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Combating ‘out-migration’ in Europe’s health professions

It is a well-known fact that EU accession has not been kind to Romania and Bulgaria when it comes to the retention of qualified health professionals, especially doctors and nurses, who have been leaving in droves, write Linda Mans and Sascha Marschang.

In Romania, the out-migration of physicians and nurses is a major concern. From 2007 to December 31st, 2013, 13.872 physicians[1] and 20.000 nurses[2] have asked and received from the National competent authority certificates that allow them to work in another Member State, with the economic crisis widening this process. The situation in Bulgaria is not much better. In light of considerably higher salaries and, arguably, better working conditions and career prospects in the richer countries, the range of destination countries has greatly diversified.

While political change is slow – including attempts to create better conditions for junior doctors eager to join the exodus – one institutional initiative in South-Eastern Romania is tackling this rising threat to health system sustainability by putting into action – at local level – some of the key principles of the WHO Global Code of Practice on the International Recruitment of Health Personnel. The solution is simple yet effective: it involves providing attractive and fair cross-border employment opportunities for medical specialists.

The Călăraşi County Emergency hospital, situated close to the border with Bulgaria, serves one of the poorest regions in Romania with a high representation of vulnerable groups and a total intake area of about 100,000 people. Like many Romanian hospitals, Călăraşi County struggled with the effects of financial redistribution away from the hospital sector and the implications of decentralisation, including compulsory accreditation and introduction of competence-based classification criteria. The departure of Romanian doctors created a shortage of medical specialists that not only compromised the hospital’s capacity but also the relevant classification and accreditation processes which in turn determine the allocation of funding received from the Health Insurance House, the main public payer.

In order to maintain its financial position, the hospital began recruiting a Bulgarian specialist who came to work part-time in Romania while maintaining full-time employment across the border. This collaboration proved to be so successful that a further six specialists were hired who are now ‘topping up’ their Bulgarian salaries via part-time work in Călăraşi. This has been praised as a ‘win-win’ scenario at local level since the Romanian patients and hospital staff appreciates the professionalism and dedication of the Bulgarian doctors, including their openness to learning the Romanian language, while the Bulgarian specialists are content because they can remain in their region without having to migrate to another EU country.

The initiative has been identified among a series of case studies by the Health Workers For All project (, which seeks to ensure that the WHO Code implementation is taken seriously across Europe by making policy makers understand the implications of aggravating health workforce imbalances and unethical recruitment practices.

Taking a closer look at this project is particularly important when placed into context: at a time when foreign recruitment agencies are aggressively recruiting highly educated professionals for health positions deemed much more attractive in France, Germany, the UK and elsewhere, it is very difficult to retain young workers even if in theory they would like to stay in the country. The Professional Qualifications Directive allows for automatic recognition for doctors, nurses, midwives, and community pharmacists (among others), and any remaining administrative hurdles have also been scrapped since January 1st 2014, making it easy for qualified health professionals to migrate to another EU country whether they wish to practise in their profession or not. Rural areas are suffering the most under the exodus given that opportunities are more plentiful in urban settings.

Although only a small, and initially circumstantial, step in the right direction, the significance of the practice adopted by Călăraşi County Emergency hospital must not be underestimated as it also contributes to the implementation of the WHO Global Code of Practice signed by the EU and its Member States in 2010 and which subsequently also became an integral part of the European Commission’s Action Plan on the EU Health Workforce. The key to success is that Călăraşi County’s management was able to develop a vision for a local solution that involved equal treatment of the Bulgarian doctors who receive similar salaries and are likewise subject to similar working conditions and opportunities, and protection mechanisms.

In an increasingly ‘regionally’ oriented Europe, this case study proves that professional gaps can be closed in a mutually beneficial way without necessarily having to recruit educated workers from faraway countries.

By Linda Mans, Wemos Foundation, coordinator ‘Health Workers for All’Sascha Marschang, Policy Manager for Health Systems at EPHA.

This op-ed has been produced in the framework of the project “Health Workers for all and all for Health Workers” DCI-NSAED/2011/106, with the financial assistance of the European Union. The contents of this publication are the sole responsibility of the project partners and can under no circumstances be regarded as reflecting the position of the European Union. 

[1] Romanian College of Physicians,, accessed on November 17, 2014

[2] Emergency ordinance 23/2014 (amending the Health Law 95/2006)

  1. […] Combating ‘out-migration’ in Europe’s health professions, Policy Review (November 2014). […]

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