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.
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.
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