The healthcare economy is a growing sector in Germany both in terms of expenditures and working population. The healthcare sector constitutes the core area of healthcare economy and is directly related to the provision of healthcare services as ambulatory, inpatient and long-term care. In the following we refer to health workers in the healthcare sector with a special focus on doctors and nurses.
The working population in the health economy increased in the period 2000-2012 by 22.6 per cent and reached 5.2 million workers in 2012. The growth of jobs in the healthcare economy 2000-2012 was three times higher than in the economy as a whole (Federal Statistical Office 3/5/2014).
In spite of the increasing working population in Germany, the healthcare sector is already facing labour shortages. Qualified health personnel is scarce. Worldwide. According to the World Health Organisation (WHO), the world currently faces a gap of 17 million health workers, of whom 2.6 million are medical doctors and 9 million nurses.The global brain drain of health workers today has become a systemic problem and constitutes a global political determinant of health, understood as being part of the “transnational norms, policies, and practices that arise from political interaction across all sectors that affect health” (Ottersen, et al. 2014).
Nowadays, almost all western countries train fewer health workers than they need for their own supply, or are unable to retain their health workforce in the country. Both demographic and structural reasons could explain this tendency. With regard to demographic reasons, reasons for labour shortages can be found on both demand and supply side. The German population is aging and will decline in future years due to increased life expectancy and fall in the birth rate. Given constant net migration of 100,000 persons annually, the German population would still decline from 81 to 65 million by 2060 (Boll et al. 2014a). Already in 2030 the number of people aged 65 and over will increase by a third, while the group of people aged under 20 will decrease by a sixth.
In view of the aging German society, the demand for healthcare services will rise substantially.
Therefore, most countries in the global north recruit their health workforce from abroad, either tacitly or openly, via recruitment services.
Developing appropriate recruitment policies and processes is a critical feature of an effective large-scale RPO program. External engagement in the hiring of health professional requires careful planning and adaption in order to be productive.
An effective recruitment program can not only help in attaining the right talent, but equally reduce attrition, which is a major challenge for health insitutions. Recruiting and selecting the most appropriate individual to fill the role is among the most essential elements that contribute to a well-functioning health institution. SGS RPO Service defines how and from where a candidate is identified, selected and assigned , including selection criteria and processes.
Before the recruting process begins, the criteria or qualifications that each individual candidate should meet, should be pre-defined. The selection criteria may include demographic elements, such as gender, age, marital status, and usual place of residence, as well as education level and ability to successfully complete training on standard competencies, which will be heavily dependent on the specific health strategy, as well as the roles and responsibilities they will undertake. Given the fact that the vast majority of candidates is coming form Eastern Europe, residency, qualification recognition and language skills are more often an important criterion in the selection of personnel.
WHAT IS THE SGS RECRUITMENT PROCESS?
The SGS recruitment process entails: establishing criteria, communicating opportunities to identify candidates, interviewing and selecting candidates, and hiring selected candidates.
Although in the real world of program implementation many of these steps are full of challenges, we define these ideal steps so that our client can modify them where and when they require:
1. Developing Recruitment Criteria
2. Communicate Position Opportunities and Selection Criteria
3. Identify, Review, and Select Candidates Based On Agreed-Upon Criteria and Decision Making Responsibility
After attention and care is spent to recruit and select candidates that meet the job criteria, it is hoped that they will continue to serve as for as long as they are able. However, high turnover is not only a common challenge, but also a red flag pointing to problems of design or execution. Carefully planning and executing a realistic and appropriate recruitment strategy can help to reduce high turnover.
How can retention be fostered?
Recruiting the right talent is important because the process of selecting and deploying appropriate and well-qualified candidates will lay the foundation. Ensuring the internal HR participation in the planning and execution of the recruitment, selection, and supervision process is considered a best practice as it can improve hiring outcomes. This is why the SGS team serves as a helping hand to the internal HR function. Once candidates have been selected and are working, it is important to consider what kinds of incentives, whether financial or non-financial, will support them to perform well and remain motivated on their jobs.
Which factors have a direct ifluence on the supply of health professionals?
Open access for qualified health workers to the labour markets in the north is shifting focus to the perspective of the health worker.
With regard to structural reasons, training capacities and attractiveness of professions influence the supply of health professionals.
Another important aspect of the health workforce migration is the question of organisation of professional development and language training in the source countries prior to the relocation, with the aim to ease the relocation process for the candidates.
SGS is directly adressing the issue in extending technical assistance by providing support in organising intensive courses in the source country.
Sufficient German language skills are a mandatory condition for recognizing the skills of healthcare staff in Germany. Good German language skills are also important for successful labour market integration in the healthcare sector, where personnel-related services and relations and technical vocabulary are essential. Language skills are a prerequisite for recognition of qualification of foreign-trained doctors and nurses. Language level B2 for German language and C1 for technical language skills (Fachsprachenprüfung) is required from migrant doctors and nurses. The examination for technical language skills is required.
As a result, the organisation of language training should be borne by the recruiting agencies or the employers respectively. The organisation and cost of language training should be given the same legal status as the general costs of education, but until this is done, SGS has partnered up with organisation in the source countries to, at least, simplify the process for candidates to some extent.
Access to the healthcare sector
With regard to foreign nationals who obtained training in health abroad, it has to be distinguished between migrant health workers that come to Germany to obtain further qualification and those that intend to pursue their profession. The former needs an academic recognition whereas the latter recognition of professional qualification. Doctors who intend to do specialty training in a German hospital thus need an academic recognition by a university, whereas those who want to work in hospital need recognition of their professional qualification by the respective institutions in charge. In the latter case, it is important whether the professional qualification is regulated or non-regulated. Regulated professions such as doctors, pharmacists, nurses and care workers require the approval by German authorities, whereas non-regulated professions such as medical receptionists can be practised without an official admission.
Migrant health workers in regulated professions need to prove;
(a) equivalent qualifications referring to the German standard
(b) sufficient German language skills
As most of the health professions are regulated, the recognition of foreign qualifications is a crucial prerequisite for accessing the German healthcare sector. To draw a more detailed picture of the prevalent access regulations, a closer look is taken at the main health professions: doctors.
Doctors in Germany need a full licence to practise in order to pursue their profession (Approbation). The Federal Medical Regulation distinguishes between two types of licence to practise differing in terms of duration and entitlements: full (Approbation) and provisional (Berufserlaubnis) in accordance with § 10 of the Federal Medical Regulation. Whereas the full licence is valid across Germany for an unlimited period of time and allows both dependent work and selfemployment, the provisional licence is issued for a period up to two years and for an individual state (Land), and the setting up of an own surgery is not allowed. German graduates obtain a full licence to practise after graduation. In the past, foreign-trained doctors from EU member states, Australia, Israel, Japan, Canada and New Zealand were entitled to a full licence, because their medical degrees were considered equivalent to the German degree (Finotelli 2014). Foreign nationals from the rest of the third countries were not entitled to a full licence and might obtain only a provisional licence even if they graduated from a German university. The current legal framework does not distinguish between nationalities and countries of origin anymore that is a major improvement related to the access of foreign nationals from third countries to the sector. According to the Recognition Law, all persons irrespective of their residence status and citizenship are entitled to start a procedure for a full licence. A provisional licence is still issued in case of a temporary professional practice in Germany and does not encompass recognition of professional qualifications by the issuing authority.
Policies on the recognition of professional qualifications
Many migrants in Germany work below their level of qualification as their foreign qualifications have not been recognized (Bils 2010; Boll et al. 2014b). The recognition of professional qualifications is particularly important for regulated occupations such as doctors, care workers and pharmacists as they are not allowed to work without a proof of the equivalence of their foreign qualification to the German standards. For a long time, the recognition of foreign qualifications in Germany had been characterized by fragmentation and differential treatment of different migrant and occupational groups.
As part of the German policy on dealing with labour shortages, a Recognition law came into force in April 2012 by which several changes in the recognition of foreign qualifications were enacted (Vogel and Kovacheva 2014). Particularly third-country nationals benefit from the law. It introduced a legal claim to apply for recognition of qualification irrespective of residence status and citizenship. In the absence of such a legal claim so far, third-country nationals hardly managed to access the recognition procedure. In the recognition procedure, it is checked whether the professional qualification obtained abroad is comparable with the German requirements for the particular profession. Currently, there are about 600 occupational groups regulated by the Recognition Law. The procedure should not take more than three months.
Furthermore, residence in Germany is not a prerequisite and an application from abroad is possible.
A further improvement of the recognition procedures with a great impact on health professions is the partial recognition, which was not possible prior to 2012 and in the past affected mainly doctors and pharmacists. In the past, applications had been rejected in case even of minor differences between foreign qualification and the German standards. Partial recognition means that only parts of the qualification are recognized and missing parts can be acquired through further courses and training.
The lack of information about recognition procedures is a main obstacle for migrant health workers, as studies among foreign doctors in Hamburg showed (Braun 2011). To support migrants interested in recognition of their foreign qualification, SGS formed councelling centres which aim at providing advice and assistance.
In addition to this, the key success criterion for the integration of migrant health workers could be associated with the integration capacities of the workplace in terms of adaptation and retention. The process of workplace integration of migrant health workers has great importance.
In order to facilitate advancements, we need more dialogue between the health organisation and the migrant health workers. That means involving policy-makers and migrant healthworkers themselves in their future development plan.
SGS plans to play a significant role in this process for each of our candidates. We can help health organisations in Germany get further by building that ecosystem.