Reconciling Freedom of Movement and Social Cohesion in the European Health Sectors
Can we preserve freedom of movement in the European Union (EU) and ensure at the same time that those who “stay home” are not left behind? Or, more precisely, can we ensure that the mobility of health professionals does not come at the expense of social justice? Freedom of movement is a double-edged sword: it enables EU citizens to take advantage of job opportunities abroad, but it also leads to problematic labour shortages, exacerbating social inequalities across the continent.
“Doctors and nurses have been in the top three most geographically mobile professions in the EU for two decades.”
The last decades have witnessed a major increase in the migration of health professionals within Europe, accelerated by the EU 2004 and 2007 enlargements. According to a study by the European Commission, Doctors and nurses have been in the top three most geographically mobile professions in the EU for two decades, typically migrating from East to West. In the meantime, access to healthcare remains an issue in Europe, in particular for the most vulnerable and deprived people. The range, quality and cost of state-run health services differ significantly between and within EU Member States. Moreover, according to an OECD study, in many Central and Eastern European Countries (CEECs), health care is increasingly offered on a private, self-financing basis, and is thus only accessible to those who can afford it.
Health professionals’ emigration and the European Union
Facing politically uncertain times, the EU must pay attention to the adverse social effects of free movement on Member States with net migration losses. The outflow can also fuel Eurosceptic sentiments, as the EU is blamed for bleeding the life out of these “weaker” Member States. In Hungary and Romania respectively, almost 40% and over 50% of the population is worried about emigration, and – according to a recent survey– half the Poles and Hungarians think that citizens should be prevented from leaving the country for long periods.
Disparities in access to health services across the EU stand in stark contrast with core EU principles of justice and solidarity, and the aims of social justice and protection that are laid down in the articles 2 and 3 of the Treaty on the European Union. For sure, there are legal limits to what the EU can do: whereas it is competent to adopt measures related to the free movement of workers, it only has supportive competence in health matters and cannot regulate or directly allocate funds to national health care systems. Nonetheless, the Charter of Fundamental Rights states in article 35 that “everyone has the right of access to preventive health care and the right to benefit from medical treatment”. This provision, which should guide EU policies and their implementation, has been recently reinforced by the European Pillar of Social Rights (EPSR) which defines the principle of “timely access to affordable, preventive and curative health care of good quality” for all of its citizens.
This study is based on a comparative case study of Hungary, Poland and Romania, countries with high outflow of qualified personnel and serious deficiencies in their healthcare systems. They spend less on healthcare than the EU28 average and their net migration of health workers is negative. Furthermore, their citizens have significantly shorter life expectancy than the average EU28 citizen.
As matters stand, there is a gap between the expectations laid down in core EU documents and the reality of health inequalities in Member States, which affect more vulnerable people disproportionately. Freedom of movement, as it currently operates in the healthcare sector, further widens this gap and therefore undermines the EU’s social cohesion objectives.
Health professionals’ emigration and social inequalities
In CEECs, emigration is one of the main causes of human resources shortages and structural deficiencies, which affect people’s equal access to healthcare.
What’s worse, the lack of qualified health professionals primarily and disproportionately affects deprived, poorer regions. Public healthcare is the most affected, as it struggles to retain its staff. The more affluent can secure access to faster and more extensive treatment by switching to private care and out-of-pocket (OOP) payments. That leaves the poorer, most isolated and marginalised groups without adequate care or with extended (and sometimes lethal) waiting times.
In addition, emigration catalyses endemic labour shortages, thereby further worsening the performance of health systems. It reduces already scarce resources, puts pressure on training and recruitment, or shrinks capacity. It does not only spur inequalities in home countries, but further increases existing structural differences in resources and expenditure between home and host countries, which are already the primary driving forces of emigration. These circular dynamics set off a deadly spiral.
The regional dimension: human resources shortages
The availability of health personnel varies greatly across the EU. According to the OECD, whilst in 2018 the EU28 average was 3.6 per 1000 people, it was only 3.2 in Hungary, 2.4 in Poland, and 2.8 in Romania. When accounting for “health and social employees per 1000 citizens”, these disparities become even more obvious. Hungary and Poland employ 30 and 25, whereas Germany, the UK and Austria reach 68, 60 and 51 employees in the health and social sector. There are also significant regional differences within CEECs. For instance, in Hungary, there are 3,5 times more health professionals per inhabitant in the capital Budapest than in deprived and poorer regions. These inequalities directly impact patients’ experiences with the public healthcare system. For example, waiting times for a hip replacement vary from 104 days in the UK, to 120 days in Hungary and 444 days in Poland (OECD 2018).
Labour shortages in healthcare and social exclusion go hand in hand in Romania and Poland, as illustrated by the strong correlation between the number of available doctors per 100.000 capita, and the regions where people experience social exclusion.
The Income-component: Increasing out-of-pocket and catastrophic spending
The inability of the public health sector to cover the health needs of these countries’ population results in a growing reliance on private healthcare, which is harder to secure by poor and marginalised groups. OOP payments represent 30% of total healthcare spending in Hungary, 23% in Poland and 21% in Romania, all exceeding the EU28 average of 18%. The group most adversely affected by OOP payment are citizens on low income, as testified by the “catastrophic spending” indicator; falling ill can push them into poverty. Around 11,5% of Hungarian households and 9% of Polish ones are affected by catastrophic spending, compared to the EU18 average of 5%. The vast majority of citizens affected by catastrophic spending in Hungary come from the poorest 20 percent of the population (almost 80%).
Impact on vulnerable groups
Health inequalities disproportionately affect vulnerable groups, in particular Roma, less educated, and elderly people, who typically dispose of lower incomes, live in more deprived rural areas, and have greater health needs.
All these groups experience more unmet health needs than the average population. In Hungary, this is the case for 15,4% of Roma, and 12,6% of those who only attained elementary education, compared to 7% for the average Hungarian population. In Romania, the percentage of Roma people who do not seek medical treatment when they need it is 42%compared to the national average of 25%.
Elderly people, typically require more healthcare than younger people and are thus particularly affected by health personnel shortages and rising private expenditure, as their pensions are not adjusted to increased costs. Unmet health needs in Poland strongly increase with age and it is estimatedthat over 30% of elderly people experience catastrophic expenditure.
What makes health professionals leave?
The main factors influencing physicians’ decision to move are similar for all three countries.
As survey data from Hungary show, salaries, working environment, and living conditions are the main considerations for around 65-70% of doctors considering emigration. Other factors are the state of the healthcare system, career opportunities, management issues, workload, social status, family reasons, “wanderlust” and language learning.
The largest study inquiring into the preferences and plans of medical students in Poland found that almost two thirds of respondents estimated the likelihood of emigration at 50%. As main pull factors, respondents mentioned higher salaries, better working conditions, new experiences, and professional stability. Only 27% of respondents assess the working conditions in Poland positively.
In a survey conducted on Romanian emigrated doctors, respondents listed working conditions, performance-based promotion, equipment, opportunities for career development, and prestige of the profession as the main conditions for returning.
In another study, a majority of respondents (52%) indicated that although securing satisfactory wages was possible in Poland, it requires significant overtime work and combining parallel jobs, which in turn causes anxiety, fatigue and diminished job satisfaction. Needless to say, the difficult working and employment conditions of the Polish health workforce result in dissatisfaction and increasing frustration among medical professionals.
In the case of Romania, the first message that future doctors get during their university years, is that they either accept to be moulded by the “system”, its customs and hierarchies, or that they should consider leaving. Young graduates question the possibility of change or the fairness of the sacrifices required from them. When asked about the general situation of the Polish healthcare system, one interviewee describedit as “hopeless”, and that only a “shock-therapy” of a deep reform could cure it. The desire for real structural change is also strong in Romania, which is facing difficulties in developing the healthcare infrastructure it sorely needs because of its struggling economy. The insufficient technological infrastructure and supplies combined with poor resources allocation and mismanagement take its toll on patients and doctors alike.
Just like the young doctors protesting in Bucharest in 2017, their Polish colleagues highlighted the stress and fatigue they face due to simultaneous hospital overcrowding and shortage of doctors. One of the interviewees recalled that although she finds overnight shifts extremely stressful as one doctor is responsible for as many as 170 patients, she feels pressured to take extra shifts as otherwise there would not be enough staff to cover the schedule.
Systemic inefficiencies combined with high emigration of health professionals expose the remaining staff to higher stress which in turn creates a further push towards emigration.
Real structural deficits push doctors to migrate
All available data confirm that doctors’ motivations towards emigration respond to real structural deficits – in both resource and management – in the CEECs health systems
To start with, there is a large wage gap between physicians in Western Europe and the CEECs, even when adjusted to local purchasing power. The adjusted average monthly remuneration in Germany, the United Kingdom and Austria, is almost triple that of Poland, Romania and Hungary.
Mismanagement and inefficient planning lead to unnecessary work for doctors, due, for instance, to avoidable hospital admissions. For example, admissions for asthma and chronic obstructive pulmonary disease (COPD), are high in CEECs, even though these are conditions which could be treated at primary care level. The OECD34 average for these conditions is 237 per 100.000 population, whereas Hungary admits 428. Romania, Poland and Hungary all score very badly on avoidable hospital admission for the five most common chronic conditions (respectively second, third and sixth worst).
Health workers feel discouraged by the lack of necessary instruments and supplies needed for adequate treatments. In all three countries, equipment such as magnetic resonance (MRI) units and computed tomography (CT) scanners are very scarce: 4 MRI units per one million inhabitants in Hungary, 5.9 in Romania and 7.9 in Poland in 2016, which are the worst rates in the EU. The same is true for CT scanners. While Poland, with 17.3 scanners, is closer to the EU28 average of 22.3, Romania and Hungary only have 12.6 and 8.9 scanners – the lowest number in the EU.
Problems arising from the emigration of health professionals have, so far, been mostly tackled at national and local levels, and often in an ad-hoc manner. In light of the complexity of the factors which drive migration and the interconnectedness of EU member states, these are, logically, insufficient. We thus recommend a more comprehensive policy strategy, which integrates EU actors and processes into addressing both the root causes and adverse social effects of CEEC’s braindrain in the health sector.
As our report clearly shows, freedom of movement, by facilitating doctors’ emigration, indirectly exacerbates health inequalities. The CEECs however did not, and sometimes cannot, tackle both the causes and consequences of health sector emigration effectively. Therefore, the EU has a legal and moral obligation to mitigate social injustice which result from, or are amplified by, policies which are central to European integration (i.e. the internal market).
Towards a new EU Commission Executive Agency?
We propose to transfer the “health” activities of the Consumers, Health, Agriculture and Food Executive agency, formerly the Public Health Agency (CHAFEA) into a new, fully-fledged agency, the European Health Agency (EHA). This transformation would enhance planning security and testify to the importance of social justice in healthcare in the EU.
The EHA should be equipped with the necessary competences and funding to exercise its core functions. Some of these can be realised almost straight away, where political will and resources can be harnessed for that purpose, whilst others require Treaty amendments. With that in mind, we suggest that, in the next round of Treaty reform, the protection and improvement of human health should be changed from a supportive (Art. 6 TFEU) to a shared competence (Art. 4 TFEU).
Salary increases seem the most intuitive way to tackle the brain drain. This, for the time being, should be done on a national or institutional level; however, in the long run and after an amendment of the Treaty provision, we can envision an EU-wide policy on health professionals’ wages.
While the proposal of an EU-wide minimum salary (adjusted for living costs) has not been met with universal enthusiasm, it may be more politically feasible to introduce it within the medical sector. The lack of human resources in the health sector is ever-more visible and politically relevant in Member States, and the impact on state budgets more limited than that of a universal minimum salary.
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