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.
From receiving to sending country
Interviews conducted with informants from professional councils and trade unions in a septe study and statistical data on foreign health workers in Portugal suggest that the country evolved from receiving foreign health professionals, mainly from Spain and to a lesser extent from the Portuguese-speaking African Countries (PALOPs) and Brazil, to sending professionals to other countries [3, 22]. Unemployment, precarious employment, and the difficulty to access specialty training were the main reasons for Spanish physicians to come to Portugal. The number of unemployed physicians in Spain was estimated at 24,000 physicians (22% total) in 1999 [23]. Emigration was estimated at 900 physicians per year between 2002 and 2006 [10, 24], with the USA [10], Portugal, and United Kingdom [24, 25] as the main destinations. Access to postgraduate specialty training was limited as the number of candidates was higher than available positions in the 1990s [26, 27]. Portugal became an option for those unable to access specialty training [26–28]. The opening of positions in the public sector in Spain from 2008 onwards triggered the return of physicians.
Unemployment was the main reason for Portuguese nurses to go to Spain. The Portuguese Nursing Council estimated, in November 2012, that 20% of total nurses are unemployed or underemployed [29]. The time between the end of their studies and their first job has increased in the last 3 years. In 2009, 29.7% of them waited 3 months to start their professional activity. In 2010 and 2011 the mode was 3 to 6 months (29.1% in 2010 and 28% in 2011) [30]. Between January and October 2012, the Nursing Council received 1,035 requests for certificates of qualification, a document needed to work in a foreign country [29].
Although one interviewee stated that the flow from Spanish nurses to Portugal has decreased after 2008, NHS data (Figure 2 and Table 2) show a trend to decrease starting in 2003. Also for physicians (Figure 1 and Table 1) this trend started before, in 2005. Previous work on physician’s geographical distribution (in 2008) had showed that being Spanish increased the odds of being based outside the Lisbon and Oporto metropolitan areas [31]. This might indicate that Spanish physicians working along the border are not returning to Spain at the same pace as those working in the biggest urban areas.
Cross-border mobility impact
Cross-border mobility impacts not only on individual health workers, but also on how health services are organized, planned, and delivered, as well as on their quality and efficiency. Like most healthcare systems, those of Portugal and Spain are challenged by workforce imbalances [32]. This is the case when the labor market cannot absorb professionals willing to work or when working conditions and career development opportunities are not seen as satisfactory. This may trigger various types of mobility: within the healthcare system from one type of job or of organization to another one, movement between regions, emigration, or even exit of the health sector. Mobility along the borders of neighboring countries is an attractive option, particularly when there are cultural affinities and when it allows maintaining close links with the country of origin, like is the case when a professional works in another country but continues living in his own. For health organizations, access to a foreign workforce close by can be seen as an opportunity to expand their recruitment area. Two recent studies [33, 34] have documented trends similar to those observed in Portugal and Spain; mobility along the borders of Austria and Hungary, Belgium and France, Belgium and the Netherlands, France and Switzerland, are examples. In our study, key informants stated that the benefits of employing professionals from across the border were much greater than the problems that they may entail, such as language differences or the difficulty to harmonize titles and degrees.
The situation after 2011
The interviews were conducted at the end of 2010 and beginning of 2011. More recent developments show that Spain and Portugal’s health sector had to bear the consequences of the economic crisis. Both countries have applied austerity measures that have greatly affected the health sector.
In the case of Portugal, there has been budget and personnel reduction of public hospitals [35], doubling of user fees (applicable to households above a certain level), cuts in reimbursement of medicines, and exclusion of services from insurance coverage [36].
Efforts to achieve fiscal balance have also affected both countries workforce, including salary cuts and freezing of promotions and a reduction of personnel replacement rates [37, 38]. In Portugal, public sector health professionals’ salaries have become less competitive with private sector’s ones, which has stimulated transfers to that sector [39]. In Spain, surgical and clinical activities also suffered a significant reduction causing an increase of workload for health professionals (mostly of nurses) [38].
In general, data on health workers employed in public services do not show reduction in total numbers neither in Portugal nor in Spain [40]. Nonetheless, there are reports of mobility of Spanish and Portuguese health workers to the UK, especially from nurses [41]. There is also some new evidence, although not official, of health professionals going to Latin America as an alternative to European Union countries. There are no signs that the economic crisis will end soon in neither country, and there is a need to monitor the further consequences on the mobility of its health workforce, which at present no mechanism is set to do.
The regulation of cross-border mobility
The responsibility for planning and regulating the health workforce in Portugal is shared between the Ministries of Health and of Education and Professional Councils. There is no explicit policy or formal strategic plan for the development of the health workforce in Portugal, even though this has been identified as a need [13]. The National Health Plan 2004–2010 recommended the development of a human resources for health plan, but no steps were taken in that direction. A position paper commissioned in preption of the NHP 2011–2016 proposed a strategic framework, including objectives for the 2011–16 period to be discussed by stakeholders and validated by further studies [11]. The discussion has yet to take place.
In Spain, each regional government usually has their functions regarding health divided between a health department and the regional health service. The health department is responsible for regulation and strategic planning, while the regional health service is responsible for operational planning, management of the services network, and coordination of healthcare provision.
The health system also draws on the input of a number of other ministries; in the case of human resources regulation, the Ministry of Education, is responsible for the regulation of health professionals’ undergraduate training and, in association with the Ministry of Health and Social Policy, of postgraduate training and human resources planning.
In both countries, the main regulatory mechanisms of physician’s numbers are the numerus clausus and the exam to access postgraduate specialty training. In Spain, in spite of unemployment and emigration of physicians, there are claims that there is a deficit of physicians [10, 24, 42, 43]. In Portugal, the numerus clausus for entry into medicine has fluctuated from 805 in 1979 to 272 in 1984, and then gradually increasing up to 1,400 in 2007 [44] and to 1,517 in 2012 [45]. The basis on which the numerus clausus and the number of specialty places are established are not explicit. There is an unmet demand for medical training which brings unsuccessful candidates to seek training opportunities abroad. An estimated 1,300 young Portuguese study medicine in Spain, Hungary, the Czech Republic, Slovakia, among other countries [46]. As in Spain, there is no consensus on whether there are enough, too few or too many physicians in the country. The absence of strategic thinking and planning results in a reactive policy of successive decreases and increases of numerus clausus and places for specialty training.
In Portugal, there is no policy to attract national physicians and nurses to regions of the interior. In fact, the Ministry of Health has opted for recruiting foreign health workers through bilateral agreements with Latin American countries, starting with Uruguay, and then with Cuba, Colombia, and Costa Rica, to fill positions in isolated or remote areas. This ad hoc strategy may be linked to the fact that Portugal’s health labor market is no longer attractive for its own professionals as indicates the success of recruitment agencies offering more attractive job opportunities to work in richer European countries and in places as far like the Gulf States and Australia [47].
