We approach the HWF mobility in the EU measuring the flows of health professionals between EU countries. We calculate a proxy variable based on the “number of positive decisions taken on recognition of professional qualifications for the purpose of permanent establishment within the EU Member States, (EEA) countries and Switzerland”. For each country, we obtain the net balance ratio (NBR): the ratio of the difference between inflows and outflows of HWF to the total number of health professionals. Concerning the flows, the source of information is the Regulated Professions Database (RPD).3 Concerning the number, the source of information is manifold. The main one is the statistical office of the European Union (Eurostat), that we have complemented with databases provided by the World Health Organisation (WHO) and the Organisation for Economic Co-operation and Development (OECD). Please refer to online Appendix A for further detail regarding the indicators used and its sources. We notice that, handling the quantitative information in the mentioned international databases, we have verified several weaknesses (gaps of information, limited comparability regarding professional categories, differences among sources…). It goes beyond the scope of this work to address these issues. Nonetheless, from the perspective of EU and national policymaking, improving the international information systems on HWF is a needed first step to support planning and forecasting.

For characterising the mobility of health professionals in the EU, we connect it to the challenges identified in the ES concerning the supply of HWF.

The supply of HWF depends on health care workers’ labour supply decisions that end up shaping the size and composition of the stock of health professionals. We have created a stylised framework that includes the main drivers of HWF supply. Concerning the size, we borrow from the OECD's approach4 and use the classic stock/flow model. As for the composition, we have selected some relevant characteristics linked to the supply of HWF, namely: age and sex distribution, geographic distribution, competences distribution, a mix of skills and workforce participation and hours worked. Additionally, we include some institutional characteristics.

In Table 1 we present that framework, which is “challenge-oriented”, meaning that, based on theoretical models, we have included those drivers of HWF supply for which challenges have been flagged in the context of the ES.

To gauge the extent to which these challenges could be considered a priority, we have measured its “intensity” by the number of countries where the component has been flagged during the period 2017-2023, where the accounting unit is the country and the year. To this end, we have created a textual database, including for each year and each country the description of the challenges flagged. The sources of information are the European Semester Country Reports 2023, complemented with the reports on the State of Health in the EU (2017, 2019 and 2021), that feed into the ES process and that provide more extensive details for the health sector (hereinafter, the reports). Please refer to online Appendix A for further detail regarding this indicator and its sources. We also complete with an overview of the ES Country Specific Recommendations (CSR).

In online Appendix B, Figures B1-B5, we show the result of our calculations for the NBR of HWF in the EU. We present them ordered, displaying in top positions those countries that are the top recipients of HFW.

The countries with a positive NBR are recipients of health professionals. For a given country, the nature of the ratio depends on the health profession. However, a set of countries are systematically recipients of HWF: AT, DE, IE, LU, NL and SE; BE, MT and UK are almost systematically recipients except that BE is an issuer country for nurses, MT for doctors and the UK for pharmacists. We highlight that, in the case of DE, though positive, the NBR is very close to 0 for all professions (please notice that an administrative positive decision granting the recognition for the purpose of permanent establishment to practise in the host country on a permanent basis might not always imply an effective migration). On the other side, BG, EL, ES, FI, HR, HU, LT, LV, PL, PT and RO are systematically issuer of health professionals; DK, EE, FR, IT, SI and SK are systematically issuer countries for all health professionals except pharmacists and CZ except for dentists. As for the rest (CY), we cannot identify a global pattern. However, the figures for CY show high positive values for doctors and dentists and high negative ones for nurses; where “high” means out of the upper or lower limit of the interval of one standard deviation around the mean of the distribution. According to that, the data point out that the countries with a “recipient profile” are LU, BE, CY, IE, AT, MT and SE. On the other hand, those with an “issuer profile” are RO, SK, ES, LT, LV, PT, BG, CY, EL, FI, HR, HU, IT, and SI. Please refer to online Appendix B, Table B5.

We also show the density of health professionals in online Appendix B, Tables B1-B4, derived from the number of health professionals used for calculating the NBR, which helps to set the background for HWF mobility in the EU. The data show a significant variability between EU countries, especially for nurses and dentists (the coefficient of variation exceeds 20%). Between 2010 and 2022, it registered a raising trend for all professions in the EU (online Fig. B5).

In online Appendix B, Tables B6 and B7, we show the results of measuring the intensity of the challenges related to HWF supply drivers as flagged by the reports. Consideration is equally focused on issues related to the size of the HWF and its composition with around 40% of intensity each one. For other labour market and institutional characteristics, the intensity drops to less than 20%.

Regarding mobility, immigration and emigration have been flagged as a challenge 15.37% of the times. The EU countries with higher intensity for the emigration challenge are RO, BG, HR, MT, PL, SK, EL, HU, IE, LT, LV, PT, CZ, EE, ES, IT and SI. On the other hand, the EU countries that have been flagged with an immigration “challenge” are LU, MT, DE, IE, UK, HU and SE. Please refer to online Appendix B, Table B7.

Mobility is used as a solution to shortages. We record shortages as stocks challenges, be it overall or for specific professions. They retain most of the concern about HWF size. Indeed, the reports have flagged issues of scarcity 25.67% of the times: out of 670 mentions to HWF challenges in the reports, 172 were to highlight shortages of the HWF (online Appendix B, Table B6 and Fig. 1).

Figure 1.

Challenges related to HWF supply drivers: intensity. (Source: author's own work based on online Appendix B, Table B6.).

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Typically, a serious challenge would receive a CSR to address the issue. Thus, it is helpful to draw on CSR to see the extent to which they are priority challenges. In 2020, 21 EU Member States received a CSR to address HWF issues, and most of them (17 times) were specifically on HWF shortages.

Shortages have revealed as a relevant threat during the COVID-19 pandemic. Indeed, as reported in the State of Health in the EU: Companion Report 2021, “The COVID-19 pandemic put shortages of healthcare into the spotlight, but this is by no means a new challenge to healthcare systems in Europe (…) In the 2021 edition of the State of Health in the EU's Country Health Profiles, HWF shortages are reported as a key health system challenge in 15 countries”. The mentioned report states that the demand and complexity of care provided in Europe has grown at a comparatively faster pace than the density of health workers due to population ageing and the growing burden of chronic diseases.

The reports have flagged issues of scarcity mainly for physicians and nurses. They documented a variety of reasons for that situation. For some Member States, the issue was a numerous clauses set at low level in the past that has been necessary to ease. In other cases, the country lacked a health education system and needed to set it to prevent depending heavily on foreign-national professionals. Emigration is a concern in many countries, which is also compounded by an ageing HWF, a notable part of which is about to retire within the next 10 years. The reports do not point to career changes in any country (which might be because of lack of data on this issue). On the contrary, working conditions have been flagged as a concern 15.52% of the times, the second component most signalled following scarcity of health workers. Low salary and increasing overburden of workload (which seem to be more extended in rural and deprived areas) are the most frequently mentioned components when working conditions are pointed out as an issue associated to emigration or to the decision of not choosing a health career. Although during the pandemic the use of part-time or temporary contracts have been recourse for swiftly increasing human resources, in some cases, like in Spain, there has been a shift towards temporary contract, which results in a large turnover. In a few countries, the reports point out to informal payments (12.30% of the mentions within working conditions). We have accounted for these mentions within the working conditions on the ground that this component has a detrimental effect on motivation.

Moving on to the supply factors in the composition side of the framework, what the reports show is the presence in many countries of notable imbalances in the geographic distribution of human resources, which are frequently compounded with an uneven concentration in urban areas. Typically, specialists tend to concentrate in urban areas. However, shortages of GP in rural areas are also importantly reported. In many cases the solution to the challenges requires innovation with the distribution of competencies to give a response to current needs. This starts in some cases with the design of new curricula. Changing the skills mix will also be needed, e.g. to take into account the increasing presence that is required of long-term care professionals and new health professions.