Portugal’s National Health Service (NHS) offers universal coverage, is comprehensive, and is predominantly financed through general taxation. The NHS is the main provider of healthcare for which user fees are applicable to persons above a certain income level, but there is a growing private sector, as well as public-private partnerships in the hospital sector. The management of the NHS mostly takes place at central and regional levels. The Ministry of Health is responsible for the definition, implementation, and monitoring of national health policy objectives, for the strategic management of funds, and employs service providers. There are five Regional Health Administrations (RHA), which have the mission of ensuring access to quality healthcare to the population under their jurisdiction and to implement the National Health Policy. Under the RHAs, which are directly accountable to the Ministry of Health, there are local health units (unidades locais de saúde), groups of health centers (ACES; agrupamentos de centros de saúde), and hospital centers (centros hospitalares). Local Health Units are groupings of health centers and hospitals, usually composed of two or more previously autonomous organizations, functioning under a common management structure. Seventy-three groups of primary care health centers have been created in 2009 to improve efficiency through better coordination and sharing of resources. In 2012, the Ministry of Health has announced that the number of ACES would be reduced to 46, as part of the austerity program which the Government of Portugal is conducting. The creation of more local structures was presented as an effort towards decentralization, but in the absence of financial autonomy, the dependency on RHAs remains strong. Hospital centers are groupings of at least two hospitals located in the same region (although frequently involving hospitals in different towns). From those hospitals most of them acquired, in the last 10 years, a legal status of financial and administrative autonomy (EPE, Entidades Públicas Empresariais - Public Autonomous Organizations). Only Local Health Units and EPE hospitals or Hospital Centers have the autonomy to directly hire health personnel [1].

In Spain there is also a NHS providing universal coverage, almost fully funded from taxes and predominantly within the public sector. Access to services is free of charge at the point of delivery [8]. Planning and the delivery of health services are done at the level of the Autonomous Communities. There are 17 regional ministries or departments of health, with jurisdiction over the organization and delivery of health services within their territory. Health expenditure is mainly determined by these regional administrations, which are accountable only to their regional parliament and are not hierarchically linked to the national level [8].

The national Ministry of Health and Social Policy has only the authority over legislation on pharmaceuticals and is the guarantor of the equitable functioning of health services across the country. The Ministry became in 2009 the national authority in the field of social and dependency care [9]. There are also local authorities in some provinces and municipalities that have the competency over sanitation and which collaborate in health services provision and direct management of ‘residual’ public health and community services [8].

The medical and nursing workforce

In Spain [10] and in Portugal [11–14] there is a deficit of updated and valid data on the health workforce in general. Multiple sources offer partial views of reality, as illustrated by the list of sources of data available in Portugal (Table 3). In the next two sections, data available will be presented and discussed.

Health workforce	Variables	Comments
Information sources
Medical Council (Ordem dos Médicos)	Name	• Only demographic characteristics and geographical distribution based on the area of residence.
	Residence
Registration	Age
	Year of graduation	• Lack of information on register updating as a result of long-term absence, death, or retirement.
	School of graduation
	Specialization (most of the times)
Nursing Council (Ordem dos Enfermeiros)	Name	• Demographic characteristics and geographical distribution based on place of work.
	Address
Registration	Age	• Lack of information on register updating as a result of long-term absence, death, or retirement.
	Year of graduation
	School of graduation
	Place of work
	Specialization
Dental Council (Ordem dos Médicos dentistas)	Name	• Demographic characteristics and geographical distribution based on the area of residence and work.
	Address
Registration	Age
	Year of graduation	• Lack of information on register updating as a result of long-term absence, death, or retirement.
	School of graduation
	Place of work
	Residence
	Nationality
Pharmacy Council (Ordem dos Farmacêuticos)	Name	• Demographic characteristics and geographical distribution based on the area of residence.
	Address
Registration	Age	• Lack of information on register updating as a result of long-term absence, death, or retirement.
	Sex
	Professional area
INE, Statistics Portugal	Resident population according to sector of activity.	• The national population censuses provide the broadest picture available of the workforce in general and of the healthcare workforce
National population census
		• Last one in 2011.
INE, Statistics Portugal		• INE uses the databases from the administrative proceedings of professional association (Councils and Labour unions).
Health workforce statistics
Central Administration of the National Health Service, Ministry of Health (ACSS Administração Central do Sistema de Saúde)	Annual data	• Personnel working in the National Health Service (mainland, not including the islands of Azores and Madeira).
	Nationality
	Profession
	Age	• Comparison of data in temporal trends is possible only for national aggregated data.
	Sex
Health personnel database	Place of work (Health Region, hospital, primary healthcare)
	Professional specialization
Ministry of Labour and Social Affairs - Strategy and planning office (Ministério do Trabalho e da Segurança Social - Gabinete de estratégia e planeamento)	Annual data	• The legal imperative of providing the information exists for all the enterprises but the practice is that the public ones do not perform this duty regularly.
	Workers nationality
	Remuneration
	Contract types
Personnel list from all the enterprises with workers (Quadro de pessoal)	Remunerated number of hours by month, normal and supplementary hours
Portuguese Foreigners and Border Affairs Department (Serviço de Estrangeiros e Fronteiras)	Nationality	• Information on foreigners; the declared profession maybe different from that the person had on its country of origin.
	Profession that allows to have means of living at the moment of request of residency
Request of residency in Portugal	Age, sex
	Level of education

Portugal

In 2010, the number of physicians per 1,000 population in Portugal was above the EU27 average (3.8 in Portugal; 3.4 EU27 average). The density of nurses was well below the EU27 average (5.7 per 1,000 population versus the EU27 average of 7.9); Portugal has one of the lowest ratios of nurses to physicians in the EU (1.5 versus 2.5 in EU27) [1].

Foreign physicians and nurses represent a small proportion of the total of professionals working in the Portuguese NHS: 6.85% of physicians and 1.19% of nurses in 2008 [2]. There has been an increase of foreign workers from 313 in 1994 to a peak of 4.490 in 2004 [14, 15]. Until 1999, the main source of foreign health workers was the five African countries with Portuguese as official language (former Portuguese colonies until 1975), but after 2002 Spain became the main source country. Last available data show that 46% (n = 799) of foreign physicians and 49% (n = 319) of foreign nurses were from Spain [14, 15] (Tables 1 and 2).

Spain

In Spain, the number of all categories of health professionals per 1,000 population has increased steadily over time, principally nurses, dentists, or pharmacists, whereas the physicians/population ratio has grown more slowly. In 2010, there were 3.8 registered physicians per 1,000 as in Portugal, and 4.9 nurses, a figure well below EU27 average [16]. National figures differ slightly from those provided by the World Health Organization (WHO) or even by regional authorities due to the absence of a central registry of health professionals [8]. There is no national data registry of health professionals but rather 17 regional registries. The National Health Service Human Resources Commission has the task of planning for the needs of the NHS [17]. Various autonomous communities have started to hire doctors trained abroad, mainly from Latin America, in certain specialties for which they expect a shortfall, but no figures are available.

The evolution of the total number of Spanish physicians and nurses in Portugal is related to the evolution of Spanish workers mobility (Figures 1 and 2). The highest peak for physicians was achieved in 2005 (1,140 physicians, Figure 1) and in 2003 for nurses (1,427, Figure 2 and Table 2).

Information on the mobility of professionals was collected by telephone interviews of key informants. This method was selected to minimize time and financial costs due to distances between health units along the border. Key informants were human resources managers or their representatives.

The study units were health organizations located along the border between the two countries. The distances between the cities from both sides of the border are typically around 100 km (for example, 101 km from Badajoz to Évora, 112 km from Huelva to Faro).

The selection in Spain was based on the Hospital National Catalogue, which publishes a list of public and private (for-profit and not-for-profit) hospitals [21]. The 26 health units, out of a total of 87, located in the Autonomous Communities bordering Portugal (Galicia, Castilla y León, Estremadura, and Andalucía) were selected. Telephone contacts were made to identify hospitals with >20 beds and which employed Portuguese health professionals: the final list included 13 units. The excluded units include a home for the elderly, two which did not meet the number of beds criterion, two which shared the same administration and human resources department of selected hospitals, and eight with no Portuguese health professionals on their staff.

Further telephone contacts were made to identify the Human Resources manager and to request an interview. Emails were sent with information on the project and with the interview schedule. The correspondence with Spain was in Spanish.

An interview schedule was designed to cover the following topics: (1) characterization of the population of health professionals from the other country working in the organization (categories of professionals, specialties, whether they live in the country of work or not, evolution of number of contracted over time); (2) reasons for mobility; (3) reasons for hiring foreign professionals; (4) consequences of mobility (for the organization, for the country, for the specific region); and (5) incentives: local and organization level incentive policies to stimulate recruitment. The interviews were conducted during December 2010 and January 2011. They were recorded and summarized according to thematic areas for analysis purposes.

All pre-selected organizations in Portugal responded (Table 4) and four in Spain (Hospital of Santisima Trinidad, Salamanca; Sanatorio of Santa María, Pontevedra; Juan Ramón Jimenez Hospital, Huelva; Miguel Dominguez Hospital, Pontevedra). No response was obtained from the other nine Spanish hospitals, even after repeated contacts by telephone. These hospitals are general district hospitals, which do not offer care in some specialty areas such as cardiothoracic surgery or neurosurgery. In Portugal, this type of specialized care is provided in central hospitals located in the metropolitan areas of Lisbon, Oporto, and Coimbra.

Mobility was mainly of Spanish physicians coming to Portugal and of Portuguese nurses going to Spain. Tables summarizing the findings are provided as Additional file 1.

Portuguese nurses in Spain

Profile

In Spain, at the time of interviews, two nurses from Portugal worked at the Hospital General de la Santisima Trinidad in Salamanca, 12 at the Sanatorio of Santa Maria in Pontevedra, and one at Juan Ramón Jimenez Hospital in Huelva intermittently. The Miguel Dominguez Hospital in Pontevedra started to recruit Portuguese nurses in 2007, and had hired 23 since then, who stayed for periods of between 1 and 2 years.

There were no reports of Portuguese physicians working in these organizations in Spain.

Reasons for mobility

Portuguese nurses look for better working conditions, or simply a job, as there is unemployment and under-employment of nurses in their country. Informants indicated that Portuguese nurses were basically attracted by the availability of positions and that they were sought after for their good qualifications and positive attitudes towards work.

Reasons for hiring

Spanish interviewees reported that since 2008 there has been an increase of Portuguese nurses going to Spain for periods of 1 or 2 years, but no specific reasons were implied for hiring Portuguese nurses besides the need to respond to the sporadic demand.

There was no report of incentive policies.

No consequences were reported. In Spanish interviewees’ opinion, Portuguese nurses are well considered and recognized as equals by their Spanish hosts in terms of professionalism and qualifications.

In general, the main reasons that bring physicians from Spain to seek work in Portugal and nurses from Portugal to go to Spain are similar. The main pull factor for professional groups is job opportunities, and for physicians, the possibility of doing a residency and access to better learning opportunities and salaries are also factors of attraction (Figure 3).

This was a first attempt to characterize the mobility of health professionals across the border of the two countries. The study was conducted from Portugal and from a Portuguese perspective. Further studies with a Spanish counterpart would most certainly constitute an added value to the knowledge on cross-border mobility between the two countries.

The data obtained is not accessible through information publicly available by the Ministry of Health, Regional Health Administrations or the organizations themselves. The design of the study allowed the authors to complete it in a context of time and budget constrains (the study was performed as part of the European Union funded project ‘MoHProf - Mobility of Health Professionals’ [22]) and to obtain new data and perceptions.

The results have to be interpreted in light of limitations relative to the number of interviewees (one per organization) and to the absence of validation against the organizations’ registries. Also, the limited number of Spanish respondents (four out of 13 eligible hospitals) means that only a partial picture of the phenomenon of cross-border mobility is available.

The 103 physicians identified as working along the border in Portugal represented about 15% of Spanish physicians working in the Portuguese NHS (Table 1) and 15% of physicians in the organizations surveyed [19], which themselves accounted for 6% of the total bed capacity of the NHS (Table 4). This is not quantitatively large, but in isolated regions of a small country like Portugal, they may have a significant impact on access to services and thereby have important policy implications.

The present study explored the mobility trends along the borders between Portugal and Spain to understand better the motives for which professionals decide to work on the other side of the frontier. Trends have been of Spanish physicians to Portugal and of Portuguese nurses to Spain. The number of professionals involved is small, but the impact on health organizations along the borders is important. The motives for crossing the border are mostly related to greater availability of work in the destination country.

In the European Union, there is freedom of movement of workers, and Member States that are geographically contiguous need to take into account as they plan their workforce the possibility that health professionals may decide to cross their borders for work. Portugal only has borders with Spain, with which it has some cultural affinities, which makes migration easier. To our knowledge, no national (or regional in the case of Spain) policy exists to ‘manage’ these flows. Key informants did not even see the need for such policy and seemed satisfied with the current situation. This not to say that it is not needed when the whole health workforce and health system is considered; for instance, migrant professionals are a gain for the receiving country, but a loss of investment for the sending one. When they reach a significant level, migratory flows are a symptom of labor market deficiencies and of poor planning. The question of the need or opportunity for governments to intervene is raised and harmonization of policies between neighboring countries may be opportune. Whether this will happen depends on the political willingness to address health workforce issues, such as that of mobility. To our knowledge, neither in Portugal or Spain there is an explicit health workforce policy and any form of monitoring and analysing mobility trends, such as exits of health professionals from the health sector or from the country. In that sense, the issue of managing the consequences of cross-border mobility is as much political as it is technical.

Claudia Leone, International Public Health and Biostatistics Unit, Center for Malaria and other Tropical Diseases and WHO Collaborating Center for Health Workforce Policy and Planning, Instituto de Higiene e Medicina Tropical, Lisbon.

Cláudia Conceição,School of Health Sciences, University of Minho.

Gilles Dussault , International Public Health and Biostatistics Unit, Center for Malaria and other Tropical Diseases and WHO Collaborating Center for Health Workforce Policy and Planning, Instituto de Higiene e Medicina Tropical, Lisbon.