6- Sistema GdAu2
6.5 Densidades de estado
National and international policies and approaches can significantly influence the migration of health care professionals. Legal regulations as well as voluntary recommendations made by international organization will be mentioned in this section.
Bach stresses the importance of state policies (Bach, 2007). The adoption of the Directive 2005/36/EC on the recognition of professional qualification is an example of an attempt to influence migration on a political level, and the Directive11 significantly shapes the EU
migration of nurses (among other health care professionals) (European Parliament, 2005). The voluntary WHO Global code of practice on the ethical recruitment of health care professionals, published in 2010, is another example of such policy. It contains guidance for international recruitment which should equitably strengthen the involved health care systems, assures the personal right of migration and provides recommendations for sustainability in the production of health care workers, as well as for the collection of data about the workforce (WHO, 2010b).
11The Directive 2005/36/EC on the recognition of professional qualification was amended in November 2013 as
DIRECTIVE 2013/55/EU OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL on the recognition of professional qualifications and Regulation (EU) No 1024/2012 on administrative cooperation through the Internal Market Information System.
32
Glinos refers to the WHO Global code, which all EU countries have signed and should follow externally (when recruiting from non-EU countries). However, in the case of intra-EU mobility of health care workers, it seems that the poorer EU countries face more often the negative consequences of this migration, while the richer countries benefit more from free mobility. Thus, the ethical message of the Code is not fully observed, while such mobility is still completely legal (Glinos, 2015). Moreover, in the UK, for example, the Code is observed only by state owned facilities and not by the private sector (Schultz and Rijks, 2014).
Skills which are not used in a source country can be efficiently used in another EU country in the case of unemployment of health care workers. Thus, mobility can enhance equity, because all health care professionals have a chance to receive fair rewards. On the other hand, considering that the qualifying education of doctors and nurses is mainly publicly funded in the EU countries, their mobility causes a less transparent distribution of these funds. Similarly, the expert skills of the migrating nurses are not always used efficiently in the destination country (e.g. Estonian emergency nurses working in nursing homes in Norway), and the costly integration training in the destination country health care system is not always performed, thus resulting in a less efficient adaptation. When destination countries cover their needs for health care professionals from abroad, they are not forced to solve the underlying problems in their own system (e.g. unsatisfactory working conditions and salaries) (Glinos, 2015), and the vicious, and ethically problematic, circle of needing to search for large numbers of smart nurses from other under-resourced countries continues. As shown in Figure 1, the ratios of practicing nurses in some of the source countries are much lower than those in the destination countries. Portugal had 5.7 nurses per 1000 population, Romania 5.2 nurses per 1000 population; the average in the EU was 7.9 nurses. For comparison, the Czech Republic had 8.1 nurses per 1000 population in 2010 (OECD, 2013). Thus, mobility of nurses from such source countries to the typical destinations countries poses an ethical dilemma. Even though the migrating nurse might eventually improve her/his personal situation (financially, career enhancement, living conditions, job satisfaction, etc.), the source country will definitely lose a qualified professional in whom it invested scarce resources during her/his education.
33
Figure 1.12 Number of practicing nurses per 1000 population (OECD, 2013).
Apart from general policy interventions which try to influence the migration of health care workers, the most authoritative organization of nurses, the International Council of Nurses (ICN), expressed their opinion on nursing migration and recruitment in two position statements in 2007, in which they recognized the right of each nurse to migrate, acknowledged the positive and negative consequences of migration, condemned unethical and exploitative recruitment, and described principles of migration. Among these principles were: a proper orientation period and supervision, the self-sustainability of countries, a safe work environment, regulation of recruitment, and freedom from discrimination (ICN, 2007b). The second statement was related to the retention and migration of nurses, where ICN stressed the need to collect data on the workforce and pay attention to nurses working conditions and environment. Here, the ICN also warns nurses about the possible problems with the recognition of their qualification abroad (ICN, 2007a).
12The ratio of nurses per 1000 population has increased in Portugal since 2010 to 6.1 nurses in 2015, the data for Romania were not available in the 2015 edition of Health at Glance (OECD, 2015c).
34
Considering the high reliance of western society on its (health) care services, as well as the current shortage of health care professionals and the demographic trends, we should be preparing more care workers, health care workers, and health care professionals, while at the same time seriously improving the image of nursing and even more so the working conditions in (health) care facilities (Bach, 2008), (Dussault et al., 2009), (OECD, 2010b). It has been known for more than a decade that there are high numbers of non-practicing nurses in each country and very often their reason for their workforce withdrawal are unsatisfactory working conditions (Kingma, 2006).
Buchan and Campbell describe the World Health Assembly decision (May 2013) to renew the interest in the health workforce, which was somewhat reduced when the global financial crisis in 2008 impacted the budgets available for the health care workforce. The major issues that should be solved now are the following: the nursing shortage, the improvement of retention, issues of attrition and out migration, the better use of the skills of health care professionals, their new roles, effective incentives as well as appropriate working conditions (Buchan and Campbell, 2013).
As shown in a study recently funded by the EU, the retention of experienced staff is high on the political debate in many countries, together with attempts to recruit more new health care professionals (Kroezen et al., 2015). For instance, the USA attempted to stimulate the attractiveness of the nursing profession by offering loan forgiveness programs for nurses, as well as specialist education and the improvement of working conditions (Schultz and Rijks, 2014). When Poland increased the salaries of health care professionals in 2007, it slowed down migration and even caused return migration (Wismar et al., 2011b).
Most recently, experts have highlighted the importance of systematic health workforce governance, mainly as a thorough planning, managing and preparing of the workforce. The governance approaches seem to differ from country to country, but there is an opportunity to learn from each other’s successful strategies (Kuhlmann et al., 2015).
This section has explored the role of policies implemented locally, nationally and internationally that can influence the migration of health care workers. Apart from the options mentioned above (workforce monitoring, sustainable production, improved working
35
conditions), there are other policy interventions which have been tested in different countries (bilateral agreements, temporary staff exchanges, intentional training health care professionals for export, and even less commonly, compensation for source countries) (Buchan and Perfilleva, 2006a). Now it is important to use these policy interventions wisely and ethically in order to provide for a stable health care workforce and care workforce, and thus for a stable delivery of health care services.