Workshop, May 16-17, 2022. Reconciling freedom of movement of labour with universal health coverage in the European Union.

Workshop summary. 

  1. As part of the project “Working together to Address Health Workforce Mobility in Europe”, the European Institute of Health and Sustainable Development (EIHSD) in Vilnius, Lithuania, has organised a series of workshops. The Augsburg workshop focussed on European imbalances in the health workforce and aimed to continue this discussion by looking specifically at differences in the health workforce across the European Union. It brought together data from various sources gathered by European institutions and international organisations. The BASYS Institute has prepared standardized country reports for 20 EU27 Member States, and a summary report and these were used as background material for the workshop. The country reports provide a general overview of the size and structure of the health workforce of each country, as compared to the EU27 average, using existing statistical information systems.
  2. The workshop opened by comparing the very substantial increase in the health workforce compared to the decline in employment in agriculture and manufacturing since the year 2000. Although the health economy has become the motor of the European economy, legal constraints self-imposed by European treaties mean that health remains a marginal issue in the European semester. For example, six times more annual ministerial meetings take place in agriculture than in health. The realities of 2020-2022, and in particular the pandemic of COVID-19, have underlined the need for a stronger European health policy. The war in Ukraine, as well as humanitarian, migration, and food crises caused by the military conflict, make the need for pan-European health action even more urgent. A central aim of this project is to make health workforce shortages a priority issue for the EU. In light of the health workforce shortages caused by the mass migration of health professionals from the newer Member States of Central and Eastern Europe to those in Western Europe, this project is designed to develop a pan-European understanding of how we can work together to develop a sustainable health workforce.
  3. The imbalances of the health workforce across EU27 MS, which are outlined in the summary report, have been identified using data from the European System of National Accounts, and other European statistical systems. The set of indicators selected is used to compile a dashboard linking supply and demand data, as well as external factors, in the health labour market. National Accounts are a very rich source of data for economic analysis and interpretation. Although the production boundary of National Accounts differs to some extent from the boundary of SHA, the indicators give basic information on size and structure of the European health workforce market. In combination with data from the Public Employment Services (PES), national mismatches may be compared with imbalances across countries. The size of the health workforce is an important determinant of access to health care and social services. Variations among MS show huge differences which cannot be explained by variations in need.
  4. In order to assess the quantitative differences between the indicators two assessment frameworks were presented, the Social Policy Performance Monitor (SPPM) and the Long-Term Services and Supports (LTSS) Scoreboard. Each approach classifies indicators into subgroups and values. Increases or decreases in indicator values must be explicitly related to policy objectives. For example, a higher share of the foreign health workforce could be beneficial from the viewpoint of European integration but detrimental from the viewpoint of national sustainability. Another challenge in designing indicator frameworks is the need to take into account the incentives inherent in different institutional arrangements, recognising that these vary between countries. For example, how are episodes of care which cross the health and social care boundary paid for?
  5. Both the SPPM and LTSS approaches consider the level of and changes over time in the indicators, but the SPPM compares countries to the European average, while the LTSS ranks countries by the aggregate of points for each indicator. Obviously, the assessment of the imbalances differs depending on the assessment framework used, how they are measured, and the comparative cut-off points used to value them. Hence key questions remain as how to measure inter-country imbalances in the health workforce, and how to use these measures to inform health and employment policy.
  6. The discussion on health workforce indicators concentrated on the comprehensiveness of the approach, the structure of indicators, the construction of summary indicators and indices, and their interpretation. Determinants of the imbalances were also addressed. The challenge is to devise an indicator system that can usefully inform health workforce policy, and which addresses the need for specific types of health professions. The European Health Data Space and other European initiatives might be used to strengthen the administrative capacities in and across MS to develop and handle health workforce data. The discussion on the availability and comparability of the data for the compilation of health workforce indicators concentrated on issues that international organisations must confront, and international comparability. Twenty years ago, national statistical offices agreed that it would be feasible to create health labour accounts linked to the system of health expenditure accounts (SHA). However statistical offices have not to date approved a standard accounting report and assigned the resources needed to do this. Experience with the design and implementation of health expenditure accounts has underlined the importance of terminology in making international comparisons. For example, the skills and job content of nurses vary between countries, and, within countries, between different sectors of care. It is also necessary to be specific about levels of care. For example, the services included in primary care delivered by general medical practitioners and their teams vary between countries. However, comparative information on details of professional structures and on levels of care would require standardized health labour accounts as proposed years ago.
  7. Participants from Slovenia, the Netherlands, and Lithuania presented further detail on HWF in their countries. This highlighted the potential and complexity of measuring current and projected levels of HWF, for specific health and social care sectors, and individual health professions. One particular challenge relates to self-employed workers, who account for a substantial proportion of the workforce.
  8. It is clear that the covid pandemic, and the war in Ukraine, are “special determinants”, which have or will influence the health workforce in the future. Discussion during the workshop emphasized that the indicators presented here should inform national policy, as well as serve as benchmarks for possible pan-European action. It was also said that the institutional framework of health systems and labour markets in the MS should be taken into account. This is also in line with earlier statements by BASYS when making international system comparisons, country-specific conditions (country descriptions) are important for assessment. Also, the selected health workforce indicators are influenced by factors such as age structure, lifestyle, etc. However, this workshop did not address what an extended indicator system including external factors should contain. The number of indicators should be limited, in order to ensure clarity and ease of reading. It was also repeatedly mentioned that the data can or should also be used in simulation models.
  9. Discussion of the migration of the health workforce in Europe and cross-country statistical measurement of this phenomenon began by referring to the annual report of the German Advisory Council for Integration and Migration. This states that migrants not only make an indispensable contribution to the functioning of the German health system but also that the migration of health workers – on the one hand into the professions directly and on the other hand into education – should be intensified. Analysis of migration flows in this project is based on the European Commission’s Regulated Professions Database (RPD), which was compared with the data published by the Federal Institute for Vocational Education and Training (BIBB). There are gaps in the data supplied by countries by professions and years. Because of the statistical differences and limitations of the RPD, the database must be combined with other information from registers and other statistics. Nevertheless, the database provides valuable information on the cross-country flows of doctors and nurses. Discussion of the indicators on migration used in the summary report showed that a very incomplete picture in the movement of the health workforce is currently available. This holds also for the education and training of the health workforce.
  10. Wage differentials across countries have a significant impact on the migration of the health workforce in Europe. Over the period 2007 – 2017, neither sigma-convergence (reduction in the dispersion of income level) nor beta-convergence (lower wages growing significantly faster than higher wages) were observed in health workforce wages. In contrast, working time, maybe as a consequence of the Working-Time Directive, has converged considerably. The impacts of education and health systems design as health workforce determinants have also been examined in this project. Tracking inflows and outflows in the health workforce are crucial for designing effective retention and replenishment policies. The analysis presented showed a divergence of foreign-trained nurses and doctors (with some countries experiencing an increase in the number of foreign-trained staff), but a small convergence of the overall health workforce. Issues of informal care and „live-in‘s“ (people with fewer qualifications, living in the household of their client) were touched on only briefly.
  11. The convergence of the health workforce might conflict with the convergence of public debt outlined in the convergence and stability report. The case of Greece illustrates this, where cost-containment policies after the financial and economic crises led to an outflow of the health workforce, and an increase of working time far above the European average. This underlines the tension between the objective of fiscal sustainability and ensuring convergence of access to health care.
  12. The data compilation and analysis carried out for this project shows that the workforce data collected by National Accounts make it possible to compile a standardized summary indicator on health workforce volume per capita, directly, or indirectly adjusted for need. However, further work is needed to develop a minimum data set to inform health and social policymakers. This might include specific policy areas such as preparedness for catastrophic events and emergency services, which would complement the work of the European Centre for Disease Control on emergency preparedness and response. This work has shown that overall health workforce volume per capita could be included now in a harmonised EPM and SPPM approach. Finally, because health workforce migration is a crucial issue in almost all countries, and the EU27 attracts considerable numbers of health workers from outside the EU27, it is needed to expand the view beyond Europe.
  13. It will always be necessary to balance the tensions between selected or more comprehensive information, and Europe-wide versus national benchmarks and standards. However, the workshop concluded that there is a strong case to be made for using a limited number of HWF indicators to help to assess convergence of access to health care in the European Union and that one of these should be health care workforce volume (in hours) per capita (needs adjusted).

The summary report in pdf format can be downloaded here: