Sweden. Mobility of Health Professionals

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1 1 Sweden Mobility of Health Professionals WIAD (Wissenschaftliches Institut der Ärzte Deutschlands) Scientific Institute of the German Medical Association Bonn, Germany, October 2011 Funded by Grant agreement No.: Health-F

2 2 This national report was written by Prof. Per-Gunnar Svensson Marie Rosberg Gustafsson Desirée Kaplan +46 (0) (0) (0) Regional research partner and contact: Dr. Caren Weilandt +49 (0) WIAD - Scientific Institute of the Medical Association of German Doctors (Wissenschaftliches Institut der Ärzte Deutschlands gem. e.v.) Ubierstrasse Bonn, Germany Telephone +49 (0) (Reception) Telefax +49 (0) Sole responsibility lies with the author. Neither the European Commission nor any person acting on behalf of the Commission is responsible for the use which might be made of the following information.

3 3 Table of content Litst of Tables... 7 Executive summary... 8 Push/pull factors summary...8 Summary and key findings of interviews Basic country information Population The National Board of Health and Welfare The Swedish Association of Occupational Therapists The Swedish Medical Association The Swedish Dental Association The Swedish Association of Health Professionals Swedish Association of Local Authorities and Regions Recruitment of non-swedish Health Care Professionals in Sweden s County Councils Regulations on Training for non-swedish Health Professionals in the Swedish Health Care System Geo-political data Economic indicators Health Status and Health System Health Indicators Health System: General Information The Labour Market in the Health Sector Supply of Health Professionals Occupational Therapists Physiotherapists Physicians Nurses Dentists Health professional education Policy Framework Immigration and emigration policies in general... 31

4 4 3.2 Other policies with inadvertent effects on migration of health workforce License for EU/EEA Member Countries and Switzerland Non-EU/EEA Members Swedish Language Qualifications for non-eu/eea Members Occupational Therapists, Physiotherapists and Nurses Physicians Dentists Shifts in politics and major political parties affecting policy change; Approach to health and approach to migration To what extent policies are enforced; responsibility for the enforcement Incentive schemes used to retain or recruit healthcare professionals Migration Flows General migratory profile Inflows and Outflows of health professionals Occupational Therapist Physicians Physiotherapists Nurses Dentists Context of Migration Flows Results of qualitative interviews Macro Findings Meso findings Micro findings Main results from the micro interviews References Annexes I: Basic country information Population Basic demographic data Numbers and indices of births, deaths Life expectancy at birth Natural increase rate Age/sex structure (age pyramid)... 61

5 Rural/ urban split Population increase over time, 2008: Population by sex and age, 2008: Population ranked by age Geo-political data Political stability indexes Transparency corruption perception index Economic freedom index Quality-of-life indexes Human development index Economic indicators GDP per capita (in USD), GDP growth rate Labor market indicators Activity rates Unemployment rate / Employment rate by sex/age Number of workers divided into sex and age Employment in the health system as a proportion of overall workforce Annex II: Health Status and Health System Health Indicators Mortality (by diseases, incl. maternal and infant mortality) Death and DALY estimates by 2002 (WHO) Morbidity (top ten by DALYs) Health System: General Information Total expenditure on health Total expenditure on health as percentage of GDP Total expenditure on health as percentage of total government expenditure Total expenditure on health per capita total Number of hospital beds per 100,000 inhabitants Supply of Health Professionals Total number of registered health workers by specialization per 100,000 population Registered health workers by specialization Registered health workers by public/ private units Licensed dental health care workers occupied within the dental health care by sector and county, November Health care professionals occupied within the health care sector by occupation, age and gender, Nov Health professional education... 78

6 Average number of education years, (Including source of/ responsibility for financing/ payment) Number of newly licensed practitioners in relation to respective overall number Annex III: Policy Framework Immigration and emigration policies in general Government institutions responsible for migration policy Annex IV: Migration Flows General migratory profile (according to IOM template) Basic facts: Immigrants Number of immigrants Status of immigrants Main countries of origin of immigrants Emigrants Number of emigrants Main countries of destination Male/female emigration Remittances: Quantitative aspects of remittances Inflows and Outflows of health professionals Nurses Numbers per occupation and age leaving and entering Dental students leaving Sweden for studies abroad Annex V: Interviews List of interviewed key stake holders Interview 1: Kalmar Landsting Kalmar County Council Interview 2: Östergötlands Landsting Östergötland County Council Interview 3: Landstinget i Östergötland - Östergötland County Council Interview 4: Tandläkarförbundet - The Swedish Dental Association Interview 5: Region Skåne - The Region of Skåne Interview 6: Region Skåne - The Region of Skåne Interview 7: Högskoleverket - The Swedish National Agency for Higher Interview 8: Education SKL - Swedish Association of Local Authorities and Regions (SALAR) Interview 9: Socialstyrelsen - National Board of Health and Welfare Interview 10: Sveriges Läkarförbund - The Swedish Medical Association Interview 11: Socialdepartementet - Ministry of Health and Social Affaires Interview 12: Vårdförbundet - The Swedish Association of Health Professionals Interview 13: Kalmar Landsting - Kalmar County Council Interview 14: Interview 15: Tjänsteman på Utbildningsdepartementet - Administrative Official, Ministry of Education and Research Utbildningsutskottet - The Parliamentary STanding Committee on Education Interview 16: Conservative Member of Parliament Interview 17 Physician from Germany

7 7 Interview 18 Physician from the Netherlands Interview 19 HR-Professional Dental Care Interview 20 Nurse from Germany Interview 21 Dentist from Poland Interview 22 Dentist from Bulgaria Interview 23 Physican from Russia Interview 24 HR Hospital Interview 25 Physician from Bulgaria Interview 26 HR-Professional Primary Care Interview 27 Physician from France Interview 28 Nurse from Burundi Interview 29 HR-Professional Hospital Interview 30 Physician from Germany Interview 31 Physician from Syria, trained in Germany Interview 32 HR-Professional Dental Care Interview 33 Physician from Germany Interview 34 HR-Professional Dental Care Interview 35 Dentist from Poland Interview 36 Dentist from Pakistan Interview 37 Physician from Germany Interview 38 Nurse from Norhern Ireland Interview 39 Dentist from Iraq Interview 40 HR-Professional Primary Care Interview 41 HR-professional Hospital care Interview 42 HR-professional Hospital care List of Tables Table 1 Occupational Therapist Licenses issued to non-swedes (%) Table 2 Physician Licenses issued to non-swedes (%) Table 3 Physiotherapist Licenses issued to non-swedes (%) Table 4 Nurse Licenses issued to non-swedes (%) Table 5 Dentist Licenses issued to non-swedes (%) Table 6 Table 7 Sampled health professionals with EU- or non-eu origin at different types of work places Sampled HR managers at different work places with different types of background... 53

8 8 Executive summary The report describes the migration flows for non-swedish health professionals (physicians, dentists, nurses, occupational therapists and physiotherapists) with a foreign education in Sweden, recruitment activities and training efforts of the Swedish employers. Our aim is to identify patterns and gain understanding of this phenomenon. The report presents three describing research questions concerning the ground research and a fourth analyzing question where the data is interpreted in a global context. The case study involves quantitative and qualitative data of health professionals coming to Sweden from other countries and other themes related to the mobility of health professionals. Contextualization is made by pointing out particularities for Sweden against the background of a general theoretical framework on mobility. The results show an extensive amount of information regarding mobility of physicians including recruitment and training efforts concerning this occupation. Regarding the remaining four (dentists, nurses, occupational therapists and physiotherapists) we have identified knowledge gaps concerning quantities as well as other lacking information regarding both recruitment and training activities. Active recruitment of physicians from the EU/EEA is common according to this research. To a smaller extent dentists are also being actively recruited. Concerning other occupations examined in this research, active recruitment is rare. The same applies for training programs offered to non-swedish health professionals with a foreign education. The county councils in general have, with some exceptions, a comparatively good picture of the situation in their organization. On the other hand, it is in our opinion still surprising that some county councils lack information and data on professionals that they have recruited themselves. Moreover, the county councils do not seem to have specific recruitment policies for foreign health workers, although they present a largely homogenous general view on the phenomenon. The training and educational efforts offered to non-swedish health professionals are focused on physicians. We were surprised to find such shortages in for example language training for dentists, considering almost 25 per cent of the dentist s work force is born abroad. Another area where there is an apparent lack of knowledge is regarding migrating health workers from Sweden. Our findings in this area are extremely limited. We realize indeed that this is a complex phenomenon to study, since it requires close cooperation and exchange of information with health care institutions abroad. Push/pull factors summary Among push factors influencing health professionals to leave Sweden are lack of job opportunities for nurses who leave in particular to Norway and limited intake of students to medical curricula. Other factors are salary levels, limited intake to further education curricula and opportunities for personal and professional development. There is also an expressed dissatisfaction with high Swedish taxes and organizational difficulties in the Swedish health care system.

9 9 When we summarize pull factors that attract health professional to go to Sweden to work, we receive a much longer list than that of push factors. This may indicate that Sweden is a relatively attractive country to migrate to for these particular professions. Work environment, working hours, opportunities for professional development and specialization, chances for a permanent job contract, egalitarian work climate, freedom of expressing ones own thoughts at work and reasonable salary levels are all factors related to the work place and as such pull factors for people to go to Sweden. Pull factors related to other aspects of life that we found are the Swedish easily accessible nature and that one will get a better life here through good health care services, better conditions for their children and the Swedish welfare system that for example give parents, to share, 18 months parental leave with only slightly reduced economical benefits related to salary levels. We did not find much information on stick factors that will prevent health professionals from leaving their home countries despite obvious disadvantages. However, information on that issue may be available in the other country reports within the MoHProf-project, in particular from countries like Poland and Germany from which Sweden receives significant numbers of physicians. Stay factors preventing migrant health professionals from returning to their home countries are mainly a selection of above mentioned pull factors. The social and work environment are also among mentioned as stay factors, democracy and equality likewise. A unique stay factor not mentioned as pull factor is the responsibility Swedish employers take for the whole family in order for them to feel welcome and happy, spouse to get a job etcetera. Summary and key findings of interviews In September-October 2009, 21 people were interviewed from 13 stake holder organizations and authorities. They represent national and central as well as regional level of decision and policy making with significant relevance to the health care sector. The qualitative interviews were performed according to an interview guide commonly agreed by the researchers involved in the overall MoHProf project. We found in analyzing the summarized interviews that answers by stake holders to the issues brought up in the interview guide could be categorized at three levels, macro/meta, meso and micro. Among the macro findings were a commonly praised appreciation of the EU directive of free movement of EU citizens within EU boarders. Also commonly agreed was the ongoing professionalization of health workers in general and not only among physicians as it was in the past. Solidarity was also commonly agreed to be applied in not exploiting countries with short supply of health workers when recruiting abroad. Stake holders also agreed among them that they assume that Sweden as destination country is much more attractive, in many ways, than the country of origin. Also informants agreed that the shortages in Sweden of health professionals, in particular physicians and dentists, have to be compensated by foreign recruits. We also found responses at the macro level that indicate a power struggle between different stake holders not only about migration of health workers but also in general about organizational and work process issues. With the exception of the

10 10 Swedish Medical Association some stake holders expressed the belief that the health care sector would benefit if there was an over supply of physicians. Finally, among macro findings, it was found that foreign health workers were received, briefed and educated in quite different ways in different parts of Sweden. Among meso findings we found a polarization at least in the past between the Swedish Medical Association and most of the other stake holders in regard to the need for increasing intake of students to medical curricula. It was said that Sweden should be self sufficient in providing health professionals to the health care system. However this should be balanced with an exchange of health workers with other countries. Most stake holders felt that Swedish health care system was attractive for foreigners because it offers a less hierarchical organization with high quality and further education opportunities. We also found that in regions/counties with a medical faculty there was no need for actively recruiting from abroad. They are self sufficient in providing health professionals to their organization. A certain phenomena called relay/baton physician is applied when one cannot fill vacancies permanently. In particular in places without medical faculty recruitment agencies provide such relay/baton physicians. Further, physicians feel that they are not listened to enough and that administrative burden take a huge toll from the essential patient work. Only 35-45% of their time is spent with patients said one stake holder. Also it was observed that the nurses union and the medical union had different views on task shifting and delegation. Increased technology and competencies has shifted the responsibilities and work tasks, making assistant nurses and nurses more qualified, resulting in changes in the hierarchy. According to the Swedish Medical Association, clinical work should always be lead and managed by senior physicians. Most other stake holders including the nurses union, The Swedish Association of Health Professionals, felt that management should be done by a skilled manager, be it a nurse, a physician or an administrator. It was commonly agreed that the traditional role of secretaries to physicians is or will be replaced by administrators with a broader competence. Finally as previously mentioned, a model is emerging that include categories or dimensions of the phenomenon of migration of health professionals sorted at three different levels: Meta/macro, Meso and Micro. The latter, micro level, has not yet been approached in the interviews but will be so in the spring of At that stage we will according to the over all plan for the MoHProf project select informants who has hands-on experience from migration of health professionals. They may be clinical managers or administrators, migrant health professionals and/or colleagues.

11 11 1 Basic country information Sweden is a multicultural society as a lot of different people live and work side by side, resulting in the meeting between Swedish and other foreign cultures making Sweden a divers country. (Daun, 2005) We believe it is relevant to describe the Swedish mentality and the Swedish culture as it affects relations and organizations. The Swedes draw a distinct line between private and official life. This can contribute to difficulties when non-swedes work in Sweden, since it is unusual for friends at work to be friends outside work. The importance of being alike, striving for consensus is central and it influences many parts of the Swedish life and culture. Swedes often avoid talking about sensitive issues were they might risk a confrontation. In other countries it is more common to socialize in bars and restaurants, while in Sweden (with an exception for the younger generations) courses or weekend classes are popular, where you can meet others with the same interest as yourself (Daun, 2005). There is also an unusually short distance between decision makers and citizens, as well as managers and their employees, and the manager is often more of an advisor than a boss (Daun, 2005). Sweden is often said to have a feminine culture that emphasizes the social surrounding in a friendly atmosphere (Daun, 1994). In a study on 40 countries, Sweden proved to be the most feminine (Daun, 2005). A feminine culture is characterized by valuing personal relationships, quality of life and cooperation. It emphasizes equality and strives to solve conflicts by compromise and negotiation. A manager in a feminine culture often seeks consensus when making decisions. A masculine culture on the other would emphasize money, competition and success, and lives to work instead of, like the feminine culture, work to live (Hofstede, 1991). The definitions we have found relevant to develop further in this section have emerged during the work of this report. As they are not multifaceted we have adopted a common definition of these conceptions. Born abroad are registered by the Swedish authorities, but born in another country. Active recruitment describes efforts made by employers to attract and recruit staff to their organization, meaning anything that does not involve spontaneous applications. Foreign health care professional is a person born outside of Sweden with a degree from any other country than Sweden, within any of the licensed professions examined in this study (physicians, dentists, nurses, occupational therapists, physiotherapists). Non-Swedish is a person who is born abroad. The National Board of Health and Welfare is a government agency under the Ministry of Health and Social Affairs that works to ensure social welfare and high-quality health care for the Swedish population. The main task for The National Board of Health and Welfare is focused on personnel, managers and decision-makers in areas, which includes health and welfare in Sweden. The Boards function is to improve, give support, influence and supervise health and care services. The Board also keeps statistics within these areas. The Ministry of Health and Social Affairs creates regulations and

12 12 guidelines in the health care and medical services area and also determines qualifications for professions in the health care sector, the Board s task is to implement and monitor these regulations and guidelines (The National Board of Health and Welfare, 2009). The Labour Unions in Sweden have a high number of members, compared internationally. The unions have an important role as the negotiator between employers and employees when issues or conflicts occur in the workplace. The unions have played an important role through the labour history of Sweden, and during the 20 th century the amount of people belonging to a labour union increased. Today, the numbers of members are more unstable, especially among younger workers, immigrants and in the recruitment agency trade. Nonetheless, Swedes tend to take the labour unions for granted, and it is assumed that every workplace has a representative for their specific union, working with questions regarding labour legislation (Kjellberg, 2001). Of all physicians in Sweden, 90 per cent are members of their labour union, the Swedish Medical Association (hereinafter, the SMA), and 90 per cent of all occupational therapists have joined The Swedish Association of Occupational Therapists. The nurses union, The Swedish Association of Health Professionals has members (this includes nurses, midwifes, radiographs, and biomedical analysts), The Swedish Dental Association (hereinafter, the SDA) has 8800 members and Swedish Association of Registered Physiotherapists has members (SMA Website, 2009, The Swedish Association of Health Professionals Website, 2009, The Swedish Association of Occupational Therapists Website, 2009, SDA Website, 2009). Sweden is divided into 18 County Councils and two regions. The County councils or Regions main responsibility is health care. Eight out of ten of their employees are working within the health care sector. The County councils or Regions have employees in Sweden and the County councils and municipalities work together within the health sector. The majority of physicians in Sweden are employed by County councils and regions. Nurses, on the other hand, are employed both by County Councils/regions and municipalities (SALAR, 2009). Sweden consists of 290 municipalities which is a part of the public sector and provides services within the fields of education, infrastructure, social services and care (of for example elderly people and disabled). The latter is a main task that accounts for almost 30 per cent of their budgets. The number of employees in Swedish municipalities 2009 is (SALAR, 2009). The Swedish Association of Local Authorities and Regions (hereinafter, SALAR) represents the governmental, professional and employer-related interests of Sweden's 290 municipalities, 18 County councils and two regions. The Association strives to promote and strengthen local self-government and the development of regional and local democracy. The operations of the Association are financed by the fees paid annually by members according to their tax base (ibid.) The international unit, based in Stockholm and Brussels, looks after the European interests of the Association's members and tries to influence policy initiatives at an early stage. Mainstreaming the European and international perspective into the daily work of municipalities and County councils or Regions is an important part of this role (ibid.).

13 Population Below we report responses from the national authorities and labour unions that have responded to our questionnaires and provided us with relevant information. See also Annex I The National Board of Health and Welfare The National Board of Health and Welfare issued licenses in Sweden to professionals from EU/EEA countries. In total, licenses have been issued during the same period of time The Swedish Association of Occupational Therapists The Swedish Association of Occupational Therapists (hereinafter FSA) has given their opinion on a department of state memorandum regarding health care professionals from third country. The Association welcomes a procedure of recognition for health care professionals from third country. The Union for occupational therapists in Sweden states that licensed health care workers is a guarantee for a certain level of knowledge and that health care professionals practice their profession and complete their duties with responsibility. The Association has on several occasions acknowledged that occupational therapists from other EU/EEA countries have completed an education not approved by the World Federation of Occupational Therapists (hereinafter WFOT). Curricula not approved by WFOT minimum standards can lead to quality issues. By issuing licenses the society secures a qualification level in the health care sector and creates a security in the care which increases safety for the patients which has to be in focus in the health care system. The Swedish Association of Occupational Therapists states that if a Swedish certificate shall be issued for a non-swedish occupational therapist with an education from third country these professionals should have a diploma from a university with an education approved by WFOT and a diploma from a higher education program that extends over three to four years. Those who do not live up to these standards shall complement their education by a Swedish university that holds courses for occupational therapists The Swedish Medical Association The Swedish Medical Association (SMA) has little knowledge about Swedish medical students emigrating to study abroad. However, the medical student s division in their organization has a group for students overseas. The Union tries to facilitate the procedures of foreign physicians to enter the Swedish labour market by informing them about working conditions in Sweden. To Nordic physicians, they offer a wide range of material, which also includes a labour market prognosis. The SMA follows the county councils work closely. Several projects have been held under the county councils regime and the SMA has mainly been involved in three of these, the Stockholm project, the Malmö project and the Gothenburg project. The projects are no longer financed by the government and the activities in the county councils have faded. Since the Swedish Public Employment Service phased out the division for foreign academics have preparations of such courses, before compulsory test for physicians from outside Europe, been cancelled.

14 14 The SMA works in different ways to reach foreign physicians for example via ILIS (International Physicians in Sweden) which is a part of the SMA that works to facilitate for foreign physicians to enter the Swedish labour market. The SMA is involved in courses held for physicians (courses for returning Swedes, physicians from within the EU member states and physicians from other countries). The SMA has a positive view of migration both within and outside Europe; the migration within the EU can for example stimulate increase of salaries when the competition for health care work force increases between employers. The SMA are members of Standing Committee for European Doctors (CPME) and has recently passed a policy that considers ethical recruitment for health care personnel from countries with a fragile health care system The Swedish Dental Association The Swedish Dental Association (SDA) states the importance of employers giving a wide introduction to the employees and clarifies working conditions in Sweden and educates the foreign dentists in Swedish laws and regulations. The SDA has no official opinions about recruitment to or from Sweden since this is a natural part of the mobility within and outside Europe. Advantages with this mobility can be that the individual is able to move to where work can easily be found and the individual can be in a place where he or she wants to live. Disadvantages with this form of mobility can be that it makes it more difficult to estimate the requirements on the labour market for dentists in the future since migration flows are difficult to predict. Earlier, the SDA issued written information to those Swedish dentists who wanted to emigrate. At the moment they provide information and can help members with issues regarding emigration. The labour market in Sweden is at the moment satisfactory for dentists, therefore the written information is no longer needed in the same way as it was 10 years ago. The Union refers to their webpage and answers questions by phone to members seeking information of emigration The Swedish Association of Health Professionals The Swedish Association of Health Professionals represents four professions; nurses, midwifes, radiographs, and bio medical analysts. The Swedish Association of Health Professionals reports difficulties with the certification process and all the paperwork it includes. Foreign employees should receive more help from employers to understand and to deal with this process according to the Union. The Swedish Association of Health Professionals has a positive experience from Stockholm County Council who had an employee who helped newly arrived workers with paper work and general integration. The process worked well and was facilitated, this was mainly a service to employees from countries outside the EU. The Swedish Association of Health Professionals declares that not enough is done to help and integrate health care personnel that have arrived to Sweden. Not only it is important to integrate foreign workers, but also to prepare the wards where foreign workers work; it is not only a question of integrating foreign health professionals but also of integrating Swedish workers and organizations with the migrating workers.

15 15 Since a few years back, the Stockholm division of the Union has a set appointment for foreign members where the participants function as a support for each other through the license process and as a social support. The Swedish Association of Health Professionals does not see any dilemmas with the mobility; it generates knowledge and develops professionals. The Swedish Association of Health Professionals has had a close cooperation with The Swedish Migration Board, the Swedish Public Employment Service, the county councils and regions, The National Board of Health and Welfare and the SMA in recruitments made to Sweden. However, when the EU was extended to 25 member states these appointments has seized since most recruitments are done within the EU. The Swedish Association of Health Professionals has had clear guidelines for the recruitment process. Recruitment agencies publish ads for vacancies in The Swedish Association of Health Professionals Magazine; the Union has no opinions regarding this. On their webpage the Union has published information for those members who are seeking to work abroad. It is uncommon for western health care personnel to end up in difficulties with salaries, employment agreements and discrimination but it occurs more often to poorer countries health care personnel. The Swedish Association of Health Professionals offers help to members to scrutinize employment agreements and contracts offered by foreign recruitment agencies. Advantages by going abroad via a recruitment agency can be that the employee receives help dealing with the license process, which holds a considerable amount of paper work, accommodation and work permit. Disadvantages can be that the worker is tied to one work place and the employee has to work a certain period of time at one place. If the worker decides to break the contract the individual can be obliged to pay a refund Swedish Association of Local Authorities and Regions The European Hospital and Healthcare Employers Associations (hereinafter HOSPEEM) and the European Federation of Public Service Unions (hereinafter EPSU) has developed a code of conduct that was sent to us by the Swedish Association of Local Authorities and Regions (hereinafter SALAR). HOSPEEM and EPSU are cooperating to create collaborations for national employers in the health care sector on European level to coordinate their work in the development processes. The code of conduct consists of 12 key principles and commitments. The first principle regards a high quality health care, accessible for all people in the EU meaning that every member state should work for quality in the health care, viewed as a basic human right for the European population. The code of conduct also points out the importance of keeping registration and data collection regarding migration in the health care sector to be able to form policies on ethical recruitment. The third principle stresses the value of having well developed HR-strategies to ensure quality and quantity of the workforce. HOSPEEM and EPSUs code of conduct highlights the importance of equal access to training and career development in order to secure competence and improve the care. By actively working for better training opportunities and lifelong learning, a high quality care will be achieved. Information regarding vacancies should be open and easily accessible for example on the webpage for the European Job Mobility Portal (EURES). Employers should always give the accurate information concerning work conditions and contracts of employment. Professionals also need to provide information on their training, education and skills. Information regarding living conditions in the receiving country should be made accessible before arrival. The migrant health care worker should also be informed about the local context and guidance in

16 16 local/national regulations. These activities are made to facilitate that the migrant settles in easily to the new environment. The code of conduct clearly takes a stand against discrimination and points out the importance of equal rights between native born health care workers and migrant workers. Migrant workers should always have the same working conditions, same pay, and also the same rights and protection of legislation in the receiving country. Health care employers shall recruit ethically and not engage a recruitment agency that employs workers on false premises. Migrant health workers should also have the right to join a labour union. The last principle formulated by HOSPEEM and ESPU concerns the implementation of this code of conduct; it shall be implemented within three years ( ), by its members. Users of this code of conduct shall also monitor and report concerning the implementation and a follow-up will be made the fourth year Recruitment of non-swedish Health Care Professionals in Sweden s County Councils Below we report responses from the nine Swedish county councils and regions that have responded to our questionnaires and provided us with relevant information. Stockholm County Council In the Stockholm County Council the recruitment of foreign physicians is focused on EU/EEA member countries. In most cases recruitment of physicians from within the EU/ EEA is conducted on an individual basis when a specific competence is needed. Most non-swedish physicians are recruited through a congress or a research project exchange. According to the Stockholm County Council the recruitment process for health professionals from non-eu/eea member countries is affected by the difficulties of receiving a residence permit in Sweden. The National Board of Health and Welfare does not by principle process applications for a Swedish medical license from applicants from non-eu/eea member countries that do not live in Sweden. The Stockholm County Council recruits nurses from within the EU/EEA. The recruitment process is initiated by a needs assessment conducted by each employer. The Council cooperates with an international agency in the recruitment process as well as using different media for job advertisements, participates in trade fairs or conducting information meetings to recruit nurses from EU/EEA member countries. The Stockholm County Council is cooperating with the Swedish Public Employment Service and its regional offices to use the resource of physicians from non-eu/eea member countries that are already living in the County of Stockholm. Thereby it is probable that they already have a residence permit. The County is offering their help to health professionals living in Sweden with a degree from a non-eu/eea member country by initiating the process to receive a Swedish medical license and introduce them to the Swedish health care system. Kronoberg County Council Approximately 32 per cent of Kronoberg County Councils physicians are non-swedish. The Kronoberg County Council has previously been actively recruiting physicians from abroad but as the number of vacant positions has decreased the recruitment process has slowed down. The countries that have been their main focus when searching for physicians abroad are Germany, Poland and Hungary. The

17 17 Kronoberg County Council does not have a policy regarding recruitment of foreign health professionals. The demand for physicians has been the determining factor. When there are not enough Swedish physicians to fill the vacancies of the council they have begun recruiting abroad. The Kronoberg County Council adds that it is primarily specialists that have been recruited, no interns or specialist interns. Kronoberg County Council have not actively been recruiting nurses from abroad, as the local universities have been able to provide them with the nurses needed for their organizations. The general opinion of the Kronoberg County Council is that international mobility is positive. They support the changes now being made in the Swedish university system, aiming to improve the synchronization with the other European education systems. They believe this will increase the mobility for Swedish health professionals, and enable them to work abroad to a larger extent. This would contribute to a higher level of competence and improve the Swedish health care system. Kronoberg County Council argues that recruitment of health professionals abroad is positive as long as it is done with afterthought. They acknowledge the risk of brain drain, as the competition of health professionals can be unbalanced if the recruitment is too focused on a few countries. The Kronoberg County Council also noticed a growing population of non-swedish health professionals applying for work in Sweden on their own initiative. Kronoberg County Council claims there are about 2000 Swedish health care students in other European countries who are likely to return to Sweden after graduating. This is an interesting group for this Council. The Council has only a few non-swedish nurses with a foreign education, as the Swedish university system have provided the region with enough nurses to fill their vacant positions. Kalmar County Council Approximately 15 per cent of the Kalmar County Councils physicians are non-swedish. They are mainly from Poland, the Netherlands and Germany. The County is actively recruiting physicians from Poland, as they have their own recruitment agency there. It is called Kalmena Rek and was established in It is based in the city of Kalmar and it has an affiliated company in Warsaw called Medena Rek Polska. There is one Swedish and one Polish managing director. Over the years the Council has brought around 60 new staff members to the health care sector of Kalmar County Council, both physicians and dentists. The new recruits get a 27 week training course in Warsaw. In fact, 50 per cent of the non-swedish physicians in Kalmar County Council are Polish. Apart from their recruitment agency, the County also participates in trade fairs abroad. The main reason for this is the lack of specialists within the County. The Kalmar County Council states that mobility of health professionals in the long run is positive. Free movement is a reality, in the same way non-swedish health professionals come to Sweden, health professionals from Sweden go abroad. According to the Kalmar County Council the exchange and spread of competence and knowledge is the most positive outcome of international mobility. This Council has no information regarding the quantity of non-swedish nurses with a foreign education working for them.

18 18 The Region of Skåne The Region of Skåne have 1072 non-swedish physicians with a foreign education and 30, 5 per cent of them are from outside Europe, 23 per cent are from EU 16-27, 19,5 per cent are from EU15, 17 per cent are from other Nordic countries and 10 per cent are from other European countries. The region does not actively recruit physicians from abroad. They are aiming to use internships in the long-term to fill their vacancies as well as to support the Regions future needs. The non-swedish physicians working in the Region of Skåne at the moment are a result of the natural international migration flows. Regarding nurses the Region has 1035 non-swedish nurses with a foreign education and 43,5 per cent of them are from other Nordic countries, 35 per cent of them are from outside Europe, 11 per cent are from EU 16-27, 10 per cent are from other European countries and 8 per cent are from EU 15. The Region does not actively recruit nurses either, but they have done so in the past. As for today, the Swedish system of higher education has provided the Region with a sufficient number of nurses. Being the most southern Region of Sweden, its geographical proximity to Denmark has affected their staff composition. Some of the Regions specialist nurses have been recruited by Danish health organizations. The Region of Skåne claims that this is not a problem to them, even though it has been affecting them. The Region points out the importance of making their health care units as attractive as possible in order for the nurses to stay working for them. In general, the Region of Skåne believes mobility of health professionals and the recruiting of physicians from abroad brings more experience to the work force. Other positive aspects of international mobility according to this Region are the exchange of competence that in the long run increases the total competence of the work force. It also increases understanding and eases situations when cultural differences or misunderstandings occur. The Region of Skåne views the mobility as a trigger to become a more attractive employer, in order for the Region to keep the staff and their competence. They are also hoping it will make nursing a more attractive profession. The Region of Skåne states that a negative side of the mobility of health professionals is the sometimes lacking Swedish language skills, as well as knowledge of laws and regulations. The Region confirms the need to create a system to fill out the possible knowledge gaps with the new recruits from abroad. This could turn out to be expensive and it also requires a higher level of knowledge from the Regions recruiters, in knowing what to look for and what qualities are needed. The Region of Västra Götaland The Region of Västra Götaland is actively recruiting physicians from other countries, mostly specialists in the areas of primary health care, psychiatry, radiology, anesthesia and internal medicine. The most common countries to recruit from are Germany, Hungary, The Netherlands and Spain. Physicians from Germany and The Netherlands do not need an extensive introduction, which makes them more attractive to recruit. Recruitment in Hungary gives many applicants, and Spain has a primary health care similar to the one in Sweden. The Region of Västra Götaland prefers to recruit specialists, and they try to avoid countries such as Poland and the Baltic countries to minimize brain drain. They have good contact with the authorities of the countries they recruit from.

19 19 The Region of Västra Götaland does not actively recruit nurses from abroad. Norway has recruited quite a few from the Region of Västra Götaland. The Region states that they can not take any measures towards this problem. The Region states that many Swedish health professionals studying abroad are likely to return to Sweden after finishing their education, which is welcomed by the Region of Västra Götaland. This Region believes positive cultural aspects to be an outcome of the mobility of health professionals. Approximately 15 per cent of the Region of Västra Götalands physicians are non-swedish. Most of the non-swedish physicians are from Iran, Iraq, Germany, the Netherlands, Poland, Hungary, Italy and Greece. The Region employs only a few non-swedish nurses. Örebro County Council Örebro County Council employs a share of 26,2 per cent of their total number of physicians from other Nordic countries, Europe and outside Europe. The County Council actively recruits foreign physicians with foreign training to their organization, mainly due to lack of physicians in certain specialties. The Council particularly recruits Polish physicians, but the selection is solely based on competence. Örebro County Council employs a share of 9,3 per cent of their total amount of nurses from the Nordic countries (except Sweden), Europe and outside Europe. However, the County Council does not actively recruit foreign nurses with a foreign education. The County Council has got 17 dentists from Poland, Russia and Germany, in their organization, but does not actively recruit foreign dentists at this time. However, the Council has previously recruited actively from Germany and Poland. Selecting the country has been due to joint recruitment with other departments within the County, but also after consulting with regional public dental administrations in other counties, who have recruited abroad. The reason behind this recruitment was an insufficient number of Swedish applicants for vacancies and/or dentist shortage. Concerning physiotherapists in the Council, 7,8 per cent are non-swedish with a foreign education and as well as 5,1 per cent of their occupational therapists. Örebro County Council considers foreign health workers as a resource, which adds new knowledge and is an asset in meeting with immigrant patients. A growing cultural diversity of staff is a positive working environment. Concerning Örebro County Council s view on the recruitment being done to attract Swedish health workers abroad, the council understand that every country that has a shortage of health professionals do what they can to recruit, and then also try to attract staff who currently work within Örebro County Council. The Council perceives the importance of announcing their attractiveness as an employer, so that the health workers stay with them. Knowledge transfer across borders and provision of a better health care worldwide is according to Örebro County Council the main advantage of mobility of health workers. The disadvantage, according to the Council, can be that some countries are being drained of skilled health professionals.

20 20 Gävleborg County Council The number of foreign physicians is not registered in their system. Recruitment of foreign specialist physicians between years of age is a necessary complement to the County Council's medical supplies during the next 5 years. The Council faces a large number of retirements and they already have severe shortage of specialist physicians in a number of areas. In particular, there is a shortage of general practitioners and psychiatrists, which is a situation Gävleborg share with most counties in the country. The County Council of Gävleborg mainly focuses their recruitment on specialists from Germany and Hungary. In their selection, the Council is keen that the spouse also, on the basis of the assessment they do, can have a reasonable chance of finding work. The County Council has only got a few foreign nurses in their organization. These nurses have accompanied migrating physicians from their home country. The County Council currently employs 16 dentists from Germany, 1 from Brazil and 1 from Poland. The Council actively recruits foreign dentists, because of the lack of Swedish dentists. The reason why German dentists are most common is because Germany has a similar education as well as EU certificate. The County Council of Gävleborg offers no general training programs for foreign dentists. The County Council of Gävleborg views the recruitment of foreign health workers as a necessary addition to ensure succession within the County Council. The Council has specific guidelines and strategies for recruitment of foreign health workers. The Council has not actively been recruiting physicians from countries outside the EU. However, they do have employees and also employ physicians from other countries outside the EU. In these cases however, the physicians have applied on their own initiative. Concerning the County Council of Gävleborg s view on the recruitment being done to attract Swedish health workers abroad, their experience is that after a few years a number of physicians return and bring new knowledge to the Swedish health care system (in the same way as physicians they have recruited return to their home country) According to the County Council of Gävleborg, the main advantage of mobility of health workers is that the Council can find specialists they suffer a shortage from. Moreover, they find it a stimulating and enriching experience with multi-cultural exchange and the opportunity for knowledge transfer between countries. The disadvantages are that it requires a lot more introduction and mentoring than with Swedish employees who are already familiar with the language and the culture. One problem area is that the County Council of Gävleborg has a shortage of tutors. Västernorrland County Council The questions are answered by the County Hospital of Sundsvall-Härnösand and the answers do not apply for the entire County Council.

21 21 The County Hospital of Sundsvall-Härnösand has about 30 foreign physicians with foreign training. They come from Poland, Greece, Germany, Iraq, Hungary, Romania, Iran, Morocco and China. In addition, there are some Swedish physicians, who are trained in Finland and Denmark. On some occasions, the County Hospital has actively recruited. They have participated in a couple of recruitment fairs in Berlin, and on three occasions made use of recruitment agencies. The companies have actively recruited in Poland, Hungary and Germany in order to search internal medicine, psychiatrists and neurologists who are scarce in Sweden. The County Hospital has successfully sought after anesthetists in Hungary and after neurologists in Poland. They have sought specialists with a few years of experience. The County Hospital of Sundsvall-Härnösand views the recruitment of foreign health workers as necessary since there is a shortage of physicians in Sweden. Nevertheless, most foreign physicians employed by the County Hospital have voluntarily applied for work in Sweden due to educational opportunities and the working environment being better than in their home country. There are some countries, for example Greece, that educates more physicians than their domestic demand, which results in that at almost all advertising campaigns, there are many Greek applicants. The County Hospital has no specific guidelines concerning foreign physicians, but they are trying to deal with foreign applicants in the same way as with Swedish physicians. Concerning the County Hospital of Sundsvall-Härnösand s view on the recruitment being done to attract Swedish health workers abroad, they suggest that since there is free movement within the EU, they must accept that their staff is attracted to other countries. According to the County Hospital of Sundsvall-Härnösand, the main advantage of mobility of health workers is that the health workers, from Sweden and from abroad can learn from each other. Understanding of other cultures is important. Having personnel with different backgrounds facilitates contact with foreign patients. The disadvantages are that there inevitably will be additional work, additional tutoring, new routines, culture clashes, organizational disruptions, communication problems etc. Värmland County Council The Värmland County Council claims that it is not possible to respond precisely to how many foreign physicians they employ and where they come from, but they have recruited about 75 physicians in the last couple of years. Their spontaneous applicants originate mainly from Greece. The County Council actively recruits through projects. These recruitments include specialists in the main shortage areas e.g. radiology, psychiatry, internal medicine etc. They have recruited mainly from Poland, Estonia, Hungary and Slovakia and to some extent from the Netherlands and Germany. The County Council of Värmland does not have any data on the number of nurses employed, with a foreign background. The County Council do not actively recruit foreign nurses with a foreign education.

22 22 The County Council does not actively recruit foreign dentists with a foreign education. They argue that it would be costly and a lengthy process. However, the Council currently employs dentists from Romania (3), Estonia (3), Switzerland (2), Spain (1), Lithuania (1) and Iran (1). The Värmland County Councils view on international recruitment is that mobility goes both ways, Swedes move abroad to work just as well as professionals from other countries move to Sweden to work. This is a result of a global labour market, and the Värmland County Councils believes it is important to be open to meeting professionals with a different training than the Swedish. The main advantage of mobility of health workers, according to the County Council of Värmland, lies in having health care providers with the same cultural background/experience as many of their patients. They argue that international mobility inevitably places greater demands for transparency and adaptation on both the employees as well as on the organization. They see the difficulties in the increasing requirements to accept differences and yet at the same time meet the common core values. Risk of misunderstanding is rising, but the possibility of increased understanding of other cultures is increasing, they conclude Regulations on Training for non-swedish Health Professionals in the Swedish Health Care System Below we report responses from the national authorities and labour unions as well as ten Swedish county councils and regions that have responded to our questionnaires and provided us with relevant information. The Swedish Medical Association The SMA stresses the importance of good communication and knowledge of the Swedish language in all situations and meetings when working in the health care. They recommend SFI, which is a course in Swedish for immigrants, in combination with work experience in the health care. After completing the SFI-course, non-swedish physicians can attend a course in health care related Swedish. The Swedish Association of Occupational Therapists The Association highlights the importance of making sure all occupational therapists have the appropriate level of education to meet those needs, regardless if they are from an EU/EEA country or not. The EU/EEA member country citizens are at the moment able to receive a Swedish license to practice occupational therapy, even if they do not meet the standards of the World Federation of Occupational Therapists. The Swedish Association of Occupational Therapists considers this to be a problem concerning the quality of occupational therapists. If occupational therapists educational background does not meet the standards of WFOT, he or she should attend further education in Sweden to complete his or her degree. The Association also points out the importance of practical experience from the Swedish health care organizations as a complement to completing education. The Association would like language skill levels as well as knowledge of Swedish laws to be regulated by law and implementation to be overseen by the National Board of Health and Welfare. They find it very important that all occupational therapists working in Sweden have a high level of knowledge of the Swedish spoken language, but also the written language, as communication with patients and

23 23 colleagues and the responsibility of documentation all are important factors of the professional performance. The National Board of Health and Welfare Health professionals are obliged to know the laws affecting the Swedish health care system; laws regarding communicable disease control, forensic medicine regulation and regulations regarding medical products. The Region of Västra Götaland This Region has a policy for the recruitment of non-swedish physicians regarding the applicant s language skills as well as their knowledge of the Swedish law. They also recommend attending a course in health care related Swedish. An introduction course in society and constitutional studies is recommended after working one year. They also need to have good communication skills in English to simplify the education process. The Region of Västra Götaland also offers a Swedish language course in the applicant s home country, but it is more common to attend the education after arriving in Sweden. They also offer the same course to the physician s partner. The education plan differs depending on if it is a specified recruitment campaign or spontaneous applications. If it is a spontaneous application the responsibility of having the appropriate language level is on the applicant. The actual regulation describes the set standards of grades in language courses taken, alternatively the TISUS test. If it is a specified recruitment campaign for physicians, it is the employer s responsibility to set up an education schedule, which usually consists of between 3-5 months full time training. An individual evaluation is conducted for physicians educated in the Nordic countries. The Region of Västra Götaland provides a mentor to help introduce the new staff member to the Swedish health care system, the work place and the health care staff. The mentor will also function as a support in the Swedish language. The Region considers communication difficulties and differences in experience to be the most noticeable problem in relation to migrant health professionals. The Region of Västra Götaland does not offer any courses for non-swedish nurses. Östergötland County Council In 2008 Östergötland County Council had an extensive course educating the health professionals in all the areas important when working in health care in Sweden, such as medical professional s responsibilities, confidentiality, custodial care, laws and regulations, ethics and organ donations etc. The course covered around 53 hours in total. This year, 2009, the course has been extended with another 14 hours. The additional part is more focused on practical issues relating to insurance, pensions, hygiene and laws. The Östergötland County Council is currently working on a quick reference guide for their managers, in order for them to help and support newly recruited non-swedish members of staff in a better way. The reference guide will focus on the establishment where the migrant is working. They also offer a tailor made Swedish language course, as well as the opportunity to learn Swedish in ones own home country. In the case of the latter, a course in Swedish will be given parallel to the work introduction,

24 24 after arriving in Sweden. Regarding completing education concerning medical knowledge, this is up to each employer to decide. Kronoberg County Council The Kronoberg County Council has a Swedish language course for newly recruited non-swedish physicians. There are additional courses if needed, such as social and cultural education. This is also offered to any family member moving to Sweden. The Kronoberg County Council have had a collaboration with Halland County Council regarding courses and education for nurses, but as for today they do not offer any courses for nurses. The Region of Skåne The Region of Skåne does not offer any courses for non-swedish physicians. The Region have been collaborating with universities and the Swedish Public Employment Service in helping nurses from non-eu countries to complete different theoretical educational programs combined with practical work experience and mentorships. These collaborations have now ended. The Region has a Swedish language course and an introduction course offered to nurses from EU member countries. The layouts of the courses vary between different employers within the Region. Kalmar County Council The Kalmar County Council offers a 6,5 months long Swedish language course available to non- Swedish physicians. It can either be formed by the employing organization or by an external part. Regarding specialists they also provide completing medical education. The Council does not offer any courses for nurses. The County Council believes that mobility of health professionals will contribute to knowledge being spread among their organizations. They also state that they have a responsibility to develop their staff s language skills but they believe it will be expensive. Stockholm County Council The Stockholm County Council has a policy document for recruiting and employing health care professionals within and outside the EU/EEA countries. Since there are no regulations regarding the applicant s language levels when employing medical practitioners from EU/EEA countries, the Stockholm County Council have put together a document of guidelines to unify the process of recruitment and education within their County. The Council initially states that the sdentistards of language level required must be met by applicants on their own initiative, or by the employer. Physicians coming from EU/EEA countries are introduced to the education program as soon as their contract has been signed. At this stage in the process they are given an introduction course in medical law and constitutional studies. Before the physician starts working in the Swedish health care they will have to attend a Swedish language course, either in their home country or after arriving in Stockholm. The employer will also be responsible to help the physician with work experience or a field trip during this course. There will also be a tutor/mentor available during their first 6 months in the workplace.

25 25 Nurses coming from EU/EEA countries will go through a very similar process. Nurses will have access to a mentor during their first year, as well as a peer. With regard to language courses, laws and regulations etc they are offered the same schedule as physicians from EU/EEA countries. Health care professionals coming from countries outside the EU/EEA personally have to take responsibility for having the appropriate level of the Swedish language, the course Swedish B or TISUS. The process of translation the degree is more complex when coming from a non-eu/eea member country. In this case, the Stockholm County Council follows the recommendations by The Swedish Board of Health and Welfare regarding language courses and proved ability of the Swedish language, the course Swedish B or TISUS. Health professionals from outside the EU/EEA countries have to take a test called the TULE test. This is to make sure they meet the Swedish standards of medical education. The test consists of a theoretical knowledge test and two practical tests. The Stockholm County Council will help the health professionals to prepare for the test and they do so by offering them a 14 week course in medicine. The TULE test is followed by work internship. The Stockholm County Council also has a one week introduction course to all non-swedish health care professionals. Here the employees are given an introduction to The Swedish Board of Health and Welfare, other public authorities and their function in the health care system, laws and regulations, cultural and ethical aspects, communicable disease control etc. The County also offers work experience in collaboration with the Swedish authorities. Örebro County Council Örebro County Council offers no general training programs. However, the Council has offered Swedish-training if found necessary. The training includes approved knowledge of the Swedish language and the Swedish health care as a system, as well as skills enhancement and updates. Appointed tutor or an accountable manager goes through a checklist together with interested dentists to eliminate any skill gaps. Gävleborg County Council The County Council of Gävleborg offers a number of training events aimed at foreign physicians. They include language training, introduction training, completing training and other types of training that may be necessary based on individual needs. Västernorrland County Council The questions are answered by the County Hospital of Sundsvall-Härnösand and the answers do not apply for the entire County Council. The County Hospital does not provide any organized training for foreign physicians, although they have several times bought Swedish courses via Folkuniversitetet (an adult educational association). On some occasions, the Council have even customized supplementary training for newly certified physicians due to lack of practical experience among those physicians. Värmland County Council The County Council offers teaching of Swedish as well as training in medical regulations. In addition, they offer language, culture and skills training. Moreover, the training is aimed at ensuring that new

26 26 employees receive the same knowledge, values and management and health care philosophy as the rest of the organization. 1.2 Geo-political data Sweden is a monarchy without legislative power, a one chamber parliament (Riksdag) with 349 MPs that are elected every fourth year. The country is vast, the distance from south to north of the country is the same as from the south to the south of Italy. Population size is around 9,3 million (SCB.se, 2009), the main part of which lives in the southern parts of the country. 14 per cent of the population is born in another country. Sweden is a neutral, non-allied country not a member of NATO, or any other military alliance but participate with military force in international actions that are supported by the UN such as Afghanistan, Kongo-Kinshasa and Korean border ect. Sweden is a member of EU since 15 years and is at present President country until the end of See also Annex I 1.3 Economic indicators Unemployment is roughly 8,3 per cent of the labour force in October 2009 (SCB.se) while 74,3 per cent of the16-64 year old were employed GDP per capita in purchasing power standards, PPS, (EU27 =100) during 2008 was 121,0 while for example the equivalent figure for Germany was 116,0 and for Poland 57,6 (Eurostat.ec). See also Annex I.

27 27 2 Health Status and Health System 2.1 Health Indicators See Annex II 2.2 Health System: General Information Health care is a central feature of the Swedish welfare state. It is the largest of all public sectors, and accounts for a large proportion of public consumption. A decent health care service with high accessibility and quality also constitutes a valuable resource for the entire population. (SMA, 2005) The Swedish health care system is government-funded and heavily decentralized. Nevertheless, when it comes to health policy, it is a national-level responsibility that rests with the Government and the Parliament. (SKL, 2008) Compared with other countries at a similar development level, the system performs well, with good medical success in relation to investments and despite of cost restrictions. The life expectancy of the Swedish population continues to rise. In 2005, the life expectancy was 78 years for men and 82,8 years for women. This can be attributed to falling mortality risks for both heart attacks and strokes. A little more than 5 per cent of the population is 80 years or older, which means that Sweden has proportionally Europe s largest elder population. (Sweden.se Website, 2009) One of the cornerstones of the Swedish health care system is that the cost is spread over the entire population via fiscal policies. For instance, patient fees (paid by the patients themselves) charged by the county councils, account for only 2,7 per cent of total revenues. (SKL, 2008). See also Annex II The Labour Market in the Health Sector The unemployment among health care workers is low, in Sweden only among 3 per cent, which could indicate that the demand is large. The Swedish health care sector predicts that within the next three years they will have to increase the number of nurses, physicians and midwifes (SCB, 2008). The Swedish Labour Market Tendency Survey is an annual sample survey providing information about the labour market and gives a prognosis on the expected development of different occupations. The general result for the Swedish labour market shows that the number of employers in the health sector looking to recruit is decreasing (SCB, 2008). In the health care field 47 per cent of the employers have been searching for staff within the last year. For the majority of all health care related occupations there are enough new graduates but a shortage of staff with work experience. There are a few exceptions to this, for example there is a shortage of newly graduated physicians. The number of employers planning to increase the number of staff the following years has decreased with 10 per cent since 2007 (SCB, 2008). There is a good supply of newly graduated occupational therapists and physiotherapists, and since 2007 it has become easier to recruit occupational therapists than previously. Physiotherapists with work experience on the other hand have become more difficult to recruit. There is a balance between supply and demand concerning nurses and dentists, but there are not enough dentists with work experience to recruit (SCB, 2008).

28 28 Concerning health professionals with work experience, occupational therapist is the only occupation where supply and demand is balanced. All other health occupations relevant to this study are suffering shortages. The largest shortage is found in physicians and dentists (SCB, 2008). 2.3 Supply of Health Professionals See also Annex II Occupational Therapists The demand and supply of occupational therapists is predicted to increase until 2030, and the demand might increase at a faster speed. This should result in a balance over time, but as the number of people aged over 80 years in Sweden will rise drastically after 2020, the demand for occupational therapists can be expected to increase (SCB, 2008) Physiotherapists The demand for physiotherapists is expected to rise mainly as a result of the ageing population in Sweden but also the increasing investments and interests in preventive health care, such as rehabilitation in the workplace. The question of whether the demand will be balanced is depending on the budget of the county councils and municipalities. If the number of newly graduates does not increase there is a risk of shortage within this occupation. (SCB, 2008) Physicians The demand for physicians is expected to rise as a result of the growing as well as ageing population in Sweden. The number of newly graduated physicians is not predicted to be enough to satisfy the demand for physicians. This is affected by the fact that a substantial amount of Sweden s physicians will retire within the next few years. The greatest demand is expected in the occupations of specialist physicians. (SCB, 2008) Nurses In general there is currently a shortage of nurses with work experience, but the situation does differ throughout Sweden. The ageing population is expected to create an increased demand, especially within the care of the elderly and the shortage will probably culminate in (SCB, 2008) Dentists Within the next 20 years a substantial amount of the dentists in Sweden will retire. Under the assumption that the immigration and emigration of dentists is balanced, and the amounts of newly graduated dentists are held constant the supply of dentists will decrease with 30 per cent until The demand is not expected to increase or decrease. (SCB, 2008)

29 Health professional education In general, health curricula and education are part of the task of Swedish universities or equivalent institutions. The Swedish National Agency for Higher Education is overseeing that curricula and education is meeting the appropriate quality standards. This is an ongoing process of continuous assessment of higher education. See also Annex II.

30 30 3 Policy Framework In order to facilitate the free provision of services, the Directive of the recognition of professional qualifications (2005/36/EC) guarantees physicians and other persons in regulated professions having acquired their professional qualifications in a member state, plus the EEA States Norway, Iceland and Liechtenstein and also Switzerland, access to the same profession and pursue it in another member state with the same rights as nationals. The Directive provides for the mutual recognition of medical qualifications on basic training level as well as specialty level. Sweden has decided to comply with a recommendation adopted by the Council of the European Union with the objective to make it possible to perform postgraduate medical practice in another member state than that of undergraduate training. This could be an opportunity for graduated physicians who need some kind of pre-registration service in order to gain the qualification listed in an annex to the directive. The relevant clinical practice available in Sweden is either the internship program of at least 18 months duration or short-time medical appointments as locum tenants in a subordinate position. To practice in Sweden a decision of appointment from The National Board of Health and Welfare is required. Furthermore, it should be noted that in order to perform this training, sufficient knowledge of the Swedish language is a condition. (The National Board of Health and Welfare, 2009) European Directive 2005/36/EC aids mobility by obliging member states to consider the qualifications acquired elsewhere in the community to allow access to a regulated profession in their territory. The rights of EU citizens to establish themselves or to provide services anywhere in the EU are fundamental freedoms in the Single Market. However, national regulations, which stipulate specific professional qualifications for certain professions, impede these fundamental freedoms. These obstacles are overcome by EU rules guaranteeing the mutual recognition of professional qualifications between member states. When it comes to approval of training from a member state other than Sweden, it can be noted that even before the 2005/36/EC came into force, Sweden already accepted third-country nationals who have training/qualification from another EU member state. The rules of common labour market and the mutual acceptance of competence are automatically applicable also for Nordic citizens (from Denmark, Finland, Norway or Iceland) who want to be active in another Nordic country. There is, however, since 1981 a Nordic agreement on the common labour market that has a wider application area as well as simplified practice for Nordic citizens, compared to the European Commission rules. Among other things, the Nordic agreement is applicable for a greater number of medical specialties than the EC Directive as well as for physicians with training from third countries that received the Nordic identity. For this reason, the Nordic governments reached a revised agreement on the common labour market, there among physicians, which came into force April 1, The regulation on the professional duties in the health care area (förordningen SFS 1998:1513 om yrkesverksamhet på hälso- och sjukvårdens område) contains a number of authorisational provisions. The regulation states that Swedish physicians may be granted competence of general practitioners (so called European Doctors), and a number of provisions that regulates the conditions for foreign physicians, within and outside the EEA, for obtaining the Swedish medical license, specialist competence and competencies as European Doctor.

31 31 Furthermore, the regulation (SFS 1998:1513) regulates the duty of the National Board of Health and Welfare to provide necessary information and issue certificate of competence, professional activities, etc. The training and authorization unit of the National Board of Health and Welfare is the competent authority responsible for such duties for health-care professionals. 3.1 Immigration and emigration policies in general Sweden has had a history of generous immigration policies during the recent 3-4 decades. Our impression though is that policies regarding refugees from third countries have hardened recently, but not as much as in our neighboring countries Denmark, Finland and Norway. 3.2 Other policies with inadvertent effects on migration of health workforce In the Swedish health care sector 21 professions are regulated by legislation by means of authorization and/or protection of title. According to directive 2005/36/EC professions regulated on the basis of coordination of minimum training conditions are physicians, nurses and dentists. Occupational therapists and physiotherapists are regulated by the general system for the recognition of evidence of training. All EU/EEA country members have the right to work and apply for work within any other member country, according to the EU principle of free movement. No national requirements beyond the ones regarding their medical license are allowed; it is up to the employer to set the standards when it comes to language levels and knowledge of laws and regulation etc. Those who have basic training in another member state than Sweden do not have to pay any registration fee. The National Board of Health and Welfare charges 2000 SEK for validation of degree awarded to medical practitioners in a non-eu/eea member state while other occupations are charged 600 SEK. The recruits of health professionals with a foreign education who can be issued a Swedish medical license can be divided into three different categories of origin: non-eu/eea member countries, EU/EEA member countries and Swedish citizens with a foreign degree. Health professionals with an education from any EU/EEA member country do not need to have their education reviewed by the national Board of Health and Welfare License for EU/EEA Member Countries and Switzerland The application regarding certification always needs to be accompanied by a European certificate of the current occupational status. This needs to be confirmed by the accurate authority in the applicant s home country to ensure that the certification is not limited or drawn back. The certificate is called the European certificate of current professional status and is not permitted to be older than three months and has to be sent in original. New EU member countries, in which the profession is regulated on the basis of coordination of minimum training conditions, needs to send any of the following certificates in accordance with directive 2005/36/EC. These certificates are issued by authorities in the country of education. Certificates are needed since the National Board of Health and Welfare has not received enough information from the new member states. New EU member countries should be able to prove any of the following;

32 32 Certificate in accordance with the directive 2005/36/EC Certificate regarding equableness Certificate that confirms that the applicant has practiced the profession for at least three years the last five years or in some cases five years professional practice the last seven years. Physicians and dentists with specialist competence can be included by this directive Non-EU/EEA Members Foreign health care personnel from outside Europe cannot work in Sweden without passing a complementary training program in Sweden. This program involves a course and a test in the Swedish language, a medical exam as well as practice and introduction courses in the medical legislation of Sweden. Due to the lack of resources to provide this complementary training, the Board is unable to offer this compulsory program to other foreign medical graduates than those who have gained status as residents in Sweden. This is granted by the Swedish Migration Board for political, humanitarian or family reasons. Even though many applicants must be regarded as fully qualified specialists within a certain field of medicine, the above restrictions have to be enforced Swedish Language Qualifications for non-eu/eea Members A complementary program cannot begin until the applicant has satisfactory knowledge in Swedish. The applicant who does not speak Swedish, Norwegian or Danish should be able to prove any of the following: Approved in the course Swedish B Approved in a university course in Swedish for Non Nordic students. Approved on TISUS, a test for foreign students who would like to study in Swedish universities. Equivalent knowledge shall be confirmed by teachers or other qualified staff that holds courses in for example in the Swedish Folkhögskola (Folk High-Schools). Physicians and dentists with a specialist qualification have to apply for recognition. A specialist nursing title is only applicable for a nurse responsible for general care who already has obtained a license to practice in Sweden. The National Board of Health and Welfare states that is not possible for anyone with a licensed occupation to work within the Swedish health care organizations, unless they have adequate knowledge of the Swedish language. They add that the basic language course given to non-swedes, Swedish for Immigrants (SFI), is not extensive enough to meet the language standards needed to be able to work in a health care profession Occupational Therapists, Physiotherapists and Nurses Foreign professionals that fill the demands of knowledge in Swedish and have a satisfactory higher education are granted to proceed with the National Board of Health and Welfare certification complementary course. If the applicant is not considered to have an adequate education the applicant is referred to universities to complement their education and the university will issue a diploma. To estimate the applicant s knowledge, a theoretical and practical test will be held. The forms for these tests are not yet determined. The complementary course also consists of a distance-learning course in

33 33 society- and constitutional studies. Nurses from outside Europe will, after being approved in the complementary courses, be obliged to practice for 3,5 to 5,5 months before being granted a position Physicians To estimate the physician s medical competence the applicant will go through a medical knowledge test in basic clinical areas provided that the physician is approved in Swedish. Physicians with a certain specialist competence and holding a significant work experience can instead be doing practice during 6 months. Physicians will have to take society- and constitutional studies before receiving a certificate. The physician will also have to perform practical clinical training often organized in internship during at least 18 months Dentists Dentists will after being approved in the complementary courses such as Swedish language courses and society- and constitutional studies be obliged to do a test to prove the odontology competence. After succeeded test the applicant shall do 6 months practice as a dentist under the supervision of a clinic selected by the National Board of Health and Welfare. 3.3 Shifts in politics and major political parties affecting policy change; Approach to health and approach to migration Generally the conservative parties (there are four of them presently governing the country) are in favour of providing a competitive market also in health and welfare. In different ways they have nationally, regionally and locally supported the public and private health care organizations. 3.4 To what extent policies are enforced; responsibility for the enforcement Above mentioned policies have been reinforced at all levels of health care in the spirit of vårdval, meaning patients have the right to select care giver, with the exception of hospitals which mainly have been kept in the public sector. 3.5 Incentive schemes used to retain or recruit healthcare professionals Among measures to retain or recruit staff, county councils have applied different means that are related to their demand for health professionals. For example one has given higher salaries to physicians prepared to move to GP duties in rural areas. There are also examples where counties offer positions in which in particular physicians will be able to spend time on research and further professional development. For more details related to Chapter 3, see Annex III.

34 34 4 Migration Flows 4.1 General migratory profile From the 1860s until World War I the emigration was far more extensive than the immigration in Sweden (Arnstberg 2008). This changed in the 1930s when the immigration to Sweden increased and continued to do so through World War II and the following years after the war (Svanberg, 1992). Sweden has always had a large migration coming from other Scandinavian countries and during the years after the war this group increased even more. Many children were also taking refuge to Sweden from the war, as well as refugees from Estonia, Hungary, Poland and Czech Republic. In the 1960s the economic situation in Sweden was stabile and the Swedish industry had a large demand for workers. Many foreign workers from other parts of Europe moved to Sweden and continued to do so until the 1970s. In the 70s the economy slowed down, but it was still easy to come to Sweden and the labour immigration was replaced by family reunifications. In the 1980s and 1990s, refugees have dominated immigration, with immigrants coming from more distant places than before (Svanberg, 1992). 4.2 Inflows and Outflows of health professionals The following chapter contains a summary of relevant statistical data provided by The Swedish Association of Local Authorities and Regions (SALAR) and The National Board of Health and Welfare. Each profession is treated in a separate section. The percentage of licenses issued is not equal to the number of licensed foreign health workers actually working in Sweden. It has been obvious that foreign health workers apply and receive a Swedish medical license, without coming to Sweden to work Occupational Therapist Of the newly recruited occupational therapists who was born abroad, 36,4 per cent came from other Nordic countries and 27,3 per cent from countries outside Europe. The number of occupational therapists born abroad differs between Sweden s County Councils, from 0 per cent in Jämtland County Council and 8 per cent in Stockholm County Council. Table 1 shows that the number of licenses issued to occupational therapists (out of all occupational therapist licenses issued in Sweden) with a foreign education barely exceed 5 per cent during the years Licenses issued to occupational therapists from third countries are very few.

35 35 Table 1 Occupational Therapist Licenses issued to non-swedes (%) Year Foreign education % EU/EEA including Switzerland % Third Country % , , ,8 0, , , , , Physicians Non-Swedish physicians with a foreign education who have been issued a Swedish certificate have increased significantly the last 10 years. Between the years of 2003 and 2004 the number of physicians born abroad increased with 6 per cent. More than every third newly recruited physician was born abroad and 29,8 per cent of the non- Swedish physicians were born in countries outside Europe. In physicians from EU16-25 represented 25,9 per cent of the foreign born physicians in Sweden. Professionals from non-european countries are dominating in this group and 43,7 per cent of all physicians born abroad are from non-european countries. In 2004 of all physicians in Sweden 23,7 per cent were foreign. In , 22 per cent of health workers born abroad and living in Sweden were physicians. This is to be compared to the Swedish born population where only 9 per cent of health workers are physicians. The number of physicians born abroad in differs to a large extent between Sweden s County Councils, from 15, 8 per cent in Halland County Council and 31 per cent in Jönköping County Council. The year 2003 is also the first year when more foreign physicians were given a Swedish license than Swedes given a Swedish license. This development continues the following years until present. In 2006 the amount of non-swedish physicians was 25,3 per cent (and 19 per cent had a foreign education) and the following year it increased to 26,2 per cent.

36 36 In 2007 physicians with a Swedish education were given 768 licenses and physicians from the EU/EEA countries received 1149 licenses. To physicians from third country 294 certificates were issued. The National Board of Health and Welfare has estimated that there are among 800 physicians in Sweden with a Swedish background and a Swedish license but with a foreign education, in average 30 licenses a year has been submitted to this group. It is estimated that 70 per cent of this group have returned to Sweden after a completed education abroad and are working in Sweden. The countries that can be recognized as the major education countries for medical students abroad are Germany, Denmark, Greece and Iceland. The labour market for physicians is not in balance and the request is especially great for specialist physicians. Employers claim some of the specialist professions are difficult to recruit and the specialist physicians can be described as unevenly spread geographically in Sweden. Table 2 Physician Licenses issued to non-swedes (%) Year Total number of Foreign education EU/EEA (including Third country licenses % % Switzerland) % % ,5 14,2 13, ,8 7,8 13, ,3 13, ,2 6,3 16, ,5 9,9 12, ,9 14, ,2 25,1 14, ,8 20,6 16, ,5 33,9 18, ,4 48, ,5 24,6 15, ,2 18,9 19, , ,3 The table shows the continuous increase of licenses issued to physicians (out of all phycisian licenses issued in Sweden) with a foreign education between the years Between the years 2005-

37 the number of licenses issued to physicians with a foreign education from another EU/EEA member country including Switzerland has doubled. The amount of licenses issued to physicians with an education from a third country has also been increasing Physiotherapists Between the number of physiotherapists in Sweden born abroad decreased with 5,9 per cent. 48,6 per cent of recruited foreign physiotherapists were born in another Nordic country. This group represents the largest group of non-swedes in this occupation in total. The second largest group is from a non-european country. In 2004 physiotherapists with a foreign origin represented 8,5 per cent of physiotherapists in Sweden this number has the last few years decreased to 7,8 per cent in Physiotherapists with a Swedish education were in 2007 issued 496 licenses and 50 licenses were given to physiotherapists from EU/EEA countries and only one was given to a professional from third country. Looking at Sweden s county councils the number of physiotherapists born abroad varies between 4,5 per cent in Västerbotten County Council and 12,9 per cent in Jämtland County Council. Table 3 Physiotherapist Licenses issued to non-swedes (%) Year Total number of Foreign EU/EEA including Third Country % licenses % education % Switzerland % , , ,7 0, ,8 1, ,2 0, , ,1 0 Table 3 shows the development for licenses issued (out of all physiotherapist licenses issued in Sweden) to physiotherapists with a foreign education between the years Licenses issued to physiotherapists with an education from a third country are very few.

38 Nurses The number of nurses educated abroad in was stabile around 14 per cent but decreased in 2004 to 7,6 per cent and had a dip in 2006 to 4, 3 per cent. In 2007 the number of foreign educated nurses was 6,7 per cent. From 2003 to 2004 the number of nurses in Sweden who were born abroad increased with 2,8 per cent. In 2003 the nurse occupation was one of the most popular ones in Sweden, 31 per cent of the Swedish health workers were nurses. Among the non-swedish population living in Sweden 24 per cent of health workers were nurses and half of them were from other Nordic countries. In Norrbotten County Council 2003 almost 86 per cent of all non-swedish nurses were from other Nordic countries. In 2003 the majority of the newly recruited non-swedish nurses, 39 per cent, were from non-european countries. The number of nurses born abroad varies in Sweden s county councils between 3,2 per cent in Jämtland County Council and 17,2 per cent in Stockholm County Council. The number of licenses issued in Sweden 2006 reached of those were issued to nurses from EU/EEA and eight from third country. In 2007, 4220 licenses were issued to Swedish nurses and 290 to nurses from EU/EEA countries and 15 from third country. The total number of nurses born abroad have the last years steadily increased slowly and made 9,3 per cent in In ,7 per cent of the nurses working in municipalities were of a foreign origin and this was stabile around that number until The total number of nurses born abroad have the last years continuously increased slowly and reached 9,3 per cent in In ,7 per cent of the nurses working in municipalities were of a foreign origin and this was stabile around that number until The foreign nurses in Sweden mainly come from the other Nordic countries, 42,1 per cent. Totally 6,5 per cent came from EU15 countries and 12,2 per cent from the EU27 countries. 10,8 per cent of the nurses came from other parts of Europe. Further on, the demand for nurses on the labour market is in balance, but for specialist nurses a need can be recognized. Midwifes have a small migration and low unemployment. A demand for midwifes can be acknowledged by the county councils and significant retirements are approaching in the future. Table 4 shows the number of licenses issued (out of all nurse licenses issued in Sweden) to nurses with a foreign education between the years Between the years the number of licenses issued to non-swedes from other EU/EEA member countries peaked.

39 39 Table 4 Nurse Licenses issued to non-swedes (%) Year Foreign education EU/EEA including Third Country % % Switzerland % , , , , , , ,8 12,4 1, ,3 12,1 1, ,6 6,8 0, , ,3 4,1 0, ,7 6,4 0, Dentists The number of foreign educated dentists has steadily increased since 2000 when 20,2 per cent was educated abroad. In 2002, dentists who had an education from a different country than Sweden raised to 36,5 per cent. In 2002 the number of dentists educated within the EU/EEA member countries raised. It continued to do so between with 6, 1 per cent. It was in fact the occupation where the number of non- Swedes increased most of all occupations in this study. The group of non-swedes in this occupation is dominated by dentists from non-european countries, 44,6 per cent, and 4 out of 10 of all newly recruited dentists in were born abroad. The number of dentists born abroad in differs to a large extent between Sweden s County Councils, from 2, 2 per cent in Jämtland County Council and 29,9 per cent in Kalmar County Council. In ,2 per cent of the dentists in Sweden were foreign born.

40 40 24,5 per cent of all dentists in Sweden had in 2007 a foreign origin, this as a development over the last years with a steady increase every year. Swedish educated dentists were in 2007 issued 171 certificates and dentists from the EU/EEA countries 123 licenses and from third country 40 licenses were issued. The unemployment among dentists is very low in Sweden; the demand for dentists is calculated to be greater than the supply. Eight out of 19 county councils expressed that they had actively recruited foreign dentists during Large retirements are expected within this profession and the Swedish education system has to answer to these retirements and expand the amount of education places on the education programs. In 2007 dentists are one of the professions where the most of non-swedish born workers are occupied in county councils, 24,5 per cent of the dentists. The Swedish labour market has a demand for dentists and this demand will grow the coming years. Without migration from other countries it is believed that there will be a shortage of 26 per cent. With an inflow of dentists in the future the demand is estimated to 20 per cent in Table 5 Dentist Licenses issued to non-swedes (%) Year Foreign education % EU/EEA including Switzerland % Third Country % , , , , , , , ,5 28,8 7, ,2 22,1 10, , , ,7 37,8 10, ,6 36,8 12

41 41 Table 5 shows the continuous increase of licenses issued to dentists (out of all dentist licenses issued in Sweden) with a foreign education. Licenses issued to dentists with an education from EU/EEA countries have increased more than the amount of licenses issued to third country members. 4.3 Context of Migration Flows The economical aspect of the global supply and demand for labour has created a situation where migration is vital for many nations. Sweden is a good example of this, as we are about to suffer shortages in some of the occupations examined in this study, and will rely on foreign labour to manage the situation of the health care system. The globalization has made flexibility a necessity, for both employers and employees. In an employees perspective work is of less importance in our lives, we value challenges and find it easier to change employer. This results in a decreased loyalty towards the employers, as we know we are replaceable. We can identify high numbers of licenses issued to non-swedish professionals with a foreign education in comparison to lower numbers given to third country members. A possible conclusion is that the principle of free movement of labour within the EU has resulted in opposite effects for non-eu member countries, making EU-member countries less eager to employ, and give residential permit to professionals from non-eu member countries. Mobility is also made easier by the fact that we no longer need to be in the same place at the same time to communicate and exchange money, goods and other services. As these systems are already disembedded, the step towards actually becoming more floating and changeable as humans seems less challenging. The results show that out of all occupations studied in this report dentists and physicians are the professions with the largest amount of non-swedes with a foreign education. Statistics from indicate numbers around per cent of the total work force in each occupation are born abroad, showing that both dentists and physicians have a high degree of mobility. Occupational therapists have a much smaller group of non-swedish professionals with a foreign education than any other profession in this study. Between the years this group never exceeds 5 per cent. For non-swedish occupational therapists educated in a third country the number is close to 0 per cent. Only one of the county councils or regions has mentioned occupational therapists at all, and they were the only one to have any statistics available on this group. Information concerning non-swedish physiotherapists with a foreign education is limited compared to other occupations studied in this research paper. The number of licenses issued to foreign educated personnel from other EU/EEA member countries seems to have peaked in before decreasing again in Of all the county councils and regions that we have contacted only one had any statistics available on this group. The Swedish Labour Market Tendency Survey state that these two occupations have a good balance at the moment and this could explain why the international mobility is relatively low. The demand is predicted to increase for both occupations, especially for physiotherapists so we might be able to see an increased mobility in the future. The licensing and qualification process is not as straight forward for occupational therapists and physiotherapists (compared to physicians, dentists and nurses).

42 42 Most county councils and regions mention nurses and have some statistics available on this group, but it is still to be considered as limited information. According to the county councils or regions there seem to be very few non-swedish nurses with a foreign education, and they are not being actively recruited. We believe there might be a bias regarding non-swedish nurses, as county councils and regions state they only have a few non-swedish nurses. By this they mean they only have a few non- Swedish nurses with a foreign education. Non-Swedish nurses with a Swedish education on the other hand are a large group. Statistics regarding nurses are, as previously stated, limited but information from 2003 reveals that 39 per cent of all newly recruited nurses were non-swedish. We can state that there is very little risk of Sweden contributing to brain draining countries of nurses, occupational therapists and physiotherapists since active recruitment from other countries is uncommon. Most non-swedish foreign educated personnel can be found within the physician occupation, and the most recent statistics (from 2007) estimates the number of non-swedish physicians to be around 26 per cent. The number of medical licenses given to non-swedish physicians with a foreign education has increased dramatically From 23 per cent in 1995 there has been a steady increase of 2-5 percentage units every year, until when the increase was about 10 percentage units. According to this research 63 per cent of all medical licenses issued in Sweden in 2007 were given to physicians with a foreign education. Within the dentist occupation the number of non-swedish foreign educated personnel working in Sweden has increased most of all occupations examined in this study. Starting at only 3, 4 per cent of the Swedish licenses being issued to non-swedish dentists with a foreign education in 1995, to the latest figure of 48, 6 per cent in Even though Sweden is experiencing labour shortages within these occupations, physicians and dentists are not irreplaceable. The shortage within these occupations creates a market where wealthier countries buy professionals from poorer countries to satisfy their own demand. It is the consumption that feeds the mobility and the supply and demand determine the market price as well as influences the calculated risks involved. In this perspective the rich countries are getting wealthier as they consume the professionals from other countries by buying their refined human capital. This includes the pay offs of the investments that the sending countries have made. In this regard we can see similar patterns for both dentists and physicians but it seems the similarities end there. Regarding educational investments for newly recruited professionals born abroad and the efforts made to actively recruit foreign educated personnel reveals differences between the two occupations, even though a labour shortage is predicted for both professions. The country of origin for health professionals examined in this research has been difficult to chart and we have only been able to retain information regarding physicians and dentists. Concerning the non- Swedes from other Nordic countries with a Swedish education the results show that 17,4 per cent of the non-swedish physicians and 9,9 per cent of the non-swedish dentists are from other Nordic countries. The number of non-swedish physiotherapists from other Nordic countries are as high as 40,9 per cent, and regarding occupational therapists the number is also high, 39,2 per cent. Nurses from other Nordic countries represent 36,3 per cent of the non-swedish nurses. The Nordic countries

43 43 also share many historical and cultural aspects, as well as similarities in language and these are all factors that simplify migration between countries (Daun, 2005). Physicians born abroad working in Sweden with a foreign education are mainly from Germany, Poland, Hungary, Greece, Iran, Iraq and the Netherlands. Dentists are mainly from Germany. Sweden has historically had a large migration from Hungary and Poland which might explain why we still prefer to recruit professionals from these countries (Svanberg, 1992). One knowledge gap we have been able to identify regarding the migration flows is the shortage of information regarding Swedes studying or working abroad. There is very limited information on where Swedes chose to migrate and what occupational groups that migrate, to what extent they do so, as well as to what extent they tend to return. This research is showing that neither the labour unions nor the National Board of Health and Welfare can give a clear picture of this. From analyzing our results we can observe the lack of training for all professional groups except for physicians where complementary training programs are provided by most county councils and regions that actively recruit foreign physicians. In accordance with the free movement policy within the EU no guidelines regarding language qualifications can be held upon professionals from EU/EEA member states. However, health care professionals from outside the EU/EEA have to be approved in basic Swedish language courses to be able to continue in the application process for a license. The National Board of Health and Welfare provides training programs for non-swedish health care professionals with an education from a third country and it is mandatory to complete the training program in order to receive a Swedish medical license. After receiving their license non-swedish physicians with a foreign education are mostly offered training programs adapted to the level of training needed; it could be language, medicine, culture, society or constitutional studies. Some county councils or regions offer training programs in the physicians home country as well. Most county councils and regions offer training for foreign educated physicians. The extent of the training differs. Some county councils offers training only if a need can be identified and some county councils and regions offers more extensive courses in language, culture, medical practice ect. Even if we can identify that courses for physicians exist in a large amount the quality and extent are unevenly spread among the employers. If the applicant from a foreign country self decide to migrate and work in Sweden it becomes the individual s responsibility to obtain the necessary qualifications to meet the Swedish standards not the employers. For more details related to Chapter 4, please see Annex IV.

44 44 5 Results of qualitative interviews The sample of key stakeholders contained the following 13 national/central and regional organizations and authorities: Swedish Association of Local Authorities and Regions (SALAR) The Swedish National Agency for Higher Education Ministry of Health and Social Affaires Ministry of Education and Research The Swedish Association of Health Professionals The Swedish Medical Association Region of Skåne Östergötland County Council Kalmar County Council The Swedish Dental Association National Board of Health and Welfare The Parliamentary Standing Committee on Social Affairs The Parliamentary Standing Committee on Education From within each one of these organizations and authorities we interviewed 1-3 individuals, altogether 21 people. When politicians were selected we tried to get representation from both opposition and ruling parties. One informant responded by e mail and two were interviewed by telephone. All others were interviewed face-to-face. In one case a selected stakeholder was replaced by a person representing that stakeholder. Most often we were two interviewers, twice all three of us were present and once (at the end of the series of interviews) one of us performed the interview. The interview period started 8 September and ended 5 October All interviews were recorded and transcribed for further analysis. Before the series of interviews started there was an investigative TV program broadcasted in a nationwide channel of the phenomena of relay/baton physicians (stafettläkare). This concept means that physicians, often provided by recruitment agencies, work a few days and then other physicians are replacing them in an often endless chain of new physicians. The TV program provided evidence that this phenomenon reduced quality of care and continuity of care. Also some evidence was provided that showed that the Swedish Medical Association during many years had argued not to expand the intake of students to medical education in spite of statistics showing the need for more physicians. Because of this TV program, the topic of our study was discussed and on the agenda in particular among people working in or concerned with health services. Further, the sample of stakeholders was influenced and expanded by the previously made inventory of available information, which showed to us to the need to include also the political and administrative authorities for higher education. The sample of regions/counties was limited to three out of 21. We have not included the scarcely populated counties in the north of Sweden. They have some particular problems that may only partly be represented among the three regions/counties that were selected by us. It is about recruitment of physicians, in particular general practitioners to remote areas. Although this was also to some extent present in the selected regions/counties, in particular in the County of

45 45 Kalmar, but it is more obvious in the North. But we believe that this particular aspect has been dealt with in a satisfactorily way in the performed interviews. Finally, all informants received about a month before the interview an introductory letter in Swedish about the MoHProf project, a support letter from WIAD and the report on available information that we presented previously. 5.1 Macro Findings There were some additional, available information that was made available to us by the informants and that will be reported in this chapter as well as categories of information that emerged from the interviews. First, some meta or macro categories that we found when analyzing the recorded interviews: -A first meta category is the praise by all stakeholders of migration in general. There was expressed appreciation of the directive of free movement within EU. Migration gives new influences, ideas, it stirs things up, it gives new ways of thinking which concerns structures, way of working and structural issues ( ) Migration is in general positive. (Ministry of Health and Social Affaires) Another meta category is the professionalization of more health workers in addition to physicians. In most rich countries nurse, physiotherapist, occupational therapist and other curricula have been integrated in universities. The health care educations have become university based and all 21 educations are in the regulation for higher education which is governmental. But universities are responsible for the educations and its content. (Ministry of Education and Research) One such meta category is the ethical/moral dimension almost all stakeholders refer to when actively recruiting health workers, in particular from countries with short supply of such workers. Stakeholders express solidarity as an important factor on labour migration and active recruitment of health care professionals. It is not loyal of Sweden to recruit health care workers from countries who has a great need themselves of physicians. It can be difficult to completely become self-sufficient within a near future. (The Parliamentary Standing Committee on Education) Another meta category is related to the assumption that Sweden as a destination country is much more attractive, in many ways, than the country of origin. Another category is the emphasis on patient rights, consumerism, continuity and quality of care. A common expression is that patients have an extensive knowledge of the health care system as well as medical issues. This results in higher expectations on the health care. This change is in progress in Sweden at the moment, which is expressed by a large organizational transformation called

46 46 Vårdvalet. This gives extended power to the patient to choose caregiver, as opposed to the traditional system where the patient automatically belonged to their local caregiver. The first tendency is focus on the patient and the patient s position, for example the care guarantee and patient s rights. It will become more important to clarify the patient s role. Patients will make requirements in the health care in terms of knowledge among health care professionals, in treatment and service. (Ministry of Health and Social Affaires) A sixth meta category is shortages of some professions within the health care sector, mostly specialist physicians and to some extent specialist nurses. By recruiting from other, in particular poorer countries Sweden have been able to fill gaps where there have been shortages. This migration is considered to be positive for Sweden and the Swedish health care system and contradicts slightly the first mentioned category. Some stakeholders express that this migration has been vital for filling gaps and therefore has been of great importance. Other stakeholders view this migration in a larger international perspective, meaning that the labour migration of health care professionals to Sweden has been of minor importance, since the quantities in comparison to other receiving countries are low. A seventh meta category is the power struggle between different stakeholders, not only about migration of health workers, but also in general about organizational and work process issues. Another meta category is the provision of a health market where services are provided in competition between different actors, be they public or private, and almost all of them paid for from. public sources, i.e. taxes. Many stakeholders express the increased specialization as an important development trend in the Swedish health care sector. This is the case for all investigated professions in this study, and a consequence of this is greater difficulties in recruiting some specialties. It also creates waiting lists for patients for hospital based specialized care. At the moment all care is around specialists and long queues are created. There is nothing in between primary care and specialist care. I would rather see a chain built around the patients. (Östergötland County Council) The shortage of physicians is very obvious when interviewing stakeholder, and many of them believe that the health care sector would benefit from a small unemployment among physicians. There is a common view that physicians are treated differently than other professional groups in society, and there is a lot of politics involved in this. No other professional group, such as lawyers or teachers, has almost non-existing of unemployment and as strictly regulated curricula as the physicians. Another issue in relation to this is the expected retirement leave among physicians. Sweden has a large number of people born in the 40s and the 50s, and their retirement will affect all parts of society and in particular the health sector.

47 47 Fundamentally there is some kind of idea that there cannot exist unemployment among physicians, but still we can have thousands of others unemployed, but that s not a troublesome question. (The Swedish National Agency for Higher Education) Sweden needs more physicians but we also need more physicians to create a small unemployment within the force, it s good for the labour markets functioning. The shortage of supply of physicians has created a dependence of recruitment agencies. (Östergötland County Council) From Sweden there is an emigration to Norway especially among nurses but also physicians to some extent. The pull factors are increased salary and better employment agreements but also a better organized health care system. It is widely known that Swedish dentists over the years have immigrated to the United Kingdom, where especially salaries have been a pull factor. Stakeholders find it difficult to estimate the quantities of dentists leaving Sweden to work abroad, but it has decreased to some extent since the 90s. The Swedish Association of Health Professionals has a cooperation with the Norwegian labour union for nurses and at present 1600 Swedish nurses have a license in Norway but in the end of the 90 s the number was among (The Swedish Association of Health Professionals) Stakeholders believe there are geographical differences within Sweden concerning the quality of the complementary training programs offered to foreign health care professionals since employers are responsible for this, but in spite of this there is no expressed opinion to centralize the training programs. Some locations of the primary care are remote and the advertising of physicians vacancies has been done without result. We have no beneficial employment agreements to compensate areas which are difficult to recruit to. (The Region of Skåne) It seems like employers rationalize by employing dental hygienists since they are cheaper than dentists, a miscalculation was done concerning dentists. There are large geographical differences in how employers choose to use and combine dentists and dental hygienists. (National Board of Health and Welfare) 5.2 Meso findings There is also a polarization in the past between the Swedish Medical Association (SMA) and most of the other stakeholders in the way information on demand for more physicians should be interpreted. SMA always underestimated the demand and thereby influenced decisions on intake to medical education. Several of the stakeholders feel this was done in order to produce a shortage and improve salaries and benefits for physicians. Even if SMA nowadays has somewhat changed its position on this matter, the effects are still present because it takes years to produce a specialist. The big issue here is why government and national authorities in education and social and health affairs gave

48 48 in for SMA. A statement by one stakeholder, a regional director, indicates that the state authorities in the field of health and social affairs are biased in favor of physicians because of the unproportional influence performed by that profession. All stakeholders agreed Sweden should be self sufficient of health care professionals and thought it was not fair to rely so much on foreign recruitment, in particular of physicians from countries with shortage of this profession. But all stakeholders found migration in general a positive phenomenon for receiving countries. Some told us that migrating physicians in some cases will return to their home countries and thereby bring with them skills and experiences that otherwise would not have been achieved. Retention sent to relatives in home country was also mentioned as an additional benefit from migration. We should educate so that we can become self-sufficient but we also want an exchange. (Swedish Association of Local Authorities and Regions) I think it should be an objective to be self sufficient of health care professionals but there are no such demands on other professional groups in society to be self-sufficient. (The Swedish Medical Association) It was obvious that available statistics on non-nationals being licensed to practice in Sweden did not show actual numbers migrating to Sweden to work. Some used this opportunity of harmonized curricula within EU only to receive another diploma to put on the wall in his/her clinic in another EU country. Some additional statistics from the National Board of Health and Welfare were claimed by them to be the most valid information on health professionals from other countries actually working in Swedish regions/counties. Regarding push factors from Germany, Poland and other countries, it was mentioned that their health care systems are more hierarchical and work conditions, salaries and benefits in the new EU countries in the East are not satisfactory. I think well educated come of economic reasons, but I have also heard that Germans that come to Sweden appreciate the Swedish working atmosphere even though they would make more money In Germany, and they like the gender equality in Sweden. (Östergötland County Council) Among the pull factors is the egalitarian climate in Swedish work places. German and Polish physicians were on first encounter surprised that young physicians dared to argue with senior physicians in meetings. Also contributing to pulling migrant health workers to Sweden was thought to be the Swedish nature and its accessibility as well as arrangements made for children and spouses. It was obvious that regions/counties with a university with a medical faculty did not need to actively recruit foreign health workers of the professions which they educate, i.e physicians, nurses, dentists. Either they are enough served by Swedish physicians and/or foreign physicians that will arrive on their own initiatives. For example a small county like Kalmar that does not educate physicians or dentists has to actively recruit in order to fill its vacancies. Regarding nurses, which Kalmar County Council does educate, they have a sufficient supply in most specialist areas.

49 49 Graduated physicians often stay at the location where they have been trained since they during their education have had time to connect to the district. We estimate that 60-70% was occupied within the county council where they were graduated a year after their exam but the demand of physicians exists all over Sweden. (The National Board of Health and Welfare) Regarding recruitment companies actively recruiting from abroad, there is one company that has been mentioned continuously. As a response to difficulties attracting Swedish health professionals to their county the Kalmar County Council started KALMENA REK AB, a company that was formed in agreement with and on initiative by the county of Kalmar. It s a disadvantage not to be able to recruit or educate enough in Sweden but there has been a tremendous resource that there has been foreign physicians that have been willing to come to Sweden, recruiting from other countries works well. (Kalmar County Council) There are also Swedish recruitment agencies providing additional relay/baton physicians to fill the gaps in the health care system. These baton physicians are considerably better paid, and many of them have employments within the public sector but choose to complement this employment with a better paid baton job. This is very expensive for the employers, who in a way are stuck in a catch 22, as they are depending on baton physicians to keep their organization afloat, yet not able to pay as well as the recruitment agencies. Kalmar last year paid about 100 million SEK for baton physicians, the double the amount compared to the five times more populous Skåne region. Skåne has a long history of medical education at the university towns of Lund and Malmö. One particular constraint is the shortage of supervisors of and positions (AT) for the newly educated medical students during their obligatory general practice period that they have to complete before being legitimized physicians. This is considered to be a bottle neck and is one important factor as to why it is difficult to expand intake to medical curricula in Sweden. The county council has to be able to receive everybody who has graduated, but we also need to tutor the graduates. It has to be possible to maintain the quality even if an extension of the medical education is put into action, and we have tried to estimate these factors. (Swedish Association of Local Authorities and Regions) Another bottle neck in the Swedish health services is the provision of specialized physicians as they need around years practice and education. Specialized nurses do not financially gain much by specializing, neither is the specialization always needed to practice in a specialized ward. It does not always lead to greater responsibilities within the profession. Even though most stakeholders express that they are positive to specialization of nurses and see a great need for them, there is also a common expression that the employers find it difficult to manage without these nurses, and are therefore reluctant to give them time off for specializing. A majority of nurses are women and usually mainly responsible for home and family. Therefore they may find it difficult to handle an education alongside with work, since they often work part time while studying. Specialist nurses are often without

50 50 economical compensation for lost salary while they undergo further education. Physicians are able to specialize while being salaried. Sweden will not be self sufficient within the next years, we can expect a large number of retirements. It takes time to build up a new system and to train a specialist physician takes a long time, about 15 years. (The Parliamentary Standing Committee on Education) The length of the specialist education is regulated by the Swedish Association of Health Professionals and it should be after the basic nursing education. But the demand had proven to be very small. They do not make more money, maybe 500 SEK, and neither do they get extended responsibilities. So there is a conflict there, and we are thinking about rewriting the regulation. (The Swedish National Agency for Higher Education) Regarding validity of information, the National Board of Health and Welfare claimed (as mentioned above) that they have the most accurate figures on foreigners employed by the Swedish regions/counties. According to one Member of Parliament (MP), conservative and professor at a medical faculty, there is a wide spread disappointment among physicians regarding their possibility to lead and guide health services. Further he expressed that physicians have too many duties not related to their profession. Due to too much administrative work, finding hospital beds for their patients etcetera, physicians skills and experiences are not used appropriately. The single biggest problem is that physicians aren t good ambassadors for their profession. The job is tough, top down managed and physicians do not get enough room for their creativity. (Conservative Member of Parliament) The same stake holder claims that in the 60ths there were 7000 physicians working in the Swedish public health care system. At present there are physicians. A comment by a representative of the Swedish National Agency for Higher Education told us that only 35-45% of physicians time was spent with patients. It seems to be a great potential here for increase of effectiveness and outcome. It seems contradictory to have a higher physician density while having a shortage of the same. Stakeholders also claim that there is a low productivity among Swedish physicians and express a need for increased effectiveness among them. They believe the health care sector need to improve its attractiveness as employers to decrease the amount of administrative work that nurses and physicians have to manage, and provide more time for patient related work. There is a shortage of physicians within certain categories, but Sweden has never had so many physicians as now. ( ) The productivity among physicians is not at all impressive, and one should be able to decrease the number of physicians (The Region of Skåne)

51 51 The public employers (regions and counties) seem to wish for a larger output of physicians from medical curricula in order to get more people to choose from in filling vacancies. Another bottleneck expressed by stakeholders is the difficulties of expanding the intake to the medical curricula and at the same time obtain the high quality that characterizes the Swedish medical educational system. Some stakeholders also claim that Sweden needs to educate physicians to provide not only the health sector with physicians, but also to support the universities with teachers. We can be dependent on foreign recruitment within certain areas until The extension of 30 places was too small this year. To accept only just enough number of people to the medical education is too little when you need people who fit into 50 different specialties. It does not add up. This is one reason why they should accept more students to the medical education. (Swedish Association of Local Authorities and Regions) There were negative comments regarding the performance of the National Board of Health and Welfare on their validation of health workers education, in particular physicians, from third countries. The process is too time consuming and much momentum is thereby lost in the validation process of physicians from third countries. Task shifting and delegation is a hot topic in particular in the relation between the physicians and nurses trade unions. Nurses as managers meet hierarchy resistance from physicians. (The Swedish Association of Health Professionals) The task shifting between dentists and dental hygienists has become more common and is a process that has been developed over many years. The Swedish Dental association claims that the supply of dental hygienists is expected to increase by 47%. There has been a shortage of dentists over the years, and employers have solved this by reorganizing tasks and giving more responsibilities to dental hygienists and dental nurses. In Östergötland County Council there is no shortage of dentists, bur there is a shortage of specialized dentists. The reason why we do not have a shortage is that they have shifted the tasks on to other professions, for instance there are receptions where you meet dental hygienists. Had this not been done, there would be a shortage of dentists. (Östergötland County Council) One can assume that if you don t have a supply of dentists, you will organize work in a different way. (The Swedish Dental Association) Task shifting between nurses and physicians is a more sensitive subject, since these professions are more protective of their responsibilities, both medical and managerial. It seems there is a constant shifting of knowledge, assistance nurses increases their competencies and are able to take over more duties from nurses. Nurses are then upgraded to taking more responsibilities that has traditionally

52 52 been physicians tasks. Stake holders express that this is a process that will be developed further in the future. Another aspect is the management and the hierarchy with the most medically competent as the main responsible for the patients safety. The Swedish Medical Association wants a person with high medical competence for management and they have always claimed that the work management has to be the medical management, while the long term health care disagrees. Personally I believe the work management should be separated from the medial management, but high competence is required. (Conservative Member of Parliament) The level of competence has increased since the 80 s. There is a fear of assistant nurses increasing their competence. Physicians secretaries and general health care administrators roles become increasingly important. This task shifting has raised the flexibility between the groups. Few tasks are tied to a certain profession, but both physicians and nurses are unwilling to hand over tasks. In the primary health care and in the northern parts of Sweden the nurses have been taking over physicians tasks, there are nurses clinics for example. Our experience is that this process is developing faster in areas where the density of physicians is lower. (Swedish Association of Local Authorities and Regions) A third dimension of task shifting can be identified in the administrative roles within the health care sector. Stakeholders clearly express that the traditional physician s secretary is gradually replaced by the more qualified and general health care administrator. Physicians secretaries has held a constant level, but there is a union conflict regarding physicians secretaries and general health care administrators. New technology has resulted in a decreased need for secretaries. The physicians should manage archives and update data files. But this is a sensitive issue, the same as with nurses being first line managers. ( ) Maybe physicians secretaries should decrease, or become more qualified. (Kalmar County Council) It has been a fast task shifting, at the moment we have 20 % assistant nurses years ago we had 30 %. Administrative tasks have been taken from physicians secretaries and laid upon general health care administrators. Physicians secretaries are fewer but are moving towards becoming a more qualified profession; general health care administrators. (Östergötland County Council) From the analysis of the interviews, a model is emerging that illuminate categories at three different levels: 1. META/MACRO 2. MESO 3. MICRO

53 Micro findings We made 11 interviews with local human resource managers and 18 interviews with migrant health professionals (physicians, nurses and dentists). There is no great demand for nurses from abroad to come to Sweden as there is a satisfactory supply of nurses from the Swedish nursing schools. Only a few categories of nurse specialists (for example in anesthesia) are in short supply. Therefore we sampled mainly physicians and dentists among health professionals. The following table shows the distribution of these professionals across relevant parameters. Table 6 Sampled health professionals with EU- or non-eu origin at different types of work places Work place Physicians EU Physicians non-eu Dentists EU Dentists non-eu Nurses EU Nurses non-eu Hospital Primary health care Dental clinics 1 4 Total: 18 migrant health professionals.local human resource managers that were interviewed were distributed as follows. Table 7 Work place Sampled HR managers at different work places with different types of background Physicians Dentists Nurses Other Hospital Primary 1 1 health care Dental clinic 3 Total: 11 HR managers. Themes for interviews were similar to the ones used in the macro phase and adapted to the micro level informants (see list of themes in ANNEX V) All interviews were performed at places where informants worked or lived and took on average one hour. The great majority of interviews were done by one of us three in the research team. Sampling of informants was done by our focal points in five counties in order to get a fair representation of different categories of regions and professionals. Summaries in Swedish of interviews are reported in ANNEX V. All together 29 interviews were performed. We stopped sampling more informants when we perceived saturation was achieved. With additional interviews there was not more information contributed by informants.

54 Main results from the micro interviews There was not much difference in responses between categories of professions. However, country of origin differentiated among professionals. The main reasons for migration for non-eu residents coming from war hit countries like Iraq, Iran and Pakistan were about family and personal security. "The reason I left Iraq was that I felt something was happening. There was no safety or security. I lived in Baghdad. "(Dentist from Iraq) The situation in my home country is not safe. That was the main reason for me to migrate. Dentists have a good income in Pakistan. Therefore, economy was not a reason for moving (Dentist from Pakistan) Professionals from non-eu countries in Eastern Europe often migrated because of underdeveloped health care organization in their home countries. When I moved to Sweden, Bulgaria was not yet a member of the EU. Therefore my migration was quite cumbersome. The main reason for me to move was the underdeveloped health care system in Bulgaria and that I met a man from Sweden whom I fall in love with (Physician from Bulgaria) My view is that working conditions in other countries are very demanding, they often have multiple jobs. It is hard to find time for their children as well, and Sweden is a family friendly country. And I think that the salary must play role for those from Poland as they had several jobs there, and it must surely be to be able to make a living, I think. (HR-professional No 8) Professionals from EU countries migrated because of lack of suitable job opportunities, long working hours, hierarchical organization etcetera in home countries. In Portugal there is an over-supply of dentists from the dental schools. These dentists will not have enough job opportunities there. Therefore we have developed a relation with one particular dental school from which we have so far recruited more than twenty dentists. (HR-professional No 9) Independent of EU origin or non-eu origin, the health professionals chose Sweden as destination country for diverse reasons, such as: Their partner lived in Sweden. I wanted to travel to New Zealand, and went to the Middle East where I worked for a while at Abu Dhąbi. There I met a Swedish man. We got married and moved to Sweden. My husband is a radiologist and it helped when I applied for jobs in Sweden. (Nurse from Northern Ireland)

55 55 Good working conditions I have always dreamt of working abroad and to have a comfortable life that I couldn t have in Russia. And now I have achieved it. I can travel, I can have children without feeling that I cannot be off work and I can receive pay during my time off. My private life adds up with my working life. (Physician from Russia) I have been well treated by my employer and the chief dentist. They gave me enough time for learning before I was asked to produce full time. (Dentist from Pakistan) Great demand in Sweden for foreign physicians and dentists The resources Sweden has when it comes to dentists is not sufficient, we do not have enough. The situation is similar all over the country. One has to cope with vacancy problems in different ways. (HR professional No 7) As Sweden is not producing enough number of dentists, we have to go abroad to recruit. (HR-professional No 9) We would not be able to run this comparably small hospital without a significant inflow of doctors from Serbia, Poland, Germany, Greece, Denmark and The Netherlands. In only one of the clinics the majority of doctors are Swedish.(HR-professional No 11s) Limited working hours. In Germany doctors usually have very long working hours. In Sweden one is applying the EU working hour directive more carefully. (Physician from Germany) Easier family life In Poland I worked 40 hours, but mainly I worked afternoons until eight or nine in the evening. My husband did his specialization and was gone all day; we had no time for the children or for each other. We decided that we must change something in our lifestyle. (Dentist from Poland) "Both my wife and I can work as physicians and still combine family. It is an advantage with the migration to Sweden. There are many other benefits of living in Jämtland, and to be able to go skiing and skating, fishing and hiking. Professionally, I had been able to make another career in Germany and work with research. " (Physician from Lebanon) Opportunities for further education, for example specialist training (ST) positions. I also get a great education as I see it; I get the best in Europe. I'm almost done with ST education and I will add emergency care in two years. (Physician from Germany)

56 56 Personal and family security. I had not planned to come to Sweden; it was because of the war in my home country, Burundi. Before I arrived I only knew that Sweden was a country in Northern Europe. (Nurse from Burundi) Swedish nature We chose Jämtland because it was good working conditions, an attractive educational program for the ST and then the mountains and countryside. (Physician from Germany) Less hierarchical organization in Sweden In Germany there is generally a rather hierarchical organization of work places like hospitals. I prefer the more egalitarian atmosphere here in Sweden. (Physician from Germany) Compared to findings from the macro phase, we achieved some important detailing in the micro phase. It was for example confirmed that: Systematic, organized recruitment from specific countries, for example Germany and Poland has decreased. We found only one case of systematic and continuous recruitment at present of newly licensed dentists from one particular faculty in Portugal to one particular county in Sweden. Nowadays the great majority of foreign health professionals are coming to Sweden due to individual contacts and initiatives. We currently have several dentists from Germany, but we have not actively recruited them ourselves. We only actively recruited two dentists from Poland. Otherwise, they have turned to us, looking for work. Through friends, through advertisements, for example. (HR-professional No 5) Also confirmed in the micro phase was the need for foreign recruits in remote, rural areas and in primary health care centers. We have an unbalanced supply with a concentration to some places. If we could spread dentists in a better way over the country we would not have a shortage. We have recruitment difficulties in rural areas. (HR-professional No 7) You have to think about if they would like it here, do Jämtland fit all? They must like to live in a place like this, and that does not only apply to migrants- even Swedes must ask themselves these questions. It often depends on their love of mountains and hiking. Otherwise it is better to live in a bigger town. (HR-professional No 5) In one particular small rural hospital with only around 90 beds, the great majority of physicians were of foreign descent. We have a majority of foreign doctors here, they're from different countries; Serbia, Poland, Germany, Greece, Denmark and The Netherlands (...) There is only one clinic with a majority of Swedish doctors, the orthopedic department, but all others have a majority of foreign doctors. (HR-professional No 3) There was also added evidence through the micro interviews that public employers, which are the far biggest ones in Sweden, had very different strategies in integrating foreign staff. The whole spectrum of possible actions was represented, from zero support to heavy involvement.

57 57 When I talk with physicians from other countries, language is a very important aspect. But I, as an employer, do not have many places to turn to offer the physicians help and education in medical Swedish. There are no channels for this within the organization. (HR-professional No 1) Most informants expressed concern about the need for good management of the Swedish language. Our impression is that migrants from the Nordic countries, Germany and The Netherlands had fewer difficulties in achieving Swedish language skills. A few professionals from other language areas had more difficulties, unless they lived in a Swedish language context, for example with a Swedish spouse. I always feel welcome. But I guess there can be a difference if you re a migrant from Germany or if you re from another country. I don t have any negative experiences to the same extent as other nationalities. I believe it s easier for us to learn Swedish, the transition between Swedish and German is small. (Physician from Germany) My Swedish language has improved quickly because I live with a Swedish man and we have many Swedish friends, with whom I communicate in Swedish. (Physician from France) The great majority of migrant health professionals are satisfied with the way their employers have treated them. However, in particular those coming from non-eu countries complained about long lead times for processing their applications for registration and also that they did not easily received information on what they had to complement (papers, courses, practice etcetera) in order to receive license to practice. Some of them had to wait for 10 years before they qualified for registration. It took me five years to qualify as dentist in Sweden. Although the theoretical tests were not demanding any additional knowledge as compared to what I had learned in Belarus, additional knowledge was needed only in relation to Swedish regulatory system and a few techniques that I was not used to. (Dentist from Pakistan)

58 58 References Arnstberg, K. O. (2008). Sverige och invandringen. Lund: Studentlitteratur. Daun, Å. (2005). En stuga på sjätte våningen. Stockholm/Stehag: Brutus Östlings Bokförlag Symposion AB. Hofstede, G. (1991). Cultures and Organizations: Software of the Mind. Intercultural Cooperation and its Importance for Survival. London: McGraw-Hill International (UK), Ltd. Kjellberg, A. (2001). Fackliga organisationer och medlemmar i dagens Sverige. Arkiv SCB. (2008). Arbetskraftsbarometern 08 - utsikterna på arbetsmarknaden för 72 utbildningar. Örebro: SCB-Tryck. SKL. (2008). Svensk sjukvård i internationell jämförelse. Stockholm: Sveriges Kommuner och Landsting Svanberg, I. (1992). Tusen år av invandring. Värnamo: Bokförlaget Arena. Websites The National Board of Health and Welfare The Swedish Dental Association Website, The Swedish Association of Health Professionals Website, The Swedsih Association of Local Authorithies and Regions Website, The Swedish Association of Occupational Therapists Website, The Swedish Institute Website. (2009). The Swedish Medical Association Website,

59 59 Annexes I: Basic country information 1.1 Population Basic demographic data 1995: : : : : : : : : : : : : : : Numbers and indices of births, deaths births/1,000 population (2009 est.) deaths/1,000 population (July 2009 est.) infant mortality rate, total: 2.75 deaths/1,000 live births Life expectancy at birth Life expectancy at birth: total population: years 2009

60 60 Table of life expectancy: Men Women Year At birth At 50 At 65 At birth At 50 At 65 years years years years ,17 28,42 15,97 81,45 32,9 19, ,51 28,61 16,1 81,53 32,95 19, ,7 28,77 16,25 81,82 33,2 19, ,87 28,94 16,34 81,94 33,3 20, ,06 29,11 16,45 81,91 33,23 19, ,38 29,41 16,69 82,03 33,3 20, ,55 29,6 16,88 82,07 33,36 20, ,73 29,64 16,9 82,11 33,37 20, ,91 29,83 17,01 82,43 33,67 20, ,35 30,19 17,39 82,68 33,92 20, ,42 30,21 17,36 82,78 33,93 20, ,7 30,45 17,6 82,94 34,13 20, ,94 30,7 17,84 82,99 34,14 20, ,1 30,83 17,93 83,15 34,28 20, Natural increase rate Annual rate of natural increase of the population (%), Annual rate of natural increase of the population (%),

61 Age/sex structure (age pyramid) 0-14 years: 15.7% (male 733,597/female 692,194) years: 65.5% (male 3,003,358/female 2,927,038) 65 years and over: 18.8% (male 753,293/female 950,171) (2009 est.) Median age: total: 41.5 years male: 40.4 years female: 42.6 years (2009 est.) Age pyramid, 2008: Män (men), kvinnor (women) Rural/ urban split Urban population: 85% of total population (2008) Other demographic data applicable to the situation of a given country

62 Population increase over time, 2008: Population by sex and age, 2008: 2009

63 Population ranked by age Geo-political data Political stability indexes Transparency corruption perception index Country rank: CPI (Coruption perceptions index) score: 9,3 Confidence range: 9,2-9, Economic freedom index Index of Economic Freedom World Ranking. Freedom score: 70,5, change from previous: -0,

64 Quality-of-life indexes 2009 Cost of Living 37 Leisure & Culture 72 Economy 47 Environment 70 Freedom 100 Health 72 Infrastructure 88 Risk & Safety 100 Climate 69 Final Score Human development index HDI: Sweden (0.963) (2007) Source: 2009

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