Skip to main content

HEALTH PROfessional Mobility in THe European Union Study

Final Report Summary - HEALTH PROMETHEUS (Health professional mobility in the European Union study)

Executive Summary:
The increasing shortages of health professionals have a significant impact on the organisation and quality of health care delivery. Although these shortages affect some regions, hospitals or health professions more than others, this is an issue of importance for the health systems of every Member State across the European Union.
HEALTH PROMeTHEUS contributes to tackling challenges related to health professional shortages and mobility by filling a substantial part of the knowledge gap on the magnitude and impacts of health professionals moving to other countries. The study provides fresh insights with quantitative as well qualitative data analyses and research on trends and policies, which aim to manage migration organizationally, nationally and internationally.

During the first half of the projectß??s lifetime the cornerstones of HEALTH PROMeTHEUS were delivered. Most importantly this included maps on the magnitude of health professional mobility and a review of the dataß??s quality which provided a unique data set and comprehensive analyses of both data sources and the data itself. It also included the delivery of 17 colourful and accessible country case studies which give insights in the reasons for and impacts of health mobility while also bringing health professional mobility in perspective of wider health system changes. These findings have been published in the book "Health Professional Mobility and Health Systems: Evidence from 17 European Countriesß??, which also included a topical analysis of the country case studies and state-of-the-art overview of trends and processes.

The study also focussed on the analyses of individualsß?? motivation, stakeholdersß?? instruments and future scenarios. Evidence concerning health professionalsß?? personal motivations around migration was created through an online survey and focus groups set-up in three countries. The results deliver valuable insights in the behaviour and motivations of individuals. International policy responses to health professional mobility, including the WHO global code of practice on the international recruitment of health personnel and the impact of Directive 2005/36/EC on the recognition of professional qualifications were assessed and resulted in an overview of policy responses, including notions on implementation and effectiveness. Also, effective in-country responses were studied including national policies as well as managerial innovations. The role of different actors in the system including recruitment agencies, workforce planners and health workers themselves were identified and elaborated.
Project Context and Objectives:
Introduction: impact of health professionals on EU Member Statesß?? health systems
People have always moved to, from and within Europe for work and for a range of other reasons. Health professionals are no different. Indeed some of the earliest health care providers were itinerant barber surgeons treating as they travelled. In recent years health workforce issues have gained increasing attention from EU policy makers, resulting in major research projects, Council Conclusions and plans for a Joint Action on Workforce Planning since 2007. This attention derives from the recognition that sustainable and accessible healthcare services substantially depend on their workforce, both in terms of availability and quality. With shortages of health professionals projected by the European Commission to reach nearly one million in the EU by 2020, gaps in the health workforce are expected to have a significant impact on the future organization and quality of health care delivery. Although these shortages affect some regions, hospitals or health professions more than others, this is an issue of importance for the health systems of every Member State across the European Union.

HEALTH PROMeTHEUS was developed around the belief that health care professionals are absolutely key to health systems and service delivery as health care is a highly labor intensive and personal. Health care professionals include a mix of skilled medical and paramedical personnel operating in a range of settings to deliver "qualified health care". They are central to all aspects of delivery from organizing services, to creating resources, to ensuring financial sustainability and good governance. The impact of health workforce on costs of care, health outcomes, and impact on access, equity and responsiveness of health systems were identified as well:

1) Costs: As much as 70% of recurrent health care expenditure is invested in staff. Salaries make up the single largest component of health sector budgets in all EU Member States. Even without the "production of personnel" (initial education) or the spending generated by clinical decision makers health professionals have a huge impact on health care expenditure.
2) Health outcomes: health services make a significant contribution to health. The availability, qualifications and performance of health sector staff all contribute to reductions in morbidity and mortality and to increasing healthy life expectancy.
3) Health system performance: Health professionals also make a major impact on the key health system performance dimensions of access, equity and responsiveness. Their availability to treat people and the way they treat them shape the experience of all those citizens and patients who come into contact with health services.

Objectives of the project: creating evidence & identifying policy and management options
Contextual and systemic changes have a range of consequences including professional mobility. Where new technologies create new demands, or when countries (for historical or political reasons) have trained insufficient staff, or when reforms mean jobs are cut and "staff surpluses" emerge it is often in the international, EU sphere that solutions are sought. The practice of recruiting health workers from other countries has been long established in some European countries. Recently though the world's richer countries seem ever less able to provide for their own needs.
As more countries have joined the European Union the perception is that intra EU migration by health professionals has increased. Although the data does have limitations, many health systems appear to rely increasingly on trained staff from elsewhere. The project has focused on the way the pressures outlined above translate into the movement of health professionals and the implications of mobility for health systems.

Since the magnitude of the mobility phenomenon was largely unknown (only limited case study evidence were available), delivery of better data and the quantification of intra and extra EU flows has been one of the core elements of the study. The project mapped factors which prompt or block mobility at the international, national, sub-national, institutional and individual levels and assess the implications of mobility for all of these. In particular:

1) International factors international impacts: Mobility is consistent with many of the aims of the EU. In the context of the Lisbon Agenda fully functional European labor markets are an asset, optimizing efficiency and market forces. Any impediment to the free movement of workers (including health professionals) is regarded as "dysfunctional" and secondary legislation to facilitate European Integration has given (or will give) health professionals rights to move across borders. Efforts to standardize training and ensure mutual recognition of qualifications (Directive 2005/36/EC) have also removed blocks to mobility. The results of these initiatives are still not clear but while mobility may be viewed as an end in itself there are real fears that progress on open markets cuts across the simultaneous commitment to the European Social Model. Quality and financial sustainability are key values and principles of a Social Europe and the mass movement of health professionals has the potential to seriously undermine the health systems of "exporting" countries and detract from the services their citizens can access.
Hence PROMeTHEUS considered the influence of EU harmonization on mobility and at the "ambiguity" of its affects in Member States while considering the effects of movement from third countries to Europe and the tensions between EU support for developing countries and recruitment policies which foster "brain drain". It included international responses including international codes for recruiting, and multilateral agreements and their contribution to managing mobility.
2) National and sub-national factors national and sub-national impacts: The pressures on health services have grown as technology develops and citizens' expectations rise in parallel with governments' demands for greater cost containment and efficiency. Similarly, changes in the wider social and economic environment; health policy reforms including workforce restructuring and changes in staffing levels and skill mix; patterns of underproduction of (certain cadres of) health professionals; uneven staff distribution (between urban and rural and richer and poorer districts); and the loss of qualified personnel to other sectors or other countries all increase the demands on health systems and their staff. Many of these act as push and pull factors for professional mobility.
In this complex context, mobility is seen both as a solution to shortages and as a threat to the planning and delivery of services. Superficially at least "destination" countries will tend to benefit while "source" countries may experience negative consequences, at least they bear the cost of training staff.
The project sought to address the combination of contextual and health system factors that prompt movement in and out of countries and which motivate or even impel governments (national or regional) to actively recruit abroad and to develop and employ instruments to retain professionals. It examined consequences for health systems including the costs (associated both with training staff who are "lost" and with helping "arrivals" adapt to a new system) equity of access to services and qualified staff (in and across countries) and responsiveness to patients (given possible language and cultural constraints). Country initiatives to tackle these phenomena including bilateral agreements, ethical recruitment codes, and compensation schemes, managed migration and training for export and consider their effectiveness as national responses to mobility have been reviewed as well.
3) Institutional factors ß?? institutional impacts: Health care providers and managers of organizations delivering health care in particular are profoundly affected by changing demands for services. Restructuring levels of care, rationalizing and harmonizing specialist services, interfacing more effectively with the community and allowing for shared care all call for human resource changes. In some countries organizations have little room for maneuver and work within clearly determined national or regional policy frameworks; in others the organization itself tackles issues of recruitment and retention with little support. In many cases managers are dealing with the consequences of undersupply and oversupply with staff leaving for other countries and with "foreign" staff coming in. This poses a range of challenges for planning and succession management, for recruitment and retention and for induction and training.
The project aimed to review the way institutions respond to these challenges, whether through adjusting staff levels or skill mix, substitution, delegation or innovation or through initiatives to create incentives, improve working conditions and generate development opportunities have an effect on staff retention. One of the objectives was to look specifically at managerial responses such as twinning, staff exchange, educational support and bilateral agreements while also assessing the impacts of professional mobility on institutions and on their staff and patients.
4) Individual factors and impacts: The dynamics of professional mobility and the positive and negative impacts on health systems have triggered a debate on why professionals move. Some may actively want to work in another country but for many moving will simply be a consequence of a malfunctioning domestic labor market. Understanding the reasons health professionals move depends on analyzing the drivers which affect individual decisions to seek employment in another county. These are best divided into push and pull factors.
The project's design included objectives that reflect on the factors that affect individual mobility and on the consequences for individuals, which are not always straightforward. For health professionals, cross-border mobility opens up opportunities and threats. Some may benefit others may face challenges of equality of opportunity in their destinations countries and find no easy way back into their source country career structures. Similarly patients may benefit from faster access to well trained staff or may experience lower quality care resulting from gaps in clinical or language skills or cultural mismatches.

Project Results:
1. Introduction and context of the debate
As labor markets become more interconnected, both globally and within the EU, health workforce policies and the movement of professionals between countries are increasingly under the spotlight resulting in increasing attention from EU policy makers. From 2007 onwards this led to major research projects, Council Conclusions and plans for a Joint Action on Workforce Planning. This attention derives from the recognition that sustainable and accessible healthcare services substantially depend on their workforce, both in terms of availability and quality. With shortages of health professionals projected by the European Commission to reach nearly one million in the EU by 2020, gaps in the health workforce are expected to have a significant impact on health care delivery. With upcoming challenges for Member States' health workforce resulting from the ageing population and health workforce, and the increasing effects of the expanding European Union's Internal Market the topic of health workforce rocketed up the policy agenda over the last eight years. Actual and projected shortages do and will affect all health systems of every Member State across the European Union, with some regions, hospitals or health professions experiencing shortages and skills mismatches more than others.

The scale of professional mobility, the range of occupational cadres involved, the numbers seeking work in other sectors, and the potential impact on health systems as professionals move are all causes for concern. Responding to these challenges is difficult, given gaps in datasets, lack of knowledge on factors that reduce or facilitate movement, and evidence gaps on the effects of mobility on services, staff and financial and health outcomes.
2. The magnitude of professional mobility and the identification of critical data gaps and limitations
In order to address the challenges of professional mobility it is necessary to understand the scale and nature of the movements taking place. The HEALTH PROMeTHEUS project therefore aimed to provide a better capture of available studies, routine data and grey literature so as to provide a map of the current situation for all EU countries. Furthermore the project's output includes a breakdown by different professional cadres and addresses health professionals from non-EU countries. As a result it is possible to signpost shortcomings in the data secured and to make recommendations to strengthen the accuracy and comparability of future data collection. This all resulted in a feasibility study on a sustainable European data collection network.

2.1 Direction and magnitude of health professional mobility
The data analysis reveals noticeable asymmetries between EU-12 and EU-15 countries. Flows are predominantly in one direction, from east to west with most destination countries in the EU-15. All European countries are subject to outflows. Most EU-15 countries show simultaneous inflows, unlike most EU-12 countries. Thus EU-15 countries have more possibilities to fill vacant positions with foreign health professionals.

In Europe mobility flows have been increasing since the major geopolitical changes that began in the late 1980s. The limited numbers of time series data available indicate fluctuating inflows ß?? increasing, decreasing or stable depending on the country. Increases in outflows are suggested in more countries. In 2008, with all new entrants to the health workforce the proportion of foreign inflows was particularly high for foreign medical doctors in the United Kingdom (42.6%), Belgium (25.3%) and Austria (13.5%); for foreign nurses in Italy (28%), the United Kingdom (14.7%) and Belgium (13.5%); and for foreign dentists in Austria (40.8%), the United Kingdom (33.7%), Belgium (19.3%) and Hungary (9.7%). In Finland, 43.2% of newly licensed dentists in the period from 2006 to 2008 were foreign trained. Much lower shares were reported in Poland (around 3% for foreign medical doctors and dentists) and in Hungary (4.7% for foreign medical doctors and 2.4% for foreign nurses). Data were not available for other countries.

Differences in flows may signal the persisting importance of geopolitical contexts and economic incentives. Lower income levels, working conditions and standards of living as well as unfinished health reforms in some EU-12 countries add to the perception of less promising perspectives (for more details, please see section 4). The lower inflows of foreign medical doctors and nurses as well as the lower level of reliance on foreign health professionals in the EU-12 reflect and reinforce the asymmetries between EU-12 and EU-15 Member States.

It is worth emphasizing that outflows from Central and Eastern Europe started well before the accession of the EU-12 countries, following the political transitions that took place in various parts of the region. For example, high numbers of health professionals in Germany's workforce stock in 2003 from Bosnia and Herzegovina, Croatia and Serbia point to decades of outflow from the former Yugoslav Republic. In some ways, it may still be too early to draw conclusions on the exact effects of enlargements and the effects of Directive 2005/36/EC on the recognition of professional qualifications. Less than 10 years have passed and the right to free movement acquired with EU membership continues to facilitate mobility. For the moment, mobility data show persisting differences between the EU-12 and the EU-15, albeit with variations within both areas. Eventually this is bound to lead to shortages in certain countries or regions.

Destination countries on the other hand are more likely to become reliant on the inflow of foreign workforce. The share of total new entrants to the system show how migrants contribute to replenishing the workforce. There is considerable diversity in the magnitude of mobility across countries as well as within countries for different health professions.
Significant reliance on foreign health professionals (in addition to high inflow numbers mentioned earlier) has been noted for the following countries. Foreign medical doctors amount to at least one in every ten medical doctors in Belgium, Portugal, Spain, Austria, Norway, Sweden, Switzerland, Slovenia, Ireland and the United Kingdom. Foreign-trained medical doctors comprised 36.8% of all medical doctors in the United Kingdom in 2008. Overall, reliance on foreign nurses seems less pronounced but does exceed 10% of the nursing workforce in Italy, the United Kingdom, Austria and Ireland. One in every two nurses in Ireland is foreign-trained. All other countries in the study show low around 5%) to negligible (<1%) reliance on the foreign health workforce.
It is important to note that intention-to-leave data are used as a proxy in the absence of data on actual outflows. However, these numbers tend to overestimate emigration. Studies in Romania and Estonia showed that actual departures were two to three times lower than outflow intentions. Peaks such as the one recorded in Estonia in 2004 may be explained by retrospective applications for diploma certification from health professionals who migrated before accession.
Overall, the EU enlargements have led to increasing flows between EU Member States but it is probably too soon to draw conclusions on the exact effects of enlargements. More recent data (2009 or 2010) from Estonia, Hungary and Romania point to a new surge in outflows, presumably related to the global economic downturn.

2.2 Data gaps
Insufficient availability of updated and comprehensive data on migration was reported in 13 of the 17 country case-studies (Belgium, France, Germany, Hungary, Italy, Lithuania, Poland, Romania, Serbia, Slovakia, Spain, Turkey, and United Kingdom). Decision makers and competent authorities do not know exactly who is entering and who is leaving their systems. Therefore it is hard to assess the implications for health workforce and health system performance.

There are several aspects to the issue of data limitations:
I. The absence of a proper definition of health professional mobility means that multiple indicators (including foreign trained, foreign born, foreign national) are used to capture mobility. Limitations in the validity of each indicator and their unsystematic use across Europe make it difficult to assess the scale and character of mobility. Countries such as Austria, Poland and Slovenia collect more than one indicator and show data values that differ significantly. With careful interpretation these variations can provide a richer picture of mobility but they also raise questions about the validity of comparisons between indicators. Moreover, the inaccuracy of general stock indicators (for example, on licensed/active or full-time/part-time health professionals) makes it difficult to assess how mobility contributes to the health workforce. Data sources are also not able to capture certain types of mobility that may be on the rise in the EU such as returning migrants, short-term mobility, weekend work and dual practice, commuting and training periods abroad.
II. Most countries find it very difficult to provide time-series data, thereby hampering the ability to understand mobility trends and monitor fluctuations. Changes in professional definitions, new collection methods and new data holders also led to discontinuity of data in EU-12 countries.
III. Data on nurses suffer from greater limitations and inaccuracies than data for medical doctors in most countries. Even where data are available the professions and qualifications included vary widely between countries.
IV. No country appears to have accurate outflow data. Intention-to-leave data are used to gauge emigration but, although an important signal, their validity is disputed. Health professionals may choose to leave without conformity certificates as they are not required by all employers. They may apply for certification retrospectively, or may apply but never leave. A study in Romania showed that only a third of medical doctors who requested certificates in 2007 actually emigrated; in Slovakia there is evidence that equivalence confirmations are severe underestimates of real outflows. Moreover, intention to leave may be susceptible to manipulation as health professionals can use requests for conformity certificates to pressurize governments and fuel political debate. Countries can address this information gap by searching the registries of destination countries but this remains a cumbersome and little used method of data collection. Such studies have been carried out in Lithuania, Germany and Belgium.

3. The impact of professional mobility on health systems
A central focus of the HEALTH PROMeTHEUS project has been to analyze the impacts of health professional mobility on the performance of health systems. Given the many expected challenges and opportunities concerning health professional mobility delivering evidence was the key focus. This also included the need for further examination of the distribution of effects between source and destination countries, by mapping the impacts that may affect health system performance indirectly through complex chains of causality. In conceptual terms this means that the project's output do not only include the assessment of visible direct impacts on health systems and services' performance, but also looked at the impact on the functions contributing to the objectives of a health system.

The perceived effects on shortages, training new generations of health professionals and financing sustainability have received much public attention in a number of EU Member States. In spite of intense debates, there is surprisingly little evidence on these subjects (no systematic reviews or studies). However this does not exclude the possibility that good practices exist. The country case studies carried out within the framework of the HEALTH PROMeTHEUS project addressed this gap by including some qualitative analysis based on expert interviews and authors' observations. As a result the case studies indicate how mobility contributes to the size, skill-mix and geographical distribution of the health workforce.

Cross-border movements of health professionals affect the size of the health workforces in source and destination countries, including the skill mix and distribution over the territory. These changes impact on systems and services ß?? the larger these movements the greater the likelihood of its impact on health systems. Further analysis was carried out by project partner WHO/European Observatory on Health Systems and Policies who analyzed the impact of health professional mobility in terms of four functions of health systems in order to identify whether mobility has repercussions for health systems and at what level. These four functions of the health system are (i) service delivery (contributes to goal achievement by providing individual and collective services, including prevention, health promotion, diagnostics and curative treatment), (ii) resource creation (provides the infrastructure including buildings and technologies and produces the staff necessary), (iii) financing (collects and pools money to purchase health services), and (iv) stewardship (contributes to health by planning, regulating and providing information and intelligence).

But before describing the impact of mobility on health systems and services it is important to note that these trends can be very difficult to capture. One reason is the time lag between noticing and measuring a phenomenon. Another is the difficulty of determining causal relationships; for example, how can a change in care delivery patterns be attributed to the inflows or outflows of health professionals? It may also take time before any effect trickles through and becomes visible. Moreover, impact likely goes unnoticed as few resources are dedicated to monitoring health professional mobility. Finally, when mobility is associated with expectations impacts may appear smaller if expected to be greater.

3.1 The impact of health workforce mobility on service delivery
Several case studies mention that outflows can worsen service delivery which matches the literature on staffing adequacy and patient safety and quality. Losses become a particular problem if they involve large numbers, rare skills or occur in already undersupplied areas. Slovakia lost a reported 3.243 health professionals between January 2005 and December 2006 but the real numbers are likely to be substantially higher. In Romania rural areas with the lowest coverage of medical doctors report some of the highest emigration rates among medical doctors and nurses. Impacts are not always related to the size of flows. Hungary, Estonia and Lithuania noted that the departure of even a few specialists can upset service provision. Certain specialties appear to be more vulnerable. In Poland, most vacant posts concern anesthetists, and emergency doctors and specialists show intention to leave. In Belgium, the emigration of child psychiatrists has been reported as problematic given important shortages in the profession.
It is also important to recognize the accumulating effect of mobility. For instance an annual outflow of 3% of total medical doctors may not appear to be significant but will leave a major mark on the size of the workforce when continuing over years. This implies that some impacts may take time to come into view.

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

High outflow undermines returns on investment and possibly the necessary skill-mix of the country. Training of foreign students affects the availability of training positions and these students are less likely to stay in a host country following graduation. Health workforce planning in Belgium is affected as inflows of Dutch and French students bypass the numerous clauses that applies in their countries to medical studies. There are similar concerns about the influx of Germans taking up medical student posts in Austria.
For destination countries, mobility can expand resources. The United Kingdom and Spain have benefited greatly from importing knowledge and skills. The former case study notes the double benefit gained as foreign recruitment helped to free up senior staff and allow them to expand training. However, if reliance on foreign workforce grows as long as domestic shortages worsen, health systems will become increasingly susceptible to the directions and intensity of flows, which remain hard to predict. Hence, domestic production of a health workforce seems a more sustainable (and responsible) approach to resource creation.

3.3 Stewardship
The stewardship function contributes to health through planning, regulation and the provision of information and intelligence. The effects of health professional mobility on decision-makers' ability to steer health systems are easily overlooked, however three interrelated aspects can be identified, concerning information, planning and regulation.

Firstly, there is a lack of information about which health professionals are leaving and which are entering the system. Without the capacity to track movements comprehensively, the ability of authorities to supervise (and react) is affected in a range of EU-15 and EU-12 countries. This situation is possibly worsened when considering the illegal or informal health workforce, which is not only invisible in official statistics but also constitutes crucial sources of care in countries such as Italy, Austria and Germany. As a result it is implied that governments lose sight of the services delivered outside the regulated frameworks in the home and elderly care sectors.
Secondly, the lack of evidence on mobility and its unpredictable nature further hamper the planning function of health systems as countries and their competent authorities do not have access to the necessary data. The planning function in combination with health workforce mobility is becoming increasingly more difficult due to the Directive 2005/36/EC as currently health professionals are not necessarily obliged to inform public authorities when entering or leaving a country.
Hence, regulation of the health workforce is becoming increasingly challenging (3). There is a lack of tools for policy makers in the EU Member States for limiting or regulating inflows and outflows between their own countries and other EU Member States.

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

There have been few reported impacts on the financing function of health systems, with the exception of the payment conditions for medical doctors. Regardless of the limited evidence, health professional mobility is bound to have important impacts on payments systems as demonstrated by incomeß??s prominence as both a motivational factor and a retention strategy.
In addition to the financial consequences of gaining or losing health professionals, there is also evidence that mobility can impact on salary levels. Spain has reported that foreign inflows helped to keep salaries at sustainable levels within a context of high demand for health services. On the other hand, the Lithuanian government and Polish independent health-care providers increased salaries in order to retain medical doctors. Such incentives raise questions about long-term sustainability and redistribution within the system.
Impacts are subtle in the sense that they are often indirect, hard to discern and non-immediate. They may be insignificant at country-level but substantial at regional or hospital level. As mentioned, the analysis of impacts is also hampered by the difficulty of establishing causal effects.

4. Personal factors that influence mobility; facilitating and mitigating factors
An essential piece of work delivered by the HEALTH PROMeTHEUS project is the study on personal factors that influence mobility. A series of focus groups and interviews in three countries, each with a different "mobility profile", resulted in essential knowledge on individualsß?? motivation to stay or leave an organisation, the sector or a country. Both "push and pull", and activating and facilitating factors are clear leads for policy and management interventions and therefore an important piece of the puzzle.
Activating and facilitating factors for migration have been mapped as well. From all focus groups it became clear that the presence of friends and/or family played a positive role in the decision to migrate. The German study also showed the high variation in professional positions nurses take up in their country of destination, not seldom in the informal care sector.
Mitigating factors for migration include bureaucracy (in particular in the case of non-EU migration) and paperwork, language issues, and personal relations that tie professionals to their home country. In turn some of these factors were mitigated through integration courses. Also some respondents mentioned that they left their initial position quite quickly to move to something better suiting their expertise and skills. For returning professionals integrating in another country appeared to be challenging.
Although findings of the focus groups differed for each country and showed variation between different professionals, some overall trends could be recognized. The differences in payment and salaries played a role in the motivation to work in another country. However this factor alone is not sufficient to explain the motivation of health workers. Motivations range from working environment related (poor working conditions, culture, insufficient resources, career opportunities and Continuous Professional Development), economic or political conditions (discrimination, low socio-economic conditions) to private or personal motivations including family and partnerships and simply the idea of "doing something else".
5. Identified good practice responses
In the preparation of the project it was recognized that a range of key actors and stakeholders, including governments, employers, professional associations and health managers, have already made a range of attempts to tackle challenges related to health professional mobility. During the lifetime of the project this scope was extended through the assessment of international policy responses and action within countries (national policies and managerial innovation). This resulted in a search for innovations applying financial incentives and remuneration; recruitment, retention and regulation policies; the role of education and training; and opportunities offered by sound health workforce management.

5.1 International policy responses on health professional mobility: (ethical) international recruitment
Recently many developed countries have been undertaking large-scale, targeted international recruitment efforts to address domestic shortages. These efforts can benefit health care professionals in terms of enhancing their professional experience and increase their quality of life. However concerns related to the impact these initiatives may have upon the health systems of source countries also need to be addressed. The outflow of skilled workers from developing countries is thought to be one cause of skills shortages in developing nations. The phenomenon has led to calls for protecting developing country health systems from losing their skilled health personnel.

International initiatives include action undertaken by the International Labour Organisation (ILO), the European Union (EU), and the World Health Organisation (WHO). The ILO launched a two year ß??Action Programme on The International Migration of Health Service Workers: The Supply Side for 2006/7ß? with the goal of presenting the ceding nationsß?? perspective on the management of health services migration that could be shared with other supplying countries. The EU has recognised its responsibility to protect the health personnel shortage in many non-EU countries through several initiatives. In December 2005, it adopted the ß??Strategy for Action on the Crisis in Human Resources for Health in Developing Countriesß?, followed by the ß??Programme for Action (PfA) to tackle the shortage of health workers in developing countries (2007 ß?? 2013)ß? in 2006. Furthermore, the common immigration policy presents approaches to avoid undermining development prospects of third countries by promoting circular migration, defined as when health personnel move to another country to obtain training or gain experience and then return to their home country with improved knowledge and skills instead.
The most recent development which received much attention is the adoption of the voluntary ß??WHO Global Code of Practice on the International Recruitment of Health Personnelß? which was unanimously passed in May 2010 at the 63rd World Health Assembly. The Code, applying to all health personnel and to all WHO Member States, aims to discourage countries from active recruitment in poor nations that face critical staff shortages. It also calls for recruiting countries to provide technical assistance, support, and training of health professionals in those countries, although there is no explicit mention of financial compensation. The Code builds on existing regional and bilateral agreements, memoranda of understanding and national and regional codes of practice, in addition to the collaborative work of many stakeholders, a public hearing and input from the WHO Executive Board. The Code is based on ten articles which outline a range of issues, including guiding principles (article 2), health workforce development and health systems sustainability (article 5) and implementation of the code (article 8). Although the code is voluntary, the WHO is tracking developments and report on the implementation of the code in 2015. The implementation of this Code is currently gaining more attention, in particular the implementation on organisational level.

Trends that came forward through analysis of the multitude of instruments promoting ethical recruitment of health personnel include: 1) pressures to not recruit from developing countries particularly those with health worker shortages, unless government-to-government bilateral agreements are negotiated; 2) the use of prescriptive country lists for non-recruitment; 3) promotion of improved employment rights and protections in order to retain their health personnel with governments facing health worker emigration. On the latter, governments can provide incentives for circular migration. As a result career pathways are determined and when a migrant health worker considers returning to his home country there are relevant posts available including a salary level that reflect the experience gained abroad.
Although there are several codes of ethical recruitment in place there are challenges facing whether these actually work in practice. Because these instruments are voluntary feasibility depends largely on the developed country adhering to the code. It is unlikely that incentives and sanctions will be provided for the consequences of adherence or non-adherence due to their voluntary nature.
To better facilitate implementation more information needs to be disseminated to the competent authorities on the desired aims of any code of practice. Support systems need to be put in place; specifically, this may entail explaining to health care managers the practical application of the code for their organisation. It is suggested that this can be achieved through additional written information or training. In addition, despite the continued interest in developing these instruments, research is lacking on the effectiveness of implementation.

5.2 National policy responses on health professional mobility
Countries use policy and managerial interventions to steer mobility or in order to respond to health workforce challenges resulting from mobility. Overall, there are substantial variations in the levels of activity concerning policy and managerial measures on mobility of health professionals. Depending on the specific health system and the workforce situation in the country, migration policies and measures are implemented at the national, regional and/or organisational level. While international recruitment remains largely a political and managerial response to workforce shortages in some countries, more recently moves towards self-sufficiency and ethical recruitment can be observed.

Different cross-border arrangements are used for simplifying procedures to facilitate the mobility of health professionals. The most widely used being bilateral agreements, followed by staff exchange and educational support. While bilateral agreements concluded on the national level have declined in importance, some countries do have special provisions in their migration legislation to facilitate the migration of highly skilled workers in general, including health professionals. At the same time in decentralized health care systems cross-border arrangements at the regional or organisational level become more prominent.
Moreover private recruitment agencies, national health services or private healthcare institutions actively recruit overseas. This contributes to the increase in mobility of health professionals. In addition, increasing use of the Internet has contributed to access to information about vacancies and possibilities for migration worldwide. Because much of the migration of health professionals is a part of a wider stream of international migrations of highly skilled people, it cannot be curbed in isolation.
International mobility of health professionals raises difficult questions about ethics and international equity, in particular when there are persistent net flows of staff from poorer to richer countries. Emigration of health professionals can exacerbate existing imbalances in health human resources, creating a need for special measures to ensure workforce retention. Retention policies seek to reduce the outflow of the health workforce by creating effective incentive systems, such as improving salaries and working conditions of health professionals. However the evidence on the effectiveness of these strategies and best practices are scarce. Measures facilitating outflow of migration, such as bilateral agreements, can be a temporary solution to an oversupply of health professionals, designed to diminish domestic unemployment. Furthermore, international migration can be a rapid and effective measure for policy makers to fill existing gaps in the health workforce. Cross-border arrangements at the national, regional or institutional level can be used to improve the management of international mobility of health workers, especially if these include clauses whereby a recipient country agrees to underwrite the costs of training additional staff; and/or recruit staff for a fixed period only, prior to their returning to the source country; and/or recruit surplus staff in source countries.

Appropriate workforce planning that takes into account the migration of health professionals plays a significant role in avoiding health workforce shortages and other imbalances. Growing interest in workforce planning and the application of sophisticated forecasting methods are observed in a few countries. Sharing information on workforce planning methods and future projections of workforce supply, demand and needs could help steer mobility of health professionals in mutually beneficial directions.

6. Understanding future challenges of professional mobility
The findings from the HEALTH PROMeTHEUS project provide the opportunity to build scenarios for future challenges of professional mobility. However it has not been the intention of this work package to implement horizon scanning on future developments or complicated predictions based on trends or econometrical models. However it does provide insights in current trends and how this might impact Member Statesß?? health workforce supply in the future, including possible courses for action. The work carried out also provides insights in the pace of change and the complexity and uncertainty around push, pull and other contextual factors.

Cornerstones of the scenarios are a range of mobility theories (sociological, macroeconomic, microeconomic, geographic theories and unifying perspectives), and theories on push and pull factors. Data is delivered through the findings of the PROMeTHEUS project, including the findings of meetings of national and international experts on the mobility of health professionals, who shared their predictions concerning this phenomenon. Furthermore, a literature review on migration scenarios was conducted including major reports such as "The future of international migration to OECD countriesß?? (OECD 2009), as well as surveys of migration intentions in the new EU Member States.
6.1 High mobility scenario
The high mobility scenario depicts intensified migration flows in line with a global competition for health professionals. A strong pull factor is the increased demand for health professionals in the destination countries caused by an ageing population and workforce. Some EU countries have failed to adapt their demand, health workforce planning systems and training capacities to the increased needs for health professionals, and nurses in particular. Changes in skills needs and role redesign have been decelerated in some countries for political and institutional reasons. Regional maldistribution is persistent in some countries and foreign trained health professionals are recruited to fill the gaps.

Changes in the economic situation of source countries are a key determinant of outflow of professionals. Unfavourable economic development and the consequences of a long-lasting financial crisis hamper economic convergence within the EU. Increased wages in source countries remain moderate because of the tight fiscal policy pursued by the EU Member States. Working conditions and access to modern technology in source and destination countries still vary substantially, further acting as a "push" factor for migration.
Regional disparities in the supply of health personnel in most source countries are exacerbated by the increased outflows of health professionals. Source countries have started to recruit from developing countries to counteract shortages in underserved regions. Recruitment of health professionals from non-EU countries increases on the whole. The WHO Global Code of Practice on the International Recruitment of Health Personnel is not implemented because of its non-binding nature. Managers and recruitment agencies in countries which experience severe shortages of health professionals continue to recruit personnel from developing countries.

6.2 Low mobility scenario
In the low mobility scenario, migration flows remain constant over the years. Demand for health professionals in the destination countries has increased due to an ageing population and an ageing workforce but EU Member States have employed more sophisticated health workforce planning systems and have been able to adapt their training capacities to the increased needs for health professionals, nurses in particular. Skills mix change and role redesign has taken place. Increased participation of elderly workers serves as an offset to the ageing and declining population.

The populations in most destination and source countries grow older but the burden of lifetime illness is compressed into a shorter period before the time of death, i.e. the age of onset of the first chronic infirmity is postponed (compression of morbidity). Focus on preventive medicine and healthy ageing diminishes the burden on the health care systems. E-health takes a prominent role in the management of healthcare.
Regional maldistribution in the EU countries has declined due to appropriate incentives for health professionals to work in rural and underserved areas and foreign trained health professionals are no longer recruited to fill the gaps.
Changes in the economic situation of the EU source countries as well as successful retention strategies (including wage increases and improvement of working conditions) restrict migration from the new to the old EU member states. After a long-lasting financial and economic crisis an economic revival takes place in the European region. Economic convergence takes place due to higher GDP growth rates in the new EU member states. Content of training for health professionals is increasingly harmonized within the EU, as are working conditions.

6.3 Moderate mobility scenario
In the moderate mobility scenario, migration flows increase over the years but only moderately. Demand for health professionals in the destination countries has increased due to an ageing population and an ageing workforce. EU Member States have employed more sophisticated health workforce planning systems and have made an effort to adapt their training capacities to the increased needs for health professionals, but not all countries have been able to fully counteract the existing shortages in the short term. Skills mix change and role redesign have taken place in most countries, but this has led to an increased demand and global competition for nurses and elderly workers.

The population in most destination but also source countries grows older (the share of Europeans aged 65 years and older has reached approximately 25 % by 2030) but the time period before death spent in bad health has remained constant (dynamic equilibrium). Chronic diseases which are typically more prevalent as longevity increases, such as cancer, diabetes, heart disease, respiratory conditions, stroke, dementia, and depression, still account for a huge burden on the health care system.
Regional maldistribution in the EU countries still persists despite efforts to create incentives for health professionals to work in rural and underserved areas and foreign trained health professionals are recruited to fill the gaps.
Recruitment of health professionals from non-EU countries has increased, together with training opportunities and tertiary education in particular, in a number of non-EU countries. Educational support and staff exchange programmes encourage temporary mobility of health professionals and transfer of knowledge. The recruitment of health professionals from countries experiencing severe shortages of health professionals however has decreased because of the gradual implementation of the WHO Global Code of Practice on the International Recruitment of Health Personnel. GDP growth rates in the developing world outstrip those of developed economies, but regional disparities remain significant.
Potential Impact:
Section prepared by the European Observatory on Health Systems and Policies, scientific lead and leader of the dissemination work package

The biggest potential impact of the PROMeTHEUS project is that ministers and other policy makers in the Member States and at Community level are now in the possession of essential knowledge and analysis for making the right decisions on health professional mobility in particular but also with regards to broader health workforce related issues.

One precondition for this potential impact was the adequate knowledge production. The general objective of PROMeTHEUS was to fill glaring gaps of knowledge and analysis in order to be able to generate recommendations for more effective human resource policies. Glaring gaps of knowledge and analysis were identified in the following areas.
- The magnitude of professional mobility and identify critical data gaps and limitations
- The contextual, health system and personal factors that influence professional mobility
- The impact of professional mobility
- Good practice responses
- Future challenges of professional mobility

A second precondition for this potential impact was that the research focused on a proper policy issue with relevance to the political agendas at Community level and in the countries. The central policy issue for this analysis is that health professional mobility impact s on the performance of health systems and these impacts are increasing in line with increasing mobility in Europe. Concerns regarding a potential "brain drainß?? with a view to the EU enlargements in 2004 and 2007 gained momentum both at Member State and Community level. It was therefore of utmost importance filling the gleaming knowledge gaps and provide analysis that is policy relevant on the following issues:

Third, we ensure that filling these glaring gaps of knowledge and analysis on health professional mobility in Europe was very closely related to the political process in the Member States and at Community level. We have been providing evidence coming from the PROMeTHEUS project in the following political contexts:
- The Belgian council presidency 2010 which resulted in council conclusions on the health workforce.
- Working with the European Commission especially DG SANCO in the follow up of the "green paper on the European workforce for health but also with DG MARKT on the directive on the recognition of professional qualifications.
- We also worked with individual countries organizing a considerable number of policy dialogues and ministerial and senior level.
- We have published a volume online; we have provided for knowledge transfer short versions in English and Russian and we will publish a second thematic volume.
- We have provided numerous conferences, workshops and presentation on the research results of PROMeTHEUS.

Both the Director General of DG SANCO and the WHO Regional Director for Europe have written forewords for the first volume published, indicating the relevance of the research for Europe and their organizations and Members.

The PROMeTHEUS project did not include an economic evaluation to assess the economic impacts of the research. However, what can be said is, that now policy makers with regards to health professional mobility and the health workforce are now in a much better position to avoid wrong decisions. And wrong decisions taken on the health workforce may have massive societal and economic consequences. They may lead to a drop in the performance of health systems: inaccessible services, growing waiting lists, quality issues, poor health outcomes and unresponsiveness are possible. Wrong decisions may also involve dramatic economic consequences since the health workforce constitutes roughly 10% of the overall European workforce.

List of Websites:
Project website address:

Name, title and organization of the representative of the project's coordinator:
Ms. Jeni Bremner, Director, European Health Management Association