Across the WHO European Region, doctors and nurses are moving between countries at an increasing rate, reshaping national workforce supply and dependency. A peer-reviewed synthesis published in the European Journal of Public Health brought together nine country case studies conducted for the WHO Regional Office for Europe, covering Ireland, Malta, Norway and Romania alongside Albania, Armenia, Georgia, Moldova and Tajikistan. The countries span different income levels, labour market conditions and positions as sources, destinations or both. The synthesis compared reported inflows and outflows, describes common push and pull factors and reviews policy interventions linked to recruitment and retention. It also highlighted how free movement and mutual recognition of qualifications within the European Economic Area can influence mobility patterns and policy options.
Migration Patterns and Workforce Dynamics
Emigration of health workers in the European Region is largely shaped by economic status and professional conditions. High-income countries, such as Norway and Ireland, attract foreign-trained doctors and nurses, while lower-income countries, including Moldova, Albania and Tajikistan, experience significant outflows. In Moldova, for instance, the number of doctors requesting certificates to work abroad between 2018 and 2024 equalled 81% of all medical graduates during that period. Conversely, Norway and Malta report negligible emigration but a high proportion of foreign-trained staff — 44% of doctors in Norway and 43% in Ireland in 2023.
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Push factors include low salaries, inadequate infrastructure, heavy workloads and limited career development opportunities. Pull factors range from higher remuneration and favourable work conditions abroad to easier recognition of qualifications within the EEA. Cultural and linguistic proximity also plays a role: Moldovan doctors often move to Romania, Albanian nurses to Italy and Tajik health workers to Russia. Destination preferences have evolved, with more professionals from Eastern Europe now seeking opportunities in Germany, Italy and the United States.
Policy Responses and National Strategies
Most countries studied have introduced measures to strengthen workforce retention and training. These include expanding medical and nursing education capacity, raising salaries and improving working conditions. Romania, for example, doubled doctors’ pay between 2016 and 2022, with senior specialists earning up to 250% more. Similar, though less substantial, pay increases occurred in Albania, Armenia and Tajikistan. However, gaps remain large between lower- and higher-income countries, sustaining outward migration pressures.
Compulsory service schemes are another policy tool. Moldova requires new medical graduates to serve three years, increasing to five by 2026. Albania introduced a tiered service obligation, and Tajikistan enforces a three-year state-funded service rule. Bilateral recruitment agreements have also been pursued. Ireland has established temporary migration schemes with Pakistan and Sudan, while Malta signed an agreement with Spain for nurse recruitment. Armenia and Georgia have arrangements focused on diploma recognition and temporary employment with various partners, though their effectiveness remains limited.
Some countries have sought to engage their diasporas to offset domestic shortages. Albania’s national strategy includes a fellowship mechanism to encourage knowledge exchange, while Georgia and Armenia support collaborations between diaspora organisations and local healthcare providers. Yet, despite formal commitment to the WHO Global Code of Practice on the International Recruitment of Health Personnel, few governments report tangible implementation of its principles.
Data Gaps and Implementation Challenges
Accurate and consistent data on health worker migration remains a major limitation for effective policymaking. Only Ireland has begun systematically tracking emigration and return of medical and nursing graduates through national statistics. Other countries, such as Norway and Romania, collect partial data, while non-EEA states like Armenia and Tajikistan lack official reporting mechanisms. As a result, the true scale of outflows and their effects on national systems remain unclear.
Education reforms, although promising, face resource and staffing constraints, particularly in non-EEA settings. Limited opportunities for continuing professional development and weak postgraduate training structures exacerbate workforce attrition. In many countries, efforts to modernise education, improve governance and strengthen data systems are ongoing but unevenly implemented. Without sustained investment and monitoring, the impact of these measures on long-term retention is uncertain.
The nine country cases show shared drivers of mobility, particularly low pay, dissatisfaction with working conditions, inadequate practice environments, heavy workloads and limited professional development, alongside country-specific triggers and shifting destination preferences. Policy responses tend to focus on expanding training capacity, improving remuneration and, in some settings, introducing compulsory service or bilateral arrangements, yet comprehensive approaches that directly target migration remain limited. Major gaps persist in tracking outflows, especially outside OECD reporting, which constrains planning and evaluation of interventions. Strengthening health labour market intelligence, expanding professional opportunities and fostering collaboration among states could support a more sustainable and equitable distribution of healthcare workers across Europe.
Source: European Journal of Public Health
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