Elsevier

Health Policy

Volume 114, Issues 2–3, February 2014, Pages 97-108
Health Policy

Review
Health professionals moving to… and from Portugal

https://doi.org/10.1016/j.healthpol.2013.05.009Get rights and content

Abstract

The mobility of health professionals in the European Union is a phenomenon which policy-makers must take into account to provide the conditions to adjust for demand and supply of health services. This paper presents the case of Portugal, a country which at the same time imports and exports health workers. Since the early 1990s Portugal became a destination country receiving foreign health care professionals. This situation is now changing with the current economic situation as fewer immigrants come and more Portuguese emigrate.

Foreigners coming to Portugal do so in part for similar reasons that bring Portuguese to want to emigrate, mainly the search for better work conditions and professional development opportunities. The emigration of Portuguese health professionals is also stimulated by the difficulty for recently graduated nurses, dentists and diagnostic and therapeutic technicians to find employment, low salaries in the public and private sectors, heavy workloads, remuneration not related to performance and poor career prospects.

The paradoxes described in this study illustrate the consequences of the absence of a policy for the health professions. Strategies based on evidence, and on an integrated information system that captures the dynamic evolution of the workforce in health are not only necessary but also a good investment.

Introduction

The mobility of health professionals between countries and within countries has received increase attention in the last few years, both from researchers and from policy-makers. The phenomenon of migration of physicians, nurses and other health workers is better understood in terms of the factors that motivate qualified professionals to migrate. The literature describes in detail the so-called “push and pull” factors behind such a radical decision. These are a mix of economic, political, professional factors at play in the places of origin and destination. The perceived negative effects of such migration on source countries, such as loss of investment in the education of qualified workers or reduced access to health services, have led to the adoption by the World Health Assembly of a Code of practice on the international recruitment of health personnel in 2010 [1]. Promoters of the Code were principally concerned with migratory flows from low-income countries and with practices by richer countries which did not seem to take into account the damages they were causing by actively recruiting in countries which already suffered from important deficits of health workers.

Even though all recognized the existence of such migratory flows, little was known on their amplitude, their direction or the form they took (permanent, temporary, cross-border, transit, circular, etc.). This lack of data and knowledge existed in the European Union, which brought the European Commission to commission research to better document the phenomenon within its borders. An additional motivation was to assess whether the freedom of movement of persons within the Union had affected the health workforce. Three studies have produced a total of 47 country cases with a view to document better mobility flows and their effects [2], [3], [4]. One point of consensus among these studies is that there are important variations between countries, between professional groups and between time periods.

In this paper, we discuss the case of Portugal, a small country of the Iberian Peninsula which presents specificities which should interest students of migration of health professionals. It went from being a source then a destination and recently again a source country. Also Portugal has only one neighbour, Spain, and flows of physicians and nurses across the borders have also fluctuated according to economic changes and to health sector reforms. We first present data on the stock of health professionals (physicians, nurses, pharmacists and dentists). We then identify the factors which influence the various flows from and to other countries, and within the country; this is of interest because Portugal is composed by a continental part and two groups of island in the Atlantic (Azores and Madeira) which have their own health care system. The final section is a discussion of the consequences of these flows on the health services system and their policy implications.

In addition to documenting the phenomenon of mobility of health professionals in Portugal, over the last decade, our objective was to better identify and understand its consequences in terms of planning and monitoring the health workforce and its implications for policy development.

Section snippets

Materials and methods

An inventory of statistical and other relevant information sources on the general context of the health sector and on the health workforce was first performed. This was conducted in 2009, as part of the European Union funded project “MoHProf – Mobility of Health Professionals” which covered a mix of destination countries within the European Union and of source countries from outside [5]. A template for the preparation of the case study was developed by project and applied as rigorously as data

The stock of health professionals

Since 2000, there has been a continuing growth in the absolute number of physicians, nurses, dentists and pharmacists and in their density per 1000 inhabitants [6], [8]. In 2009 the density of physicians per inhabitants was above the European Union average, whereas density of nurses was below [9].

In terms of the geographical distribution of registered professionals per population, the coastline is significantly advantaged [6], [10], though the regional distribution of nurses and of pharmacists

Discussion

Even when health workers migratory flows are not quantitatively large, in small countries like Portugal, they may have a significant impact on access to services and thereby have important policy implications. Outflows of nurses appear to be an increase, and recent information indicates a similar recent trend among physicians [30], [31]. If the flows augment, shortages may result and access to services may suffer. At the same time, young Portuguese who studied medicine abroad may be making the

Conclusion

Since the early 1990s Portugal became a recognized destination country, receiving foreign health care professionals. This situation is now changing with a clearer trend in the emigration from Portuguese health professionals.

There is no monitoring of health professionals migratory flows, and no strategic plan for the development of the health workforce in Portugal. The paradoxes described here illustrate the consequences of the absence of a policy for the health professions. This policy, in line

Conflicts of interest

None declared.

Acknowledgements

This study was part of the MoHProf (Mobility of Health Professionals) project, supported by the European Commission Directorate Research's 7th Framework Programme, Grant agreement No.: Health-F2-2008-223049, and coordinated by WIAD (Wissenschaftliches Institut der Ärzte Deutschlands), in Germany, 2009–2011. The authors are grateful to all the entities that provided data, information and interviews, and to Andreia Silva, Paulo Ferrinho, Nuno Sousa, Giuliano Russo, for their help in obtaining

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