Freedom of movement is one of the cornerstones of the European Union. When it comes to providing health care in the bloc’s poorest countries, it’s also a problem.
More doctors and nurses move from one country to another than any other highly regulated profession in the EU, and the flows often go from East to West, from poorer EU countries to richer ones. A POLITICO analysis of European Commission data found the exodus of health care professionals is especially pronounced from Eastern and Southern Europe. In effect, these countries are training doctors for their richer neighbors.
Take Ingmar Lindström, who graduated from the University of Tartu’s medical school in Estonia in 2001. All he had to do to quadruple his salary was move 200 kilometers.
He was making about €600 a month as a doctor in Estonia, doing family medicine work and studying for his Ph.D. He enjoyed his job and liked the place where he lived. “But it didn’t pay all the bills,” he said. “That’s the main reason I thought I might go to Finland.”
Just across the gulf, young doctors made €2,000 or €3,000 per month — four to five times what they could make in Estonia — and a shortage of Finnish doctors made it easy to find a job. “A few years after I graduated, 30 to 40 percent of each graduating class was moving,” Lindström said.
* * *
Educating doctors is a long and expensive process, but not every country can reward its graduates equally. Health spending per capita varies drastically in EU countries, from €816 per year in Romania to more than €4,000 in Luxembourg, Germany and other Western European countries. And so doctors and nurses follow the money.
A survey just before Estonia’s accession to the EU in 2004 — just three years after Lindström graduated from medical school — shows that more than half of Estonia’s 17,749 health care workers were considering working abroad. The country had 4,312 practicing doctors in 2004; more than 1,800 doctors have applied for qualifications abroad since then.
In 2011, a member of the Board of the Estonian Family Doctors Society warned of a future in the country in which “there is no family physician within a radius of 100 kilometers,” according to local media.
Estonia isn’t alone in watching its health care workers leave.
Romania lost half its doctors between 2009 and 2015. A few years after Poland joined the EU, more than 60 percent of fifth- and sixth-year medical students planned to pursue work abroad. Slovakia had about 15,000 practicing physicians when it joined the EU in 2004; 3,800 have applied to leave since then.
Hardest hit by the exodus of doctors and nurses: the EU’s newest members, plus crisis-hit Portugal and Greece, according to POLITICO’s analysis of Commission data.
This westward migration of mostly young professionals is taking place at a time when the average age of a doctor in the EU is rising. More than one in three doctors in the EU were 55 or older in 2014. By 2020, this “retirement bulge” will mean that more than 60,000 doctors — 3.2 percent of the workforce — will leave the profession each year, according to the Commission.
In some countries, the loss of doctors and nurses seems to be already taking a toll. In Romania, for example, 10 percent of the population reported going without medical care.
When it comes to recruiting nurses and doctors from developing nations, it’s accepted that host countries have a responsibility not to sap dry the countries they recruit from. In 1999, for example, the U.K. Department of Health implemented standards for “ethical international recruitment,” including a list of developing countries from which health care worker recruitment should be restricted.
The list included Croatia — which has lost 570 doctors (5 percent of the total) to EU emigration since it joined the bloc in 2013 — as well as several countries now in EU accession talks.
The EU has also adopted policy papers acknowledging its responsibility to protect some non-EU countries from worsening health care shortages. But within the union, there’s no such admission; in fact, the Commission has moved to make migration easier.
* * *
The process of moving to another EU country has traditionally been clunky for strictly regulated professions, such as doctors or nurses. Applicants aren’t always sure where to submit their applications to have their credentials recognized, requirements vary between countries, and national authorities often miss deadlines for responding to the requests.
Last year, the Commission launched a program that streamlined the process for some workers by bringing it online. Through the European Professional Card website, professionals working in five of the credentialed professions with the most intra-EU mobility — nurses, pharmacists, physiotherapists, real estate agents and mountain guides — can see what’s required in each country, upload their qualifications and pay a registration fee. Once the host country accepts them, they can move and (assuming they meet any language requirements) begin to practice. If the host country misses the deadline for responding, the application is automatically approved.
The Commission considered similarly streamlining the process for doctors when it began shaping the program in 2014, but decided to postpone that part of the initiative until a potential “second stage.”
This delay was partly due to concerns about patient safety and operational aspects of the program, according to a Commission staff working document, and partly due to “the political sensitivity” of introducing the program for doctors “in the light of existing shortages of medical doctors in certain national health care systems.”
The Commission is reviewing how the program works for nurses. An analysis to be published later this year may include a proposal to expand the program to other professions.
* * *
That would mean more stories like that of Lindström, the Estonian doctor who relocated to Finland.
Lindström recalls a slight pressure from the Estonian media to stay in the country and work, but it was never explicit. Anyway, he was far from the first or only doctor to emigrate for the higher pay. Wasn’t that the point of freedom of movement, that if someone could do better somewhere else, he had the right to?
“The taxpayers were worried they have paid for our studies and then we were leaving the country,” Lindström said. “But I had worked in Estonia before I went to Finland, and the pay by these taxpayers was so low I thought, ‘They have allowed me to go.’”
Romania lost half its doctors between 2009 and 2015 | Andrei Pungovschi/AFP via Getty Images
The structure of the medical system in Finland was different: Unlike Estonia, no patient could see a specialist until they’d been to a general doctor first, so more was expected from him as a GP. He was nearly fluent in Finnish already, so the language barrier was not an issue, and cultural similarities meant the move wasn’t as drastic as it could have been.
Still, it added stress to an already high-stress career, as he traveled back and forth to Estonia often to see family.
* * *
Estonia’s situation has improved somewhat. It has begun recruiting from even farther east, in Russia, and the national government increased health professionals’ wages to persuade them to stay. Other countries have taken this approach as well, sometimes with the EU’s financial backing.
Last year, the Hungarian Ministry of Human Resources warned that the country could lose half of its 6,500 family doctors in the next 10 years to emigration and retirement. It has boosted funding for basic medical services and introduced a series of measures — from grants for individual doctors to EU-subsidized “health development offices” scattered around the country — aimed at improving the medical system for general practitioners.
“It was a bit hard having practiced in Finland to come back in Estonia” — Ingmar Lindström
And sometimes, doctors do come back: When Lindström’s children started school, he decided to return to home. He now works at his family’s practice in Tallinn.
But his experience shows how difficult it can be for countries like Estonia to keep their medical professionals.
After working in Finland, he’s aware of how different his job can be, even if the two countries are just a gulf apart.
“It was a bit hard having practiced in Finland to come back in Estonia,” Lindström said. “Finnish doctors have 15 patients a day, and the 16th patient they are quite unhappy and tell everyone about it.
“Estonian doctors take, maybe, 30 patients a day and they don’t say anything.”