The international migration of health professionals has been a growingfeature of the global health agenda since the late 1990s. In Europe, theaccession of more countries to the European Union (EU) since 2004 hasincreased the scope for mobility among health workers and raisedadditional issues within the European context.• The dynamics of international mobility, migration and recruitment arecomplex, including individual motives and the different approaches ofgovernments to managing, facilitating or attempting to limit the outflowor inflow of health workers.• Health worker migration can have positive and negative aspects. It can bea solution to staff shortages in some countries, can assist countries thathave an oversupply of staff, and can be a means by which individualhealth workers can improve their opportunities and standard of living.Nevertheless, it can also create (additional) shortages of health workers incountries that are already understaffed and undermine the quality of andaccess to health care. It can also affect the morale of the health workforce.• There are various types of migration, which may have different effects andrequire different types of policy attention, and which vary according towhether a country is a source of or a destination for health workers.• Migration of health workers is part of the broader dynamic of change andmobility within health care labour markets and in terms of policy shouldnot be addressed in isolation.• To meet the policy challenges and to manage migration, three areas ofaction are required:- improving the available data on migratory flows of healthprofessionals so that monitoring of trends in flows can be moreeffective;- paying more detailed attention to options to manage the processes ofmigration in order to reduce any negative effects on supply of healthprofessionals; and- in all affected countries, ensuring that human resource policies,planning and practice in the health sector are effective and thus allowsupply to be better maintained.Managing migration of health professionalsExecutive summaryMigration of skilled workers is generally on the increase. In the health sector,physicians, nurses and other health workers have always taken the opportunityto migrate in pursuit of new opportunities and better career prospects. Inrecent years, however, the level of this migration has grown significantly.Source countries that lose skilled health staff through out-migration may findthat their health systems suffer from, for example, staff shortages, lower moraleamong the remaining health care staff, and a reduced quality or quantity ofhealth service provision. Nevertheless, the migration of health workers can alsohave positive aspects, such as assisting countries that have an oversupply ofstaff and offering a solution to a shortage of staff in destination countries. Itcan also allow individual health workers to improve their skills, careeropportunities and standard of living.Migration among health workers is part of the broader dynamic of change andmobility in health care labour markets, and in policy terms should therefore notbe addressed in isolation. Moreover, the dynamics of international mobility,migration and recruitment are complex, covering: individuals' rights andchoices, health workers' motives and attitudes, governments' approaches tomanaging, facilitating or attempting to limit the outflow or inflow of healthworkers, and recruitment agencies' role as intermediaries.In the WHO European Region, the accession of more countries to the EuropeanUnion (EU) in 2004 and 2007 increased the scope for mobility of healthprofessionals. Some countries, particularly those in the eastern part of theRegion, are concerned about the out-migration of health workers as a result ofaccession.This brief considers the policy implications in Europe of the internationalmigration of health workers and addresses the question of how the migrationof health service professionals can be managed in ways that reduce anynegative effects on supply.

It focuses on three related aspects:

• monitoring migration (understanding trends and flows);• motives for migration (why health professionals move and the implicationsfor policy formulation); and• managing migration (what the aims are, and what is feasible in relation tothe appropriate management of migration).MonitoringAny examination of health worker migration must relate the numbers leavingor entering the country to the overall number leaving the health workforce. ForPolicy briefexample, many health workers may actually remain in the country but will haveleft the health sector. There are also different types of migration requiringconsideration.

Thus there are two important measures of migration that policymakersshould consider:

the stock of migrant workers in the country as apercentage of the total stock available to work or practise (this indicates theextent to which the country is reliant on migrant health workers); and the flowof workers into and/or out of the country (critical in assessing how significantoutflow might be). Measuring flow can also provide insight into the currentmigratory connections between countries.Overall, the available data suggest that migratory flows of health professionalshave increased, in terms of flows both into Europe from other regions and fromthe EU accession countries into western Europe and elsewhere. To date,however, the flow from accession to longer-standing EU Member States has notoccurred at the rate predicted before accession.MotivesIndividuals are motivated to move for different reasons. Migration is not justabout a one-way flow from source to destination. Health workers may leaveone country to work in a second, and then either return home or move onto athird country, or both. They may even live in one country and regularly cross anational border to work in another. Policy-makers must develop anunderstanding of the drivers of the migration of individuals and occupations ifthey are to develop policies that effectively manage the supply flows.ManagementTo assist in mitigating any negative impact on the supply of health workers,policy-makers should examine three types of measures.Measures to improve monitoring of health worker migrationPolicy-makers should ensure that the two main indicators required for assessingthe relative importance of migration and international recruitment are available:trends in the inflow of workers into the country from other source countries(and/or outflow to other countries) and the actual number of internationalhealth workers in the country at any point in time.Measures to direct migratory flowsSeveral policy interventions can be used actively to direct the inflow or outflowof international health workers, including bilateral agreements and codes ofconduct, but the current absence of research and evaluation in this area is amajor policy constraint. A priority for policy-makers must therefore be toManaging migration of health professionalscontribute to improving the evidence base by sharing experiences andcommissioning evaluations of their effects.Measures to improve human resource policy and practiceThe migration of health professionals does not occur in isolation from otherdynamics within health care labour markets. Migration may be a symptom ofdeeper problems in health systems, such as the challenges of retaining healthprofessionals and improving workforce planning to reduce over- or undersupply.Attention must therefore be paid to more general human resource practice inhealth systems, and specifically to fair and equitable treatment for all healthprofessionals (be they home-trained or international) and efficient deploymentof their skills. This requires collaboration among different governmentdepartments and with other stakeholders. Improvements in this direction willassist in reducing any negative effect that migration would otherwise have onhealth system performance.