28th Sep 2023

'Healthcare drain': the EU's market-based medic migration migraine

  • Credit: Alejandro Tauber's magical feature image creation studio (Photo: Screenshot Google Images)
Listen to article

In April 2020, during the first phase of the pandemic, Romania was confronted with the highest number of corona infections and deaths in all of Europe. Not only because of suspicion about the vaccine. But there was also simply too little healthcare staff to care for patients.

According to the Vienna Institute for International Economic Studies (WIIW), between 2010 and 2018 no other European country lost so many doctors to other (European) countries. Gheorge Borcean, director of the Order of Romanian Doctors, estimates the number of doctors that left at 14,000, more than a quarter of all Romanian doctors. According to the World Health Organization (WHO), Romania takes the lead within Europe in terms of avoidable mortality: 2.5 times the average in the rest of Europe.

Read and decide

Join EUobserver today

Become an expert on Europe

Get instant access to all articles — and 20 years of archives. 14-day free trial.

... or subscribe as a group

The WHO calculates a current worldwide gap of 17 million health workers, of whom 2.6 million are medical doctors and 9 million are nurses and midwives. In all European countries this shortage is felt, but not everywhere with the same intensity, since EU Member States in the south and east of Europe are source countries for other European countries. This leads to higher shortages in those countries (and also in low and middle income countries outside Europe).

'Essentially, everyone has the same problem,' said Professor of Health Economics Jochen Mierau of the University of Groningen, who looks at what trends are visible on the health market. 'More need of care and fewer people to provide this care. This is happening at an organizational level because vacancies are not filled. Also, at a regional level since waiting lists rise. And furthermore, at an international level. We notice an increasing demand for personnel from abroad, while these countries themselves also need those health workers.'

What does attracting healthcare workers from abroad mean?

Inequality in access to health also is a concern to the World Health Organization, as becomes apparent from the WHO report Health and care workforce in Europe: time to act, published in September 2022. It shows that countries with fewer medical personnel per population, such as Eastern European countries and Central Asian countries such as Uzbekistan and Kazakhstan, have a relatively low life expectancy — although it should be noted that this is a correlation, not a causal relationship.

People in Western European countries live to an average age of eighty-seven, in Central Asia and Eastern Europe to an average of seventy. Even more poignant is the table of deaths of children under the age of five. In some parts of Central Asia (with an average of seven doctors per 100 inhabitants), the under-five mortality rate is 43 percent, while the under-five mortality rate in many Western European countries (with 20 to 30 doctors per thousand inhabitants) is about 3 percent.

Just like Romania, other Eastern European countries, such as Serbia, supply healthcare personnel to the wealthier European countries — without much they can do against it.

Germany, for instance, is on the receiving end. While in 2013 the share of foreign — mainly EU — nurses in the German nursing workforces was at 5.8 percent this number doubled to a current 11 percent, with an absolute number of 200,000 non-German nurses working in the formal German health care system. 43 percent of these are coming from other EU member states and 17.5 percent from the Western Balkan countries, Heino Gueldemann, a freelance researcher, concludes.

Gueldemann drafted the report Health worker migration and mobility in Germany for the Pillars of Health partnership of Wemos, an organization working on improving health worldwide.

In the report, he gives an overview of where the various healthcare providers in Germany originate from. Gueldemann: 'Germany is a giant within Europe. It has good reasons to adhere to the ethics of staff recruitment and the principles formulated by the WHO, such as 'all member states must meet their own needs for healthcare personnel'. But in practice we see the opposite: poorly paid nurses with appalling working conditions and, as a result, an increasing demand from Germany for healthcare personnel from other countries, especially nurses. The systematic brain drain of healthcare workers to Germany is a European and a global health scandal.'

According to Gueldemann, about 14.7 percent of doctors working in Germany received their training outside Germany, mainly in Eastern and South-Eastern Europe. 50 percent of foreign-trained doctors in the country come from these European regions. The same applies to nursing staff. 'Currently there are more nurses from Bosnia working in Germany than in the whole of Bosnia itself. The population in the rural areas of these countries pays the costs. Smaller hospitals in these countries lose their staff.'

In the opinion of the director of the Order of Serbian Doctors, Milan Dinic, it would be wise if agreements were made at European level about the number of necessary doctors per inhabitant, he told the German newspaper Der Frankfurter Algemeine. Serbia, a country of seven million inhabitants, has 27,000 doctors, one in 260 inhabitants. In Romania the number of doctors is 53,000 out of a population of 20 million (one in 377) and in Germany, with more than four times as many inhabitants as Romania (83 million), 400,000 doctors (one in 207 inhabitants), a quarter of whom came from abroad.

Sufficient care for everyone, but not everyone

But the tendency to recruit from other countries is difficult to resist in ongoing times of scarcity. In the Netherlands for instance, the Ministry of Health, Welfare and Sport (VWS) commissioned projective research. Outcomes were that health care shortages in the country could rise to 140 thousand people in 2030. Hospitals will probably face a shortage of 24,400 people in 2031. Nursing homes are expected to have an even harder time with a shortage of 51,900 people.

Last September, the Dutch Advisory Committee on Immigration Affairs (ACVZ) advised the cabinet to make efforts to attract labor migrants from outside the European Union. For example, by concluding partnerships with countries such as Turkey and Indonesia (so-called Global Skills Partnerships).

Monique Kremer, chairman of the ACVG, emphasized to the Dutch national media-outlet the NOS the importance of 'sufficient' care for everyone, hence her organization's recommendation to look beyond national borders. But the question is what is meant by 'everyone'. Does this also include people in the countries where the healthcare workers come from?

In Indonesia, the number of doctors per thousand inhabitants is 0.5, according to the World Bank. The country dangles far at the bottom of the list of density of doctors per capita.

Currently, mainly nurses and not doctors are migrating from Indonesia to the Netherlands, but the figure still raises questions about the quality of care in Indonesia compared to that in the Netherlands. Another example is Turkey, also a country the report recommends for recruiting nurses from. According to the WHO report Health and care workforce in Europe: time to act, this country currently has the lowest number of nurses (2.5) per thousand inhabitants in Europe.

Fair international recruitment

Heino Gueldemann: 'We pay our own nurses too little, so they quit. As a consequence, we recruit nurses abroad. That is problematic. We need to reduce the demand for health workers from abroad and make the profession more attractive for our own residents. As Western countries, we ourselves are the problem, not the country from which we get the medical personnel.'

According to Pablo Sanchez of EPSU, the European Federation of labor unions of public services (including health services), the European Commission is stimulating the recruitment of health workers from outside Europe because of the blue card policy that makes it very easy for foreigners to work in Europe and at the same time is preventing governments from taking adequate measures. "The EU policy is urging countries not to spend money on structural adjustments, so for instance on wages."

But according to professor of health economics Jochen Mierau, raising salaries or increasing job satisfaction will not work either: 'Higher wages may attract people to the sector, but the labor shortage affects the entire semi-public sector, including education and the police. Healthcare is the last labor-intensive sector left in the Western world. In the past, many healthcare problems could be solved with more money and therefore staff. But staff isn't available anymore. We are in the transition from care provided by baby boomers to care for baby boomers.'

Recruiting staff from abroad is not a solution, said Gueldemann. 'The right to care is a human right. You cannot leave that to the market. But you make few friends if you ask the EU to regulate this. The EU does not like to intervene because the health care system falls under the mandate of member states. And the more powerful countries are within the EU, the more they benefit from the free market.'

Serbia and Romania nevertheless made efforts to halt the exodus of healthcare workers. Gueldemann: 'Serbia has canceled the recruitment program for nurses of the GIZ (the German government body committed to development cooperation, JJ), as well as the cooperation with the German Federal Employment Agency. In addition, Serbia is actively pursuing legal action against healthcare companies that illegally recruit nursing staff in Serbia.'

Romania opts for temptation. Doctors' salaries have doubled and, in some cases, even quadrupled in 2019. Hopefully, as a result, more doctors and nurses choose to stay in the country.

Author bio

Janneke Juffermans is a freelance journalist. Her articles deal with inequality, climate change and biodiversity loss and preferably with the relationship between all three of them.

Welcome to Work Week

In the spirit of ongoing experimentation, EUobserver presents our very first themed week. It's about work.

Tackling 'healthcare drain': lessons from Eastern Europe

For years, doctors and nurses from countries such as Romania, Bulgaria and Latvia have been leaving for other European countries with better working conditions. Here are some of the measures their authorities have taken to address this 'healthcare drain'.

Swedish doctors and nurses' battle for proper rest breaks

"There are a lot of rural areas in Sweden and we must be able to secure people's right to healthcare and access to water, food and medicines. At the same time, we must protect the workers' right to daily rest."

Supported by

Latest News

  1. Poland's culture of fear after three years of abortion 'ban'
  2. Time for a reset: EU regional funding needs overhauling
  3. Germany tightens police checks on Czech and Polish border
  4. EU Ombudsman warns of 'new normal' of crisis decision-making
  5. How do you make embarrassing EU documents 'disappear'?
  6. Resurgent Fico hopes for Slovak comeback at Saturday's election
  7. EU and US urge Azerbijan to allow aid access to Armenians
  8. EU warns of Russian 'mass manipulation' as elections loom

Stakeholders' Highlights

  1. International Medical Devices Regulators Forum (IMDRF)Join regulators, industry & healthcare experts at the 24th IMDRF session, September 25-26, Berlin. Register by 20 Sept to join in person or online.
  2. UNOPSUNOPS begins works under EU-funded project to repair schools in Ukraine
  3. Georgia Ministry of Foreign AffairsGeorgia effectively prevents sanctions evasion against Russia – confirm EU, UK, USA
  4. International Medical Devices Regulators Forum (IMDRF)Join regulators & industry experts at the 24th IMDRF session- Berlin September 25-26. Register early for discounted hotel rates
  5. Nordic Council of MinistersGlobal interest in the new Nordic Nutrition Recommendations – here are the speakers for the launch
  6. Nordic Council of Ministers20 June: Launch of the new Nordic Nutrition Recommendations

Stakeholders' Highlights

  1. International Sustainable Finance CentreJoin CEE Sustainable Finance Summit, 15 – 19 May 2023, high-level event for finance & business
  2. ICLEISeven actionable measures to make food procurement in Europe more sustainable
  3. World BankWorld Bank Report Highlights Role of Human Development for a Successful Green Transition in Europe
  4. Nordic Council of MinistersNordic summit to step up the fight against food loss and waste
  5. Nordic Council of MinistersThink-tank: Strengthen co-operation around tech giants’ influence in the Nordics
  6. EFBWWEFBWW calls for the EC to stop exploitation in subcontracting chains

Join EUobserver

Support quality EU news

Join us