In the case of the equitable movement of people for work, there is however a dichotomy between the principle and reality. This is partly because the principle applies primarily to workers with ‘desirable’ professional profiles and their family members. Moreover, the right to work is intertwined with the right of residence as per Article 45 of the Treaty on the Functioning of the European Union (TFEU). As a consequence, residency restrictions apply to unemployed EU citizens living in another Member State, while specific labour market access barriers were put in place for workers from the Central and Eastern European accession countries (currently in force in 13 countries for Croatian workers, at least until mid-2015). The welcome is thus only lukewarm for economically inactive individuals without family ties or savings, especially from Central and Eastern Europe.
Europe’s effort to stimulate cross-border mobility for employment purposes has been restricted to those who possess the intellectual, social or monetary capital to migrate successfully in the first place. Recent political debates and media reports about Romanian and Bulgarian migrants – many of whom belong to the Roma minority who are less likely to possess sought-after professional competences or academic qualifications – have clearly demonstrated this. For vulnerable individuals who might gain most from mobility there are few opportunities to obtain formal employment, on the contrary, they are often accused of wrongfully taking advantage of social security benefits and healthcare services.
National regulations can quickly turn unqualified individuals into ‘irregular migrants’, which is why many Europeans bypass formal registration procedures and work in precarious, low-pay black market jobs. They might be EU citizens but their status is second-class. In cities like Brussels, they live side-by-side with migrant populations from outside of Europe who also may or may not have a regular residency status. EU and national policies (employment, migration, health, development, etc.) lack coherence and are ill-suited to the new patterns of global mobility.
From a public health perspective, the limits of mobility also entail other problems. ‘Undocumented’ residents, whether Europeans or third country nationals, in many countries are unable to access healthcare, which aggravates their specific conditions, creates potential health threats for the wider community (e.g., due to lack of vaccination, transmission of communicable diseases, etc.) and causes mental distress. This is clearly unacceptable and has nothing to do with solidarity as it creates a rift between ‘them’ and ‘us’.
Migration for work in healthcare services has also demonstrated the potential drawbacks of stimulating migration without giving thought to its effects. Over the last years, thousands of Southern and Eastern European doctors and nurses have left their countries in search of higher salaries and better working conditions elsewhere; amplifying health professional shortages in many regions. Likewise, the 2010 WHO Global Code of Practice on the International Recruitment of Health Personnel needs to be implemented by stakeholders at all levels to avoid further ‘brain drains’ from the developing world to Europe and encourage ethical recruitment practices. Third country nationals are much more vulnerable to exploitation, and often they do not have the power to speak up for themselves in case of disrespectful treatment or discrimination. Their freedom of movement tends to be restricted to one employer or sector in one Member State only. The sustainability of Europe’s health systems should not rely on countries that have far fewer resources to organise, educate and retain their own health workforces. Hence Europe needs to take urgent action to solve the crisis.
The free movement of people, goods and services in the EU also impacts greatly on the quality of healthcare, especially in areas that are ‘undersupplied’. On the one hand rural and economically disadvantaged regions in migrant sending countries struggle to provide basic healthcare services due to growing resource limitations, and on the other hand receiving countries experience problems related to health systems’ ability to adapt to international flows. The increasing role of the private sector in healthcare (e.g. international recruitment agencies, outsourcing) and subsequent ease of migration has revealed that not all mobility is necessarily desirable as it can exaggerate existing health inequalities. Finally, discussions over the modernised Professional Qualifications Directive have brought to light mounting concerns over the competences and communication skills of migrating health professionals, and the transposition of the Cross-border Patients’ Rights Directive has been uneven, with problems experienced by non-national residents of other EU Member States.
To conclude, mobility and its impact on health systems is complex and it is in the EU’s best interest to work towards sustainability and prevent violation of health workers’ rights. As noted by Linda Mans of the Wemos Foundation and Project Coordinator of the Health Workers for All (HW4all) partnership:
‘If European member states would invest more in sustainable health systems, the free movement of people, goods and services in the EU wouldn’t erode national health systems. But the growing inequality in access to health providers in Europe shows differently. As healthworkers4all we call upon Europe to see strong leadership and commitment ensuring that issues related to health workforce mobility firmly remain on the EU agenda.’
Sascha Marschang is Policy Manager for Health Systems at the European Public Health Alliance (eEPHA)