts and dimensions and economic costs have been be analysed as well. In particular the impact of financial or non-financial incentives and policies were considered in order to evaluate their effectiveness in addressing mobility trends. Therefore, relevant economic, legal and political issues, including organisational, financial and regulatory aspects of health systems, were taken into account.

The final results of MoHProf are presented in different but related formats.
a) National Reports: detailed country specific reports integrating all macro and micro data of micro and macro research in each of the 25 countries
b) National Profiles: short version of the main outcomes at national level including respective national conclusions and recommendations
c) Final Summary Report: provides a comparative and comprehensive summary of the project based on the national macro and micro data as well as updated information on the global context to present the state of research achieved by MoHProf.
d) Recommendations: general recommendations for Europe and third countries based on the research activities and input from stakeholders during the final conference included in the MoHProf summary report.

All information and reports are available at the project webpage www.mohprof.eu.

Project Results:
1. Approaches

An innovative approach generated comparable, specified and qualified data gathered by mainly qualitative research. Thus, the essential methodological feature of MoHProf was a qualitative approach which looked for quantities of migration flows as well as detailed qualities. Studies on the nationwide macro level guided by a common analytical approach were followed by studies on the micro level on specific issues according to national peculiarities resulting from the macro studies in order to investigate general features of mobility of health professionals and its impact on national health care systems as well as a range of detailed differentiations and qualities.

Key stakeholders representing the relevant units, organisations, and sectors in the national health care systems provided existing quantitative data and statistics, but, above all, enabled the generation of new, qualitative data. In-depth interviews with representatives of these key stakeholders based on thematic guidelines allowed a triangulation of the data: their expertise on health professionals mobility and its impact on structures and processes of health care systems qualified quantitative findings and helped to explore what health professionals' mobility means for the health care systems and the persons and organisations involved.

While on the one hand research at micro level was guided in terms of content by national peculiarities which emerged during macro phase, on the other hand the perspectives of migrants and their employers were covered and included. In order to have a shared approach for that part of the micro studies, which should be comparable in all countries involved, guidelines with questions for qualitative interviews with migrants had been developed as well as the general structure for a sample of these migrants and of representatives of employers of migrants like, hospital human resource managers. The latter were to be interviewed with an adapted version of the interview guidelines for representatives of key stakeholders interviewed in the macro phase.

2. Overview on work performed

In November 2008 a kick-off meeting together with a public project launch took place in Brussels and a project website was established. Research guidelines including an analytical framework to ensure comparable reports were developed by the partners during a methodological-theoretical pilot phase and finally discussed during a second meeting in April 2009 in Bonn followed by training seminars for national consultants carried out by regional research partners.

The empirical focus of MoHProf comprised two phases to conduct field studies by national researchers in 25 countries. Field studies were carried out by national researchers in 2009 which gathered information and data on the macro level including available statistical data and qualitative interviews with key stakeholders at national level. The findings were incorporated in overviews on mobility of health professionals and its impact on national health care systems. The outcomes also comprised proposals for the subsequent micro studies according to national peculiarities and issues of particular interest regarding sectors, professions, regions or directions of migration streams.

Lack of comparable quantitative data and statistics on mobility of health professionals turned out to be a major problem in many countries. A great heterogeneity of data available concerning variables, indicators and categories as well as ways and time points or periods of data collection causes serious difficulties in terms of comparability. Assumptions on international migration streams and national migration balances are difficult and limited. On the other hand, the very different situations in single countries enabled to come to substantial and particular questions for micro research. This approach was appropriate for MoHProf as a mainly qualitative project, where subsequent steps had to be developed and decided upon in the on-going research process on the base of the precedent findings. Thus, research on macro and micro level were stronger related to each other.

At the end of April 2010, the third meeting of the research steering group took place in Brussels. First results on macro research as well as proposals and concepts for the forthcoming studies were presented and discussed. Suggestions for research on the micro level comprised a wide range of issues according to national particularities. The further proceeding concerning the following field studies carried out by the national researchers at micro level were agreed, including national specific questions as well as common issues.

Subsequent to the meeting of the project partners, a policy-round-table took place with representatives of different Directorates General of the European Commission, national and supra-regional professionals associations and interest groups, the World Health Organization and national health authorities participating. Objective of the round-table discussions was to present the results of the first research phase and to discuss those with the participants on the one hand and to identify basing on the macro research priorities for the second research phase at micro level on the other hand.

The research steering group decided to conduct investigations according to national particularities as well as include qualitative interviews with migrants and employers as common approaches. In order to have a shared approach for that part of the micro studies, which should be comparable in all countries involved, guidelines with questions for migrants had been developed by WIAD as well as a general structure of a sample for these migrants and of representatives of employers of migrants, which have then been be interviewed with an adapted version of the interview guidelines for representatives of key stakeholders interviewed in the macro phase.

In 2010, data collection on the micro level the second phase of field studies was conducted in the partner countries by the national researchers according to national peculiarities as well as including qualitative interviews with migrants and employers as common approaches. Until spring 2011 at the time of the fourth meeting of the project steering group in May 2011 in Brussels a high heterogeneity of the available outcomes of the project, i.e. the national reports, became obvious in terms of content as well as in terms of format as result of the open qualitative research process which characterises MoHProf. Thus, additional efforts to generate comparable outputs were needed.

The project steering group finally decided that in addition to the 25 national reports so called national profiles were developed for each partner country. Selected issues should be summarised according to a common scheme using the already existing data and successively adding more information where necessary and possible in parallel to the research at micro level. A draft for such a scheme had already been developed by WIAD and was refined in the following phase. Thus, in parallel to the process of finalising the integrated national reports including all macro and micro data, national profiles as short versions were provided comprising in a largely comparable form the main results on macro and micro level as well as respective national conclusions and recommendations deduced from these findings. This material was the basis on which the general recommendations for Europe and third countries have been formulated. Thus, the improvement of the presentation of macro and micro findings was done in parallel with the development of recommendations.

The national profiles were also the base of the MoHProf summary report comprising a comprehensive and comparative summary as well as conclusions and policy recommendations. This draft was provided by WIAD as input to be presented for further discussion at the final international conference Ensuring Tomorrow's Health: Workforce Planning and Mobility, Brussels, Husa President Park Hotel, 79 December 2011 (see http://hrh2011.belgium.iom.int/) of the project in December 2011. This conference addressed experts, stakeholders and policymakers and was the conjoint final event of MoHProf as well as two more projects funded by the EU and related in terms of content on international mobility of health workers: PROMeTHEUS and RN4CAST. The conference was not only planned as scientific exchange of the MoHProf partners together with other researchers and experts to discuss and finally develop the projects results, but also to disseminate its outcomes. It brought together experts and key institutions of the participating countries, researchers as well as persons working in the health system, and the participants of the project. In order to directly address policy and decision makers in the European Union, the conference took place in Brussels.

Inputs and contributions of these discussions in general and the common development of a final version of the policy recommendations for Europe and third countries were integrated in the MoHProf summary report during the following months after the conference. Moreover, updated information on the global context for more general insights concerning mobility of health professionals and its impact on national health care systems were included to present an up-to-date state of research achieved by MoHProf together with valuable input from stakeholders which WIAD had received when the draft version of the final recommendations was circulated within several relevant networks as follow-up to the conference.

In the following sections the main results of the project are summarised. One analytical tool applied by all researchers to generate comparable findings was a matrix of push, pull, stick and stay factors which influence migration. Since the European dimension is of major importance, the respective results are described more detailed. Subsequently, general conclusions and challenges are presented.

3. Summary of the main results of the MoHProf project

3.1 Factors contributing to mobility of health professionals

Factors in the different sending and receiving countries varied considerably, but the emerged issues give a good impression of the wide scope of aspects to be taken into account when analysing and managing migration flows of health professionals. (The following boxes summarise the most important factors contributing to migration, which have been identified in the 25 countries under investigation.)

Push factors

Personal and social factors
? General social-economic factors
? Living conditions
? Health threats
? Political situation and corruption
? Demographic and health related factors
? Geography, language, climate and proximity

Health work related push-factors
? Medical workers: (further) qualification and training
? Professional development / career prospects
? Bureaucracy
? Insufficient or lacking work options
? Remuneration
? Work load and working conditions
? Hierarchy
? Social status

Health system related issues
? (Lack of) Funding
? Health policy, organisation and management
? Infrastructure, equipment and supplies

Migration related policies and cultures
? General policies
? Migration as a (cultural) fact of life
? (Bilateral) agreements and recruitment
? Absent regulation
? Discrimination and unhappiness
? Migrants deskilling
? The push to return

Pull factors

Personal factors
? Adventure and experiences
? Personal safety
Social factors
? Options for the family
? Pre-existing networks and image
Society
? Economy
? Social security
? Quality of life and living conditions
? Gender equality
? Geography and proximity
? Political stability and rule of law
? Demography and health
? Professional life
? Health system demands
? Immigration policies

?
Stick factors

Personal factors
? Language
? Cultural differences
? Personal circumstances
? Personal convictions
? Social factors
? Transaction costs
Economy and living conditions
? Political stability
? Socio-demographic change
Professional issues
? Cost, amount and quality of education and training
? Labour markets aspects
? Remuneration
? Working conditions and work load
? Professional status
? Professional transaction costs
? Contractual obligations
Health system
? Financing and organizing the system
? Infrastructure
Migration policies
? Policies of receiving countries
? Policies of sending countries

Stay factors

Life style and personal assessments
Social aspects
? Family, friends and social networks
? Immigrant communities
Social and personal security
Status
Professional issues
? Opportunities in the labour market
? Incentives for migrant health workers

3.2 The European dimension

The MoHProf consortium spans 25 countries across four continents. This enables a wide perspective on mobility of health workers. With the EU context in mind, relevant questions are: what conclusions can we draw based on the MoHProf reports about the context of the EU in relation to health worker mobility. First of all this question relates to flows and stocks of health workers. Do the data give any information about flows to and from the EU, and what can we say about flows within the EU, before and after the 2004 and subsequent 2007 expansion? A second perspective relates to relevant regulations that aim to develop level playing fields within the EU. The two most relevant are the directive that aims to smooth internal mobility and, second, the one harmonising working time.

3.2.1 Coming to the EU or to a country?

Migrant health workers from non-EU countries do not seem to acknowledge, or even recognise, the EU in their plans. This is also reflected in the national reports of countries sending health workers to Europe, which tend not to mention the EU as a receiving unit; but tend to report receiving countries that are a Member State of the EU first and then may report the European context. Egypt reports the development of the EU as a factor prohibiting outflow of medical professionals to the West. This is supported by recent data showing that immigrants to the EU, with comparable skill sets, are disadvantaged as compared with natives with the same skill-sets. This outcome is in line with broader European policies, which focus on an internal market and free movement of skills within but not necessarily to the EU. Angola reports that the market in Europe is very restrictive but this could also be a reflection of the assessment of Angolan medical education being weak.

Some European receiving countries (e.g. France), explicitly mention the EU context, especially the 2004 and 2007 enlargement of the EU as a background for the increased inflow of health workers with foreign qualifications, especially from the EU2. Moreover, the French report points to medical doctors from former French colonies, working in French hospitals. Their education and language strongly resemble that of France, which leads them to migrate to France. However, as France is part of the EU and, due to their origin outside the EU, these migrants have major problems in getting their qualifications recognised. A consequence thereof is that these health workers work as associée instead of as full-blown medical doctor in French hospitals.

India has had a long-term relationship with the UK, however a combination of policies geared to more self-reliance and implementation of EU requirements have led to substantial negative effects for Indian medical students wishing to specialise in the UK. In April 2006, postgraduate doctors and dentists who had graduated from UK medical schools remained eligible for a category, formerly known as permit-free postgraduate training status, allowing them to complete their medical education, acquire full registration with the GMC and attain foundation programme competencies. However, all other doctors in training who would previously have been eligible for the postgraduate doctor category now required a work permit (now known as Tier 2) under the changed rules. Although this was later revoked for those currently studying, based on legitimate expectations, it is however implemented for new non EEA-students.

The Canadian report suggests that, after the 20042007 enlargement of the EU, countries like the UK and France are, more often than in the past, used as job-hopping areas by health professionals, before hopping further to Canada. At the same time, both Ireland and the UK tightened entry provisions for non-EU health workers, in line with EU Internal Market provisions. Typically, these outcomes are mirrored by some of the sending countries, such as Egypt, Morocco, and Ghana.

3.2.2 Out-migration of health workers from the EU

A relevant question is to what extent the EU loses qualified health workers. The MoHProf data provide some information about this question.

The main non-EU migrant destination countries are well known as immigrant countries, mostly English (or French) speaking countries: Australia, Canada and the US. According to recent OECD data, the ranking of countries of origin for migrants to these countries have remained fairly stable since the early 2000s. The importance of Chinese, Indian and Philippine immigrants in all countries is notable.

For Australia, the UK is a traditionally important country of origin of foreign-born health workers, together with Italy. While seeing increased numbers of non-EU nurses and midwives entering, Australia has installed specific regulations for smoothing recognition of EU-nurses, while it already has a history of enabling relatively smooth entry of health workers from the UK. One could expect, therefore, that immigration from the EU to Australia may increase.

For Canada the UK comes at the fifth place (with the US at the fourth place) of all entries and Canada reports high inflows of from EU countries, especially from France and the UK. In 2007, furthermore, 3% of its foreign registered nurses were Polish by background. Flows from other EU-countries may be present but are not substantial enough to reflect in the Canadian top ten source countries. Nevertheless, impact is clear. Moreover, 20% of all internationally educated health workers come from the EU, with the UK as by far the biggest supplier (12%). Even though quantitative data are lacking, Canada reports that the expansion of the Internal Market, with the expansion of the EU, led to more health workers using work experience in France, Ireland or the UK as a springboard for working in Canada. For African health workers, however, South African medical study serves as a similar springboard to Canada.

US data suggest that the EU is not a major supplier of internationally educated health professionals based on the proportion of foreign (trained) health professionals: only 8% of this stock has a EU background, as compared to 30% from Asia (13% from the Philippines) and 28% from Central America (22% from Mexico). Part of these latter health professionals will be American citizens trained abroad.

While some of these countries also experience outflows to Europe, these are generally smaller than the inflows. Thus, the EU, at the moment, other than from France and the UK, and seen from the perspective of the receiving country, is not losing substantial numbers of health workers to the major receiving countries. However, although data are poor, the impression is that overall, the EU is losing health workers.

3.2.3 Coming from a non-EU country: bypassing the EU?

In the national reports from sending countries, not much thought is given to the issue of going yes or no to the EU, or yes or no deliberately avoiding the EU. Only Morocco quotes a World Bank report, which clarifies that Europes migration gains are found in the lower qualified workers, while highly skilled workers from the Maghreb prefer the US and Canada. Philippine data suggest that Europe, other than the UK and Ireland, plays a very limited role in out-migration of Philippine health workers. For a number of reasons, including historical ties and educational similarity, as well as potential for earning, other areas of the world are much more in demand (especially Saudi Arabia, for temporary workers, and the US, for permanent migration). South African data suggest that the EU may be an interesting location for (advanced) medical studies and thus for temporary migration but that the US or Canada are preferred as destination country for establishment. While some of the EU members are forced to implement fierce measures to combat the financial markets, measures that also affect demand for health workers, the US health care labour market has, thus far, kept growing and expectations are that there may be a shortage of 100,000 physicians, one million nurses and 250,000 public health professionals by 2020.

Such data indicate that, in the global competition for qualified health workers, the EU may play only a limited role as a receiver of health workers, even if it were to deliberately formulate such policies, which could easily lead to processes not compliant with the WHO code. Moreover, the EU is, to some extent, losing health workers, a result of pulls from other countries, including Australia, Canada, and the US.

3.3 EU expansion: migration before and after 2004 and 2007

3.3.1 The European internal market

The European internal market enables mobility within the boundaries of the EU and applies to all EU members; and applied as of date of entry to new EU members, although the actual process was gradual. After the big bang (2004) and the small bang (2007), transition periods have been, and are, taken into account before workers from new member states gain free access to the labour markets of the other member states. This is done to prevent major shocks to labour markets in the previous member states, especially when wage and GDP per capita differences are large between previous and new members.

For health professionals, qualified in one of the professions doctor, dentist, nurse, midwife, or pharmacist, the process of automatic recognition applies according to Directive 2005/36/EC. This system, however, is not really automatic everywhere and may, depending on the country one wishes to enter, require endurance of the applicant due to administrative hassles including checking of personality and qualifications, checking the source registry etcetera. This process will, for instance, require certified copies of documentation; which may be burdensome to acquire. However, the implementation of the process varies widely across the EU. For instance, Austria reports that recognition of qualifications can be arranged within 30 minutes.

The gradual opening of the internal market also affected the options for health workers from these new member states to freely seek establishment (and recognition of their qualifications) in the other EU countries. For instance, when France opened up its market for Romania, it led to an inflow of Romanian doctors with the purpose of establishing themselves, while Germany counted 800 Romanian doctors in 2008. However, when looking at indicative data (not counting temporary flows), and although there has been some increase in establishment in EU15 countries from the EU12 as result of the gradual opening up of the internal market, data show, first, that a general inflow (not specified for health workers) was already taking place before EU-enlargement took place and, second, that inflow into the EU15 from non-EU27 countries is far more relevant.

This is also observed by Poland where, in the 1990s, emigrants had rather low qualifications, which according to the Polish report was due to institutional restrictions in the EU15 that directed/ forced/ limited Polish migrants into the informal labour market, which was no option for the highly skilled. After 2004, the proportion of university graduates among migrants increased quickly. Now 20% of migrants have graduated from university, compared to 14.3% of university graduates in the overall population of Poland

Within this broad picture nuances are required. Ireland, for example, experienced a doubling of its rate of foreign nationals as of 2003, especially from the EU10. However, when the crisis hit Ireland in 2008, as one of the first in the EU27, rates dropped to a 2010 level that is 20% lower than in 2008. A similar observation, although at a much lower rate, is possible about the UK. Ireland is the only country, however, where rates of foreign nationals from the EU10 were consequently above the 1%.

In most of the EU15, however, no fundamental changes could be observed over the years analysed, which also implies no major outflows: foreign residents stay in the receiving country, partly because opportunities in the countries of origin may also have deteriorated, or may have deteriorated further than in the receiving country. In the EU10, however, non-MoHProf country, Estonia experienced a continuous drop of non-EU27 nationals from 18% in 2003 to 15% in 2010; and Latvia, saw a similar drop from 22% of its population to 16%, while other rates hardly existed over the years analysed (European Commission, DG Employment and Social Affairs and Inclusion, 2012); declines that combine with the major economic downfall in these countries.

The gradual opening up of the internal market led to outflows from the EU12 to only six of the EU15: especially the UK and Germany, followed by Ireland, Italy, Spain (especially the construction sector) and Austria, with 75% of the U2 movers being in Italy and Spain. A substantial share of those in Italy can be considered to be working in its care system and also in the Austrian home-care system. A questions, therefore, is to what extent health worker migration within the EU is different from labour migration in general. Migrants from and to the EU15 are less than the resident population working in health or households, whereas EU10 recent movers are somewhat more than the resident population working in health or households. The data from the EU2 and from third-country nationals, however, are staggering. While of the total resident population in the EU2 0.4% is working in households, 17.5% of the recent movers is working in such situations. Third-country nationals are also very much over-represented in households as employers. This does suggest selective processes in immigration and work opportunities.

EU enlargement has clearly also led to flows from the EU12 to the EU15. Ireland, France, the UK and Germany are the main recipients of registered health workers with qualifications from the EU12, while Austria and non-MoHProf countries Italy, Spain, Portugal and MoHProf country Austria (and to a lesser extent Germany) are among the main recipient of non-registered health workers. Thus, it appears that flows from registered health workers from the EU10 were smaller than expected but are much bigger than expected from the EU2. Moreover flows from unregistered health workers have been substantial but may be underrepresented statistically due to relatively short working shifts abroad.

3.3.2 Recognition of qualifications of health workers in the EU/EEA

Directive 2005/36/EC harmonises qualifications to enable free movement of EU-trained health workers within the EU by a system of automatic recognition. The system applies to doctors, dentists, nurses, midwives and pharmacists. For health workers coming from the EU12 a system of acquired rights may apply by which a combination of pre-harmonisation qualification and years of experience may lead to recognition. For other health workers whose qualifications are from within the EU, but who are not regulated, a case by case approach applies as it does to non-EU doctors, dentists, nurses, midwives and pharmacists.

The Directive only discusses hours of training and not content, which leads to frustration in some countries, as, for instance, medical diplomas acquired in Romania are not considered to be equivalent to the French but are to be recognised in France. At the same time, non-EU qualifications that could be considered equivalent (those of former French colonies, where the education is often still based on the French system) do not lead to recognition and thus to registration until a mandatory examination has been passed successfully. Moreover, the non-EU health professionals in question often have better French language capabilities than their Eastern European (especially Romanian) recognised colleagues. As a consequence, and even though the mutual recognition framework exists, and even without the language issue, automatic recognition does not always imply that health workers qualified in one EU Member State can easily practice their profession at the same level in the other. This is also an issue for Ireland, which refuses Eastern European nurses because of a lack of language capabilities. Accessing the local labour market may require additional adjustments to the receiving countrys system, for instance, by means of a licence or proof of language capabilities.

Furthermore, given the need to match supply with demand, countries develop solutions primarily within their own specific health system, leading to new professions and differentiations across the EU. This may lead to national monopolies of health workers for which there is no European equivalent but that, in the case of national shortages, may endanger care, as inflow from abroad is hardly possible. The monopoly position leads these workers, in general, to have relatively good bargaining power within their country, as observed in the Netherlands and the UK, but also leads them to relative isolation.

The Directive leaves EU members free to deal with health workers who want to provide services in a receiving country on a temporary basis. It appears that this issue, according to the European MoHProf reports, does not play a significant role. Part of the reason may be that in some cases, such as nurses, temporary service provision takes the shape of not wanting full professional recognition and working below ones level, albeit for better pay than in the sending country.

Currently Directive 2005/36/EC is under review. The review aims for more pro-active communication between regulators about professionals unfit to practice. Some registrars communicate pro-actively while others are restricted to do so by national, privacy, legislation. The current proposals do not discuss the national governments requirement to empower their regulators to pro-actively communicate with one another. Moreover, such mechanisms will not solve the pending cases, health professionals under investigation of possible (professional) misconduct, of which a case is reported in the Dutch national profile. Finally, revisions will not solve the necessary delays involved between complaints, formal investigations, verdicts and their translation in the register and subsequent communication: and other holes will remain.

The internet-based Internal Market Instrument (IMI) enables regulators across the EU to communicate more easily with one another and verify qualifications and registration in ones own language. Use is voluntary and restricted to key questions in the process of mutual recognition. The system requires trust in sending registrar answers. One proposal, currently under discussion, is how to improve. One proposal is a European card, but advantages are not clear.

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3.3.3 Working time: impact in or on the medical workforce?

The Working Time Directive (93/104/EC), especially its amendment of 2000, harmonises the working time of employees, in this case salaried health workers, especially salaried doctors. Moreover, the issue applies especially to doctors in training. Full and rapid implementation was considered risky. It was, for instance, calculated that it would lead Germany to need to recruit between 15,000 and 27,000 doctors, the Netherlands 10,000 additional workers, and the UK 1,250 additional staff as well as 10,000 doctors. Malta would need to double its number of specialists at the highest level with an additional increase of a third more doctors in training. This led to a transition period. So a question is whether MoHProf data show an impact of the Directive. The Irish report suggests that full implementation of the Working Time Directive is in line with the previous calculations: it could lead to reduced hours and salaries for doctors, which could inspire them to seek earnings elsewhere; in which case the US could be a choice, with high remuneration and a community of (Irish background) physicians.

Some of the national profiles mention the Directive, while others refer to national legislation, probably based on the Directive. There is, however, no sudden shock in human resources (needs), which suggests gradual adaptation. For instance, while Germany reports no direct impact of the Directive, this may be also caused by the fact that German law has not yet fully implemented the Directive. Furthermore, it reports attempts to avoid appropriate recording of working hours of physicians in hospitals but, at the same time, a steady decline in working hours coinciding with early retirements and feminisation of the medical workforce; trends that all increase the need for physicians and make it hard to distinguish the Directives impact. Sweden, where most doctors are salaried, reports that the Directive led to reducing working hours of physicians, combining with several other trends that also led to an reductions of working hours of physicians, and a subsequent increased need for health workers, especially dentists. Dutch data report no consequence of its implementation, possibly also due to an already on-going discussion about reduction of working times, especially for medical graduates, and most recent documents suggest no substantial reduction in working hours for qualified doctors and specialists during the last ten years. French data do not explicitly mention the relevant European framework but, instead, report initiatives to reduce the number of hours in the working week, leading to a need for extra staff, which is required to work in extra stressful circumstances as there are shortages of nurses and a lack of paramedical staff in geriatrics. Moreover, France reports the generational issue relating to other work-life balances, leading to additional staffing needs. In a similar vein, Germany reports increased feminisation of the medical workforce combining with a small reduction in working hours.

Lithuania reports a new working-time law equalling weekly working hours to 38 hours although it is assumed that this, especially for the medical workforce, is mostly theoretical because Lithuanian physicians, on average, work at three different medical institutions. Imposed working time regulations may lead physicians, such as in Sweden and Lithuania, to find a second employer for work during the weekend, or may lead them to travel to a neighbouring country to do so. In other countries dual employment, for instance in both the public and private sector, is taken into account when deciding on the number of working hours. For instance, for doctors employed in Portugals NHS full-time working represents 35 hours per week but it can be topped up to 42 hours per week; but then no private practice is allowed. Due to perceived low incomes, many doctors also work in the private sector, outside the reach of the Directive. This is no exception. In many countries, within or outside the EU, there exists this duality of health professionals working both in the public and in the private sector. Such fundamental dualities interfere with the content and aim of the Working Time Directive. Finally, adjusted skill mixes may ameliorate the effects of the Directive.

The Polish report suggests that shortages of medical doctors may have increased as a consequence of the implementation of the Working Time Directive. At the same time, its implementation led to demands for extra salary for doctors working overtime (more than 48 hours per week), while it (as in other countries) may have encouraged both physicians and some nurses to change their employment into flexible civil contracts and subsequently work (harder) at several places at the same time. For nurses, according to the Irish report, the Directive implies more opportunities as it leads to more advanced roles.

A specific issue, however, reported by South Africa, is the effect of the European Working Time Directive on English junior doctors in comparison to those that went to South Africa for a year working as doctor in an Out of Programme Experience. Signals are that changes in UK regulations combined with the implementation of the Working Time Directive affect learning curves and opportunities for junior doctors negatively as it reduces their number of hands-on working hours.

The above leads to the conclusion that the implementation of the Working Time Directive seems to have led to creativity in attempts by both health systems and health professionals to avoid its implications. Moreover, the scope of the Working Time Directive appears not to be able to capture the complexities of health systems and health workers opportunities and needs. At the same time, when consequences are felt, they impact on junior doctors most.

3.4 Other issues

3.4.1 Transfer of social protection and posting of workers

Migration of health workers between neighbouring countries plays an important role, especially between countries (partly) sharing the same language. In part such migratory waves imply cross-border commuting (living on one country, working in the other). In these cases, transfer of social protection rights between member states becomes relevant. Whereas the Dutch report mentions this issue of cross-border commuting (on a daily basis), there are no discussions in the national reports about this portability theme. Thus, one may assume that this issue warrants little attention for health workers, that they found solutions that suit them or that the researchers did not receive signals about this issue.

3.4.2 Health workers: highly skilled migrants?

The EU, along with the rest of the world, wishes to attract highly skilled migrants. However, only Morocco mentions the relevant Directive on the conditions of admission of third-country nationals for the purposes of studies, exchange, training, research and voluntary service, allowing for filling short-term gaps and targeted immigration. Morocco also reports that, at least from the Maghreb countries, the EU is far more likely to receive lower-educated workers and people than highly skilled (medical) workers, possibly with the exception of France.

The Dutch used their scheme for recruiting highly skilled migrants when university hospitals recruited theatre assistants from India in 2009. Because theatre assistants in the Netherlands are not a legally regulated profession (such as nurse or doctor), and as universities are among the key users of highly skilled migrant schemes, the universities, using intermediaries, recruited 54 theatre assistants, which led to political debates about poaching.

Ireland, in 2007, introduced a green card scheme for health professionals from non-EU/EEA countries and stimulates non-EU/EEA students to apply for jobs in Ireland. Such developments, while in theory in line with the 2020 strategy, can however also be seen as clashing with what became the 2010 WHO Global Code of Practice on the International Recruitment of Health Personnel. One may expect such clashes to become more frequent when health workforce shortages, once more, increase.

3.4.3 Bypassing EU-legislation

Morocco also mentions bilateral agreements, such as with France and Tunisia which also include health workers, and which France and Morocco are likely to sign. Such agreements allow for bypassing the European principle that job-positions should be offered first to EU national or resident before it can be offered to third-country citizens.

4. Conclusions

4.1 An interplay of factors jointly leads to migration

International mobility of health workers is a complex phenomenon and both part of a wider international movement as well as of wider mobility of health workers. International mobility of health workers occurs by a combination of push- and pull factors and the perceived associated transaction costs and benefits, both at individual and collective level. Mitigating transnational health worker mobility requires:

reduction of push factors;
reduction of pull factors;
increase of transaction costs and decrease of transaction benefits.

Some of the major general push-factors are:
frail states and conflict;
human rights violations;
standards of living;
culture of out-migration.

Some of the major health system related push factors are:
corruption within the health system;
lack of options related to practice and professional and personal growth (especially for medical professionals);
lack of options to earn decent wages (for both medical and nursing professionals).

Some of the major general pull factors are:
thriving societies and economies;
political stability;
language likeness.

Some of the major health-system related pull factors are:
undersupply and growing demand;
developed health systems;
recognition and valuation of health and care workers;
earning opportunities.

Some transaction costs are:
personal: psychological, social and material costs of the entry in to a receiving countries health system;
health systems: requirement to adjust to incoming workers.

Some of the transaction benefits are:
personal: (perceived) better future professionally or economically, adventure, remittances;
health systems: more hands and heads to provide care, without most of the cost for training locally.

Available data suggest, however, that mobility of health workers follows different pathways than mobility in general, or that of lower-skilled labour mobility. Within this context, mobility of doctors follows different paths than mobility of nurses.

4.2 Health workers and other migrants: different paths and consequences

A major question is to what extent migration of health workers differs from migration of other professions. There are several related issues here: It remains unclear whether emigration or immigration processes for health professionals follow general pathways of migration, or that special routes and factors play a role. It does appear, however, that pathways are different for doctors than for nurses, where the former will travel for further qualification and establishment and the latter, especially in Europe, are more likely to travel for sometimes multiple subsequent periods of limited duration. Moreover, for different specialist doctors, different mobility patterns can appear.

The combined existence of public and private educational systems for health professionals or a combined existence of public and private health systems in one country can lead to imbalances where production for the market versus production for the public services can contribute to imbalances.

Emigration of health workers can deplete a countrys health resources because of loss of investment for the public good, loss of practitioners and thus negative impact on public health care delivery in the source country. Furthermore, migrating health workers, along with other often highly skilled professionals, require recognition of qualifications, more than other migrants, to be allowed to practice in the destination country.

4.3 National policies can have multiple international effects

Policy actions implemented in one country can have major effects in another one, thus the supranational impacts of workforce related methods applied at national or even regional level have to be taken into consideration.

Some policies may also have double faces and undesired effects. Several systems for fast-tracking recognition procedures exist, including the European internal market. Such systems aim to limit personal frustration for the migrant as well as increasing their productivity in the destination countrys health system. A rough estimate is that this would, on a global scale, limit the global shortage of health workers by hundreds of thousands of workers. However such policies, while attractive, can have as a side effect that the transaction costs for migration decrease. Thus, the net effect may be that migration is enhanced, leading to more outflow from countries with already substantial shortages. This was experienced by the newcomers in the EU, Romania and Bulgaria. Moreover, such policies can also enhance global competition between domestic and foreign workers. Such policies can also affect patient safety as language and culture may affect health provision in receiving countries, while shortages enhanced by or due to emigration affect patient safety in source countries. Thus the development of workforce-management policies and strategies that are connected to mobility should take such potential side-effects into account.

Specific attention for health workers is required because more often than not, they are trained by a public system (or trained with at least partly public funding) and are serving peoples health.

4.4 Uncertain future of health worker mobility

An overall outcome of the project is that the differences between some of the sending countries involved in this project, and countries that have been called receiving countries, whatever the indicator applied, are big and very consistent over time. This suggests that even without any programme targeting for active recruitment of foreign health workers, the combined push from the source countries as well as the pull from receiving countries, such as, quality of life and opportunities for health workers, will ceteris paribus lead to continuing flows. Even when, on some indicators, some harmonisation takes place, the overall picture is one of remaining very big differences, which are likely to continue to influence flows. Currently, however, pulls are shrinking, due to the effects of the subsequent economic crises, to an extent that some previously receiving countries are now rapidly changing into sending countries.

Ageing health workforces, however, point to a lack of green inflow and thus to potentially lacking strategies in preparing for this upcoming massive replacement need, even with gradually growing workforce sizes. However, efforts will need to expand as there are signs that, especially in Western countries, younger generations of medical and nursing professionals tend to desire different work-life balances as compared to that of older workers. Not accommodating these and other trends by means of strategic thinking and planning may well lead to increasing global competition for scarce medical resources and is, thus, likely to increase the tendency to migrate of medical students as well as qualified doctors and even specialised doctors, especially when countries under economic pressures cut back on education of health workers, thus creating future shortages. As the examples of the US and the Ukraine clarify, such trends are also likely to reinforce maldistribution across health professions as students will seek professions where earnings are highest instead of where need is highest. This can lead to a health workforces not geared to the needs in society, such as in Angola.

The ageing of the health workforce is seen both in Europe, as well as in countries like Canada, Japan, and the US. In this context and given the sheer size of the medical workforce, its ageing medical workforce presents a major challenge not only to the US, but to the EU, and to the world. The US is a major receiving country of health workers and data suggest that ceteris paribus the demand for medical workers is likely to soar. Recent measures in the US to improve the pipeline of education and training of health workers may not be able to meet the required replacements and growth, which is enhanced by the dynamics related to the rapid increase there of the cost of medical tuition, which is likely to translate in further maldistribution across regions and across professions. Moreover, it remains an open question if the improvements prove financially sustainable. In the UK signs are visible that inflow in nursing education, for instance, is falling due to cutbacks, leading to expected future higher foreign recruitments. For these reasons, it is more than likely that, as long as it is economically feasible, the US will continue to recruit high numbers of health workers from abroad. And given the relevance of the WHO code, this may well lead to outflows from the EU. Within the EU, flows, although currently slowing down, may tend to become more diverse, not only East-West, but also South-North.

At the same time, data in this report suggest that, for most, circumstances have to be relatively dire before people consider out-migration, or that opportunities abroad are such that temptation cannot be resisted. In some countries, despite shares of health workers intending to move abroad, some will stick to their own country.

4.5 Conclusions relating (also) to the European context

The study also allows for a number of conclusions relating to the European context, and especially the EU context, of the project.
Health worker mobility in the EU takes place especially from EU12 (EU2) to some of the EU15; but for registered health workers different pathways apply than for non-registered health workers. Moreover, there are more opportunities for physicians than for nurses.
Health worker mobility to the EU takes place especially to the major prior colonial countries with linguistic and cultural connections with source countries.

EU enlargement did not lead to overall massive outflows of health professionals but in some of the EU12, and especially Bulgaria and Romania, it has led to critical shortages, in particular of medical doctors, thus endangering the sustainability of the respective health systems. In part the outflow was the result of poor and deteriorating circumstances in these countries.

Economy acts as a serious pull but it appears that the EU may, in general, be by-passed by third country nationals who prefer the US or Canada. This would also relate to the competition for scarce (specialist) education, although English language tuition enhances inflows.

With the expected shortages of health workers in the US, there may be an upsurge in active recruitment in EU member states. Recruitment agencies are already preparing further expansion of their activities. This may exacerbate existing shortages in the EU, while in some EU member states it may also ameliorate the negative effects occurring as a consequence of the economic crisis. At the same time, it is unlikely that the EU will be able to attract health workers from outside the EEA, as Directive 2005/36/EC restricts access of non-EEA health workers. Moreover, countries fully implementing the WHO code may restrict their opportunities. Both arrangements are to some extent in contrast to desires to recruit high-skilled migrants.

The Working Time Directive is most relevant for the medical workforce in Europe, especially for those doing internships and employed. The Directive led to creativity of both governments and stakeholders, leading to a limited impact, which mainly affects junior physicians. At the same time the scope of the Directive fails to deal with the complexities of especially medical health worker specificities. Dual employments, for instance, in public and private health care, or in different regions or even countries, or being employed and self-employed, all diminish the relevance of the Directive.

The EU internal market does not, as formal EU documentation suggests, function as a mechanism to distribute health workers to where they are most needed. Free movement of health workers leads them to seek better opportunities with sometimes personal and professional ethics colliding. This is the case both within and outside the EU. As such the Internal Market is counterproductive to an improving distribution of health workers across areas and countries.

Resource poor and rural or remote areas feel most consequences of the internal market for health workers. As these are also the areas where the ageing process progresses more swiftly due to outflow of youngsters, the needs in these areas are highest. This is even more the case as health workers in these areas are likely to be aged more than their urban colleagues and will retire without replacement. This natural outflow of health professionals, including not attracting young qualified health workers, can then contribute to the overall lack of available services and, thus, to further out-migration.

As a consequence, special efforts are required to develop and maintain cost-effective infrastructures, skill mixes and services in rural and remote areas.
While some health workers move abroad out of a desire, most health workers do not wish to move abroad and do so out of perceived necessity. While relevant wages to earn a living are important, other factors could be at least as important to retain health workers in the country. Among these other factors are improvements in health systems, including working conditions, context and management, all of which can support health workers in their professional functioning.

5. Challenges

The MoHProf project has identified a number of health system-related challenges that do not only apply to EU Member States:

Health care systems need to adapt their policies and services to an aging population and an aging health workforce, both resulting in increasing needs for human resources for health. With already expected shortages, demographic ageing is to peak around 2050, while potential recruitment reservoirs will shrink due to degreening and increased labour market participation of women. This suggests that shortages may well increase rapidly and are likely to soar beyond 2020, leading to increased international competition, especially, but not only, for medical doctors. Integrated efforts are, therefore, urgently required to not only reduce demand but also to better balance demand with supply of health and care workers.

Similarly, health workforce characteristics in the EU are changing including working hours, gender typologies, work-life balances and specificities of medical work across Europe, which requires adjustments in the health systems to cope.

Competition (between countries, regions, sectors, public and private employers) on the market for human resources for health is increasing and long-term local strategies are needed on a global market.
Moreover, countries populations are changing in character and composition, with migration of health workers being part of a wider picture of migration. This leads to other questions requiring attention, including health and care provision to migrants and to those foreign-born.

The current and on-going financial and economic crises are already impacting on countries capacities to develop and maintain their health systems and may have severe impact on volumes and allocation of and within health systems. These events are affecting health worker opportunities as well as migratory waves. In and by itself, value for money is an important topic for ever-growing health expenditures. However, with the crises in mind, it is urgently required to develop and implement strategies that substantially increase value for money in health and care.

Data and information on stock, flows and trends of health workers at national and EU level are limited, difficult to compare and currently insufficient for long-term strategic planning.

Source countries (inside and outside the EU) lose significant investments in health worker education, not only due to out-migration of health workers but also due to competition by other, partial, sectors within these countries. Such trends are as least as harmful as out-migration as they weaken health systems.

Currently there is a lack of strategic planning to address the above challenges at Member State level.

Even though sometimes there is an overall lack of attention on the health care sector, most attention is often paid to the plight of physician, while in many countries they have more opportunities than other health professionals to manage their own interests, amongst others by serving in dual systems. In such contexts, however, attention for nurses seems to be lacking.

Tightening immigration as a consequence of the economic downturn leads to fewer opportunities for health workers abroad. This may lead migrants to return but can lead to them not being welcome as in the country of origin resources may be thin and competition stiff.

The economic downturn is also likely to affect health workforces in low-income countries, amongst other things by the effects of currency volatility and policies by donors that may restrict funding for development aid.

Potential Impact:
Dissemination

The objective of the dissemination work package was to communicate outcomes and information to the project partners and to make it available for a wider public taking into account different target groups.

The following main dissemination activities have been carried out during the course of the project:

Development and ongoing update of the project web page www.mohprof.eu
Project kick off meeting, 13-14 November 2008, Brussels
Meeting of the research steering group 27-28 April 2009, Bonn
Meeting of the research steering group, 26-27 April 2010, Brussels
Meeting of the research steering group, 12-13 May 2012, Brussels
Round table with researcher, policy maker and key stakeholder, May 13, 2011, Brussels
International conference Ensuring Tomorrow's Health: Workforce Planning and Mobility, Brussels, 79 December 2011 (see http://hrh2011.belgium.iom.int/).
Publication and dissemination of MoHProf summary report (download, print version, open access book and CD ROM)
Publication and dissemination of National Profiles (online and CD ROM)
Publication and dissemination of National Reports (online)
Publication and dissemination of Recommendations (online and integrated part of the MoHProf summary report

Several further publications in peer reviewed journals of selected research results are currently under preparation. Furthermore, the MoHProf project and its outcomes have been presented at several national and international conferences and meetings. The following lists some of those; the complete list of events is attached to the final report:

WHO/Europe Ministerial Conference on Health Systems, 25-27 June 2008, Tallinn
Global Ministerial Forum on Research for Health, 16-20 November 2008, Bamako
EC working group on health workforce planning 2009-2012, Brussels
Northern Dimension Partnership in Public Health and social well-being, 2009 -2012, Northern Dimension Area
12th WORLD CONGRESS ON PUBLIC HEALTH; Panel on Managing the migration of public health professionals - Engaging with the Diaspora, 27 April -1 May 2009, Istanbul
12th European Health Forum Gastein, 30 September - 3 October 2009, Bad Hofgastein
European Health Workforce Working Group Meeting, 3 February 2010, Brussels
Workshop on HRH Be-cause health, May 2010, Brussels
Health Bridges Across The Bosphorus 3 (HBAB 3), 13 17 May 2010, Essen
OECD Workshop Monitoring Health Workforce Migration, 31 May 1 June 2010, Paris
Global Health Conference, June 2010, Brussels
Sub-regional Policy Dialogue Health professional mobility in the Baltic Sea region and neighboring countries, 1-2 December 2010, Vilnius
Second Global Forum on Human Resource for Health, 27-29 January 2011, Bangkok
Sub-regional Policy Dialogue Health professional mobility in Central and Eastern Europe, 5-6 April 2011, Budapest
International Dialogue on Migration (IDM) 2011 The Future of Migration: Building Capacities for Change, 12-13 September 2011, Geneva
14th European Health Forum Gastein, Migration and Health in the European Region, 7 October 2011, Bad Hofgastein
7th European Conference on Tropical Medicine & International Health, October 2011, Barcelona
Health Worker Migration Global Policy Advisory Council Meeting, Aspen Institute, 22 November 2011, Washington

A web site to disseminate information about the project was established by WIAD as planned in November 2008 including a public as well as a closed sector for the partners of MoHProf only. While the former was used to provide general information on mobility of health professionals and to publish and disseminate all reports, data and information, which have been developed under the umbrella of the project, the latter comprised mainly all relevant information like guidelines, materials, and templates for the partners who carried out the research activities. This webpage will remain online for at least five years following the completion of the project.

The kick off meeting as well as all meetings of the research steering group took place as planned. The third meeting of the members of the research steering group, which took place in April 2010 in Brussels, was combined with a round table with policy makers and key stakeholders. At this event key findings of the macro research as well as the issues of the following micro studies were presented to and discussed with a wider public, key stakeholders and policy makers and valuable input for the forthcoming research activities a micro level had been discussed.

Besides the fourth meeting of the project steering group on 12-13 May 2011 in Brussels, the most important dissemination event in the second project period was the final international conference of the project, which took place in Brussels on 7-9 December 2011: Ensuring Tomorrow's Health: Workforce Planning and Mobility, Brussels, Husa President Park Hotel, 79 December 2011 (see http://hrh2011.belgium.iom.int/).

This conference was not only planned as scientific exchange of the MoHProf partners together with other researchers and experts to discuss and refine the projects results, but also to disseminate its outcomes. Thus, it brought together experts and key institutions from each of the participating countries, researchers as well as experts working in the health system, all participants of the project and was organised as conjoint ending of MoHProf as well as two other projects funded by DG Research related in terms of content on international mobility of health workers: Health PROMeTHEUS and RN4CAST. In order to directly address policy and decision makers in the European Union, the conference took place in Brussels.

Additionally, WIAD and IOM continued contacts and exchange with related projects on mobility of health professionals, first of all Health PROMeTHEUS and RN4CAST. Furthermore, various dissemination activities on national and international level have been performed (for details see final report list of dissemination activities), in particular tasks related to preparation of the final conference.

The results of MoHProf research activities are presented in different but related formats:

a) National Reports: detailed country-specific reports integrating all macro and micro data in each of the 25 countries.
b) National Profiles: short versions of the main outcomes of macro and micro research at national level including respective national conclusions and recommendations.
c) MoHProf Summary Report: provides a comparative and comprehensive summary of the project based on the national macro and micro data as well as updated information on the global context to present the state of research achieved by MoHProf.
d) Recommendations: general recommendations for Europe and third countries based on the research activities and input from stakeholders during the final conference (included in the final summary report).

The MoHProf summary report provides a comparative and comprehensive summary of the project at large based on the national macro and micro data mainly from the national profiles but also with references to the national reports as well as updated information on the global context to present the state of research achieved by MoHProf. The final general recommendations for Europe and third countries on the basis of this summary, together with various additional inputs during and after the final conference, are also included in the report.

The MoHProf summary report together with the national profiles as well as all national reports all are publicly available on the MoHProf-website www.mohprof.eu for download. Furthermore, a printed version of the MoHProf summary report and a CD ROM have been produced, including all outputs available for a wider audience.

Impact

1. Background

The policy dimension of MoHProf comprises recommendations on human resource policies in Europe and relevant third countries for policy and decision makers on the basis of sound empirical research and data which were lacking so far. A key part of the policy recommendations was the development of conceptual frameworks for monitoring systems concerning the mobility of health professionals to generate valid and reliable information on the magnitude of migration streams. Considerations on further research on the base of the empirical research and its findings were also part of the recommendations. Differentiated knowledge on specific qualities enables effective and efficient policies that reflect the needs of receiving as well as sending countries. Meetings with policymakers the policy round table and the final international conference in particular served to gather input on what is of particular relevance in their view as well as to disseminate findings. Dissemination within the scientific community as well as the wider society, again related to the conference in particular, ensured and enlarged the impact and use of the project.

Since these recommendations are the most relevant outcome to be disseminated, first of all addressing European policy and decision makers, this part of the results is presented in the following sections.

The MoHProf recommendations were developed in close collaborationwith the MoHProf consortium and were discussed during a European conference in early December 2011. The draft recommendations were subsequently made available for comments on the project website.

As a result, the following recommendations are based on the evidence presented in the MoHProf summary report. These overall recommendations should be seen separately from the recommendations that have been made by each of the 25 country teams vis-à-vis their national analyses. The relevance of their recommendations, also available in the national profiles, is based upon their research and national outcomes. The recommendations here aim to focus on wider issues using the helicopter perspective.

2. Features and particularities of mobility of health workers

2.1 Fundamental need: self-sustainable health systems

There is a general need for countries to become, to a greater extent, self-sustainable in their health systems and human resources for health. Policies addressing self-sustainability and strategies need to be formulated and implemented in order to reduce unequal distribution of the health workforce around the globe.

This does not imply that either the migration of health workers per se or the freedom of individuals to move between countries should be restricted, but the mobility of health professionals across source and receiving countries should become mutually beneficial for both systems as well as for the migrants themselves through managed migration policies, meaningful human resource management policies at (sub-)country level, better information sharing through monitoring and tracking systems and further research, inter alia, into the effectiveness of human resources for health management strategies. These arguments are not always fully shared by actors within health systems, for a multitude of reasons. Thus, working towards sustainable health care within national health systems is a first and overarching challenge needs to be kept in mind by all actors.

2.2 Manage the rural/remoteurban split

In all countries included in the MoHProf project, there is a crucial distinction in health provision between urban areas and rural areas, with shortages appearing first in rural or remote areas. Whether in source or receiving countries, this is a shared experience. This implies that shortages in rural areas of receiving countries tend to exacerbate shortages in source countries and thus to aggravate already critical shortages in their remote areas. Many receiving countries tend to send their foreign health workers to the undesirable areas, sometimes with a promise of better opportunities later on. Thus, whatever approach or strategy is formulated to innovate in strategies addressing health services in source countries as well as receiving countries, innovation in rural and remote areas should be considered an absolute first priority.

2.3 General strategic planning at EU and country level

Encouraging Member States to articulate policy targets for self-sufficiency of their health workforce is vital to address human resources for health needs of the future. In the long term, countries should aim at self-sufficiency by producing their health workforce based on rational analysis, planning and forecasting of the demand and developments within their health systems, health workforces and regions.
For the time being, those countries that still rely on a foreign-trained workforce have agreed to abide by the WHO code for recruitment (WHO, 2010), apply appropriate strategies to integrate foreign trained health workers into the receiving workforce and receiving society and aim at faster tracking of acknowledgement of certificates. One such strategy could be the development of a EU-wide portal (linked to health workforce monitoring bodies) for comparing non-EU qualifications, enabling registrars to verify qualifications.

As health and care needs across the EU are changing, strategic rethinking of health and care systems is required to be able to meet changing demands, in particular in a post-crisis period. Such a rethink should include health and care literacy, widespread introduction and implementation of self-management tools and techniques, including ICT, new job-descriptions and responsibilities of health professionals and substantial support to both family caregivers and volunteers as well as to those unlicensed care workers that may be providing care on 24/7 basis.
EU Member States need to adjust education and training to the current and forthcoming health care labour-market needs and this means, for most of the countries, that they have to prepare for increasing their domestically trained health workers. Moreover this may require better retention strategies to increases in the share of graduates as opposed to inflow into education,. The latter may be required because in many countries the working-age population is likely to shrink as a share of total population, implying that competition between sectors may also increase. In particular, potential nurses and auxiliaries may find themselves in positions where other options become more attractive and easily available.

2.4 Monitoring and managing health workforces

Since there is an urgent need to improve the monitoring (as prerequisite for informed management of migration flows of health workers) it is recommended that a centralised EU-wide data and information collection system be established. This coincides inter alia with the conclusions of the Green Paper on the European Workforce for Health, the Council Conclusions on investing in Europes health workforce of tomorrow (Council of the EU, 7 December 2010) and an OECD/WHO communication (OECD and WHO, 2010).

This recommendation has already been expressed for a long time by researchers and policy makers at national and international level but the fact that efforts towards improvements and harmonisation of data and information to support decision making about workforce planning are developing, but slowly, leads to the conclusion that there is a need for stronger support and coordination at EU level and for further investments in monitoring and management of mobility of health workers to, from and within Europe, where (under an EU umbrella) health workforce planning can be supported by information on actual current and future needs, which requires reliable data and information. Among other things this will require the following tasks:

a. Develop common key indicators on stocks, flows and trends in collaboration with other international bodies that are involved in monitoring the migration of health professionals.

b. Increase compatibility of definitions of health professionals, migrants, migratory processes, etc., in order to increase the comparability of data and information.

c. Set up guidelines for data and information collection at national level.

d. Collect, analyse and report clear and specific quantitative data to be complemented with qualitative information on the following.
Stock of health professionals according to profession, specialisation (differentiating between nationality, country of birth, country of original health professional training and country of additional health professional training)
Flows of health workers to, within and out of the EU, short term/long term migration.
Internal flows including mobility between subsectors of the health system as well as to other sectors.
Different types of mobility like short-, mid- and long-term temporary, circular and return migration, weekend shifts abroad, dual employment etc.)

e. Collect, analyse and report information about health professional education and training and compare education/ training and demand in order to adjust education and training to the current and forthcoming labour-market needs.

f. Improve dialogue, data quality and sharing of information (in particular registration bodies) between source and receiving countries.

g. Facilitate data and information exchange and dissemination and build up links with other source and receiving counties outside the EU.

h. Develop policy options and recommendations for action at global, EU, country and regional level.

i. Publish and disseminate examples of good practice in health professionals workforce policy, strategies and planning.

j. Analyse the effectiveness of specific workforce management strategies.

k. Develop and adapt (existing) common guidelines for recognition of licenses from non-EU Member states, facilitate recognition of licenses and establish training-equivalency recognition.

l. Contribute to the development of strategic plans to address the health-worker shortages in the EU member states.

m. Formulate priorities for further research into the mobility of health workers and health workforce management.

2.5 Assist countries to build and maintain sustainable health systems and strengthen international cooperation

One of the key outcomes of the project is that free movement of health workers within countries, the EU and the globe, is likely to deplete under-resourced areas of its health workers and coincides with, and may in fact stimulate, wider flows of health workers to urban areas. Moreover, as the pattern is worldwide, it is also clear that no easy solutions are available, even though some countries put in efforts to address the issue, amongst others by stimulating immigrating health workers exactly to these areas where domestic health workers do not wish to practice.

This leads to challenges relating to health workforce management that need to be reflected in wider European policies. Among these are Commission policy areas such as those of Development and Cooperation, Employment, Social Affairs and Inclusion, Enterprise and Industry, Health and Consumers, Internal Market and Services as well as Education and Culture, and Economic and Financial Affairs. Preferably a horizontal approach by and between these and other EU institutions is required to achieve the goals mentioned.

The importance of international cooperation to address the global shortage of health workers should in particular be reflected and incorporated in the EU development and cooperation strategic planning. DG Development and Cooperation (EuropeAid) has a clear case of reducing push factors by supporting health systems in low- and middle-income countries. Financial and policy assistance for global health workforce capacity development need to be taken into account when agreement with low- and middle-income countries are negotiated.

The EU, and in particular the main destination countries of non-EU trained health workers, should invest in strengthening health systems and health care strategies in source countries. These investments should focus primarily on innovative workforce approaches, health workforce training, retention policies, health systems and information improvements and address health care needs in rural areas. Such approaches may be even more required now resources are thin.

Where international cooperation is required to reduce general global pushes for health worker migration, concerted actions are needed, well beyond the scope of the management of human resources for health. Issues relate to supporting frail states, defending human rights of health professionals and their personal health, as well as the fight against corruption in health systems.

2.6 Other suggested strategies at EU level

EU member states need to learn from each others experiences and those gained in third countries in building and maintaining sustainable health systems and related workforces. OECD work, for example, is of great value. However, the EU has a wide array of instruments available to enhance such exchange of knowledge and experiences, which can be used beyond mere data gathering and monitoring. For instance EU funding, including that related to the Open Method of Co-ordination could assist in knowledge development and exchange on research, stakeholder and (sub-national) government level. Moreover, instruments such as Twinning and TAIEX have been and are used to assist acceding states and neighbourhood countries to implement and discuss consequences of, amongst other things, EU-policies. These instruments could also be used for a wider exchange and development of knowledge. Similarly EU educational funds such as Erasmus could be specifically used for wider knowledge development and exchange on this issue.

2.6.1 Learning by doing: knowledge development and exchange
Overall, it is urgently required for the EU to stimulate, facilitate, evaluate and endorse (cost and quality) effective workforce management strategies related to its Member States. This would require to stimulate, identify, publish and disseminate examples of good practice and cost-effectiveness in health professionals workforce policy, strategies and planning including health workforce management. Such examples could include issues such as:
innovative use of recruitment pools and re-recruiting;
professional education and profiles, (continuing) professional training;
bridging the gap between education and health employment
improving productivity with at least the same quality of health care delivery
innovation on the job, in the job and between the jobs including adjustment of skill mixes (medical extenders, nursing extenders)
retention strategies (including, policies adjusting workplace stress, age-related worker policies, worker-oriented management and patient-oriented organisation, E-health, task shifting, work-life balance)
integration of foreign-trained health workers

2.6.2 Other possible EU initiatives and concerns
Furthermore a number of initiatives should be taken at EU-level.
Regulate rights and duties of international recruiters of health worker to protect the health workers, and make employers accountable for not using regulated recruiters.
Work towards a EU knowledge base of third-country qualifications or certificates that could assist and could be approached by registrars from across the EU.
Develop common guidelines for recognition of licenses from non-EU countries, facilitate recognition of licenses and establish training equivalency recognition.
Analyse options, while protecting basic human rights of health professionals under investigation of misconduct, to stimulate governments to discuss the issue of pending cases or to reduce the length of time required between first investigation and verdict by a (professional) court and subsequent registry measures.
Stimulate member states to develop policies geared to prevent parallel grey markets in health care.
Investigate the competitiveness, as well as options to improve, in what is expected to be a more fiercely competitive global market for health workers.

2.7 Wider areas of research and innovation

Further analyses of short-, medium- and long-term factors behind, and consequences of, mobility of health professionals for the individual migrant, the social networks (for example, remittances and social costs), the health systems and economies of the source and receiving countries are urgently needed at national and global level as well as sound research into the effectiveness and consequences of health workforce management approaches.

2.7.1 Policies and health systems
Further research into the global market of health workers to increase better understanding of global developments beyond national strategies in order to better respond to and manage national and local human resources for health.
Examine implications of the financial crisis on health care systems, at regional, national and EU level, for workload and burden, career opportunities, wages and working conditions, management, system innovation etc.
Further analyse pull, push, stick and stay factors, focusing primarily on the stick factors, i.e. factors that effectively prevent migratory waves that harm health systems in source countries.
Identify potential areas of harm and benefits due to health worker migration including financial cost, social costs and returns.
Assess the impact of international agreements, codes of practice and other health workforce management strategies (such as, twinning, bilateral agreements etc.) on health worker migration and their effects on health systems.
Analyse different forms of migration of health workers on patient safety.
Analyse the issue of nurse migration from wider perspectives, including that of female migration in general and that of the grey care market at home including the impact of legislation on social home-care services and protection of the rights of migrants.
International recruitment is changing, with widely differing roles of recruitment agencies and increased use of the Internet as a tool to bring parties together. It is thought relevant to analyse the impact of the Internet as recruitment tool on (international) health workers and to develop good practice.

2.7.2 Migrants / individuals
Qualitative research into emigrating populations: profile, motives, career plans, intentions regarding temporary/permanent stay, relevance of family bonds and other social factors in relation to economic factors.
Channels of foreign-trained health workers entering the systems and, in particular, the role of recruitment agencies.
Tracking of health science graduates from education to employment and deployment, including those receiving bursaries (from destination countries).
Analysis of experiences (expectations and reality, job satisfaction, career, etc.) of emigrated health workers from different types of source countries in terms of integration or discrimination in different types of receiving countries in term of policies (migration, integration, health system, insurances, job satisfaction, career development etc.)
Further analysis of the relative value of each of the pushes, pulls, sticks and stays, both related to internal, inter-sectoral and international mobility of health workers including return migration.
Further analyse cases of migrant health workers ending up in receiving countries in (a) different sectors (b) the same sectors but lower-qualified jobs or (c) illegal labour arrangements.

List of Websites:
www.mohprof.eu

Dr. Caren Weilandt
WIAD
Scientific Institute of the Medical Association of German Doctors
Ubierstraße 78
53173 Bonn
Germany
caren.weilandt@wiad.de
wiad@wiad.de
tel +49 228 8104 172

Final Report Summary - MOHPROF (Mobility of Health Professionals)

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