The social and health crisis that has hit the world in the last few months has made more and more evident that National Health Systems (NHSs) are not sustainable for most of the world’s countries, both in the case of public and universalistic or private and insurance-based systems[1].
Many factors are at play behind the overall consequences NHSs will face in the short term if no concrete actions are taken by every single country involved in the current crisis: lack of fundings, centralization of healthcare facilities in large urban areas, redefinition of fundamental assistance. Above them all, the one that might affect us the harshest is the lack of healthcare providers operating in public facilities in the near future.
According to the World Health Organization and United Nations forecasts, by 2030 there will be a shortage of more than 18 million[2] healthcare professionals, including doctors,nurses, biotech lab experts, social assistants and all other health-related workers.
Despite the popular idea that this crisis will hit Third World and developing countries harder, European nations cannot feel safe from the health wreck coming from it.
The European Commission itself points out that already in 2020 we are facing a deficit of around 1 million workers in European NHSs.[3]
That can’t but have dramatic consequences on the quality that healthcare systems can offer to the national populations.
In Europe…
The uneven distribution of health professionals both inside each country and within different countries can only make things worse. The urbanization of high quality healthcare centers, usually college-based, has been leaving rural and suburban areas with an insufficient and underfinanced healthcare system[4] unable to respond the the health needs of an ageing population with chronic and non communicable diseases.[5] This is true not only in richer, but it has become a common phenomenon throughout Europe
At the same time, on a transnational level, better wages and working conditions act as pull factors on healthcare workers from eastern Europe toward those countries in the central and northern part of the continent.[6]
This results on the one hand in a shortage that their home countries struggle to compensate; and on the other in an excess of healthcare workers that NHSs are not able to absorb with obvious implications such as the widespread inequality.
Within European countries…
The consequences of such disproportions on the national healthcare systems of both areas are easily foreseeable.
in the past few years, various national and international associations and institutions have been focusing on finding realistic solutions to this puzzle. Although very little, if any, concrete implementation has been put into practice by national governments.
Looking at the Italian case we notice that, before the Covid-19 crisis, the country’s 2019 Budget Law contained a financing of 337,7 million euros for medical residencies for the five years between 2019 and 2023; plus 10 more million euros each year of the same timeframe for general practitioners’ education[7]. These investments are deemed as insufficient by many experts as they can’t provide for the number of doctors that would be necessary to replace the ones retiring from the italian NHS in the next 15 years[8].
These dynamics can be found all over Europe. Decades of expansionary policies had allowed Portugal to rely on a proportion between physicians and citizens higher than the European average (in 2017 the country had 497,6 physicians for each 100.000 inhabitants while the European average was of 372)[9]. These positive numbers are now at risk due to the reduction in the number of specialty spots offered by portuguese medical schools in more recent years. In 2019 the national call for medical residencies received 2641 applications[10] for 1830 spots[11], leaving 811 medical graduates unable to work in the portuguese NHS.
In a federative nation like Germany, the differences in healthcare delivery among the various regions get even stronger. Despite the existence of some guidelines developed by the central government regarding health workforce planning (Bedarfsplanungsrichtlinie), their implementation is left to local policies in each member state (Länder). The latter have the power to elaborate their own healthcare plans in terms of facilities-population ratio[12]. While at a first glance this might seem a proper strategy to ensure an adequate workforce planning, within the bigger picture the inequities among different states become much more evident[13].
The IFMSA is the International Federation of Medical Students’ Associations. It is a NGO associating all Medical students. https://ifmsa.org/
All actors involved, from patients to health workers, students and institutions are nowadays fully aware of the consequences that the current situation will have on European healthcare systems.
Whatever the solutions to these problems will be, they will need to structurally reform the way we conceive our NHSs and guarantee continuity, efficiency and proficiency in the long term. They cannot be a temporary solution only to face the unprevented emergency situation healthcare systems have been facing for the last few weeks.
The future of each healthcare system in Europe depends on the proper education of future professionals. It cannot disregard an appropriate assessment of the required skills and competencies and the adequate number of health workers needed country by country.
All other solutions, such as the broadening of available positions in med schools without a coherent increase in funding for medical specialties/specializations, are pure demagogy that tries to deceive the population and it’s likely to make things worse in a future closer than we might expect.[15]
So far the policies implemented by the EU and its member states appear pale and weak compared to the gravity of the crisis. They also proved ineffective when it comes to ensuring healthcare workers the right skills, at the right time and place and in the right amount[16] so as to meet the health needs of the whole population, regardless of their wealth or home address.
Matteo Cavagnacchi
[1] “Country Health Systems Surveillance Platform” – WHO Department for Health Statistics and Informatics (2010)
[2] UN Agenda 2030 for Sustainable Development
[3] Health 2020: the European policy for health and well-being
[4] Report Osservatorio GIMBE n.6/2019 “La Mobilità Sanitaria Interregionale nel 2017”
[5] The 2009 Ageing Report: Underlying Assumptions and Projection Methodologies for the EU-27
Member States (2007-2060), Joint Report prepared by the European Commission (DG ECFIN) and
the Economic Policy Committee (AWG)
[6] “Recruitment and Retention of the Health Workforce in Europe”, European Health Management
Association, April 2015
[7] Report Osservatorio GIMBE n.7/2019 “Il Definanziamento 2010/2019 del Servizio Sanitario Nazionale”
[8] La Programmazione del Fabbisogno di Personale Medico, Proiezioni per il Periodo 2018-2025: Curve di Pensionamento e Fabbisogni Specialistici – ANAAO AssoMed
[9] Eurostat/Instituto Nacional de Estatística
[10] Lista definitiva retificada de candidatos admitidos e excluídos ao Procedimento Concursal IM 2020 – Administração Central do Sistema de Saúde
[11] Mapa de Capacidades Formativas Nacional Procedimento Concursal IM 2020 – Administração Central do Sistema de Saúde
[12] User Guidelines on Qualitative Methods in Health Workforce Planning and Forecasting“Germany, Country Profile” WP6, Centre for Workforce Intelligence, United Kingdom. Fellow and Edwards 2014
[13] Kuhlmann, E., Lauxen, O. & Larsen, C. Regional health workforce monitoring as governance innovation: a German model to coordinate sectoral demand, skill mix and mobility. Hum Resour Health 14, 71 (2016).
[14] International Federation of Medical Students Associations (IFMSA) – European Regional Priorities 2019/2020
[15] Anelli F. “No all’aumento dei posti a Medicina senza aver prima azzerato l’imbuto formativo” FNOMcEO 2020
[16] Stokker, Judy & Hallam, Gillian. (2009). The right person, in the right job, with the right skills, at the right time. A workforce-planning model that goes beyond metrics. Library Management. 30. 10.1108/01435120911006520.