Luglio-Agosto 2022, Vol. 57, N. 4 Riv Psichiatr 2022;57(4):190-197 doi 10.1708/3855.38384 Scarica il PDF (528,3 kb) Mobility trends in Psychiatry trainees: an Italian perspective titolo - split_articolo,controlla_titolo - art_titolo Mobility trends in Psychiatry trainees: an Italian perspective autori - vau_aut_id Lia Orlando1,2, Francesco Altamore3, Claudia Palumbo4, Mariana Pinto Da Costa1,2,5 affiliazione_autori - art_affiliazioni 1South London and Maudsley NHS Foundation Trust, London, United Kingdom; 2Institute of Psychiatry, Psychology & Neuroscience, King’s College London, United Kingdom; 3Psychiatric Day Hospital, Carpi - Department of Mental Health and Drug Abuse, AUSL Modena, Modena, Italy; 4ASTT Papa Giovanni XXIII, Bergamo, Italy; 5Institute of Biomedical Sciences Abel Salazar, University of Porto, Portugal. riassunto - art_riassunto Summary. Background. Psychiatry has been affected by the ‘Brain Drain’ phenomenon for decades, with professionals usually migrating from lower- to higher-income countries. Whilst Italy faces a decreasing Psychiatric workforce in the near future, little is known about the factors that influence migration of Psychiatry trainees in Italy. Aim. To explore the migration tendencies of Psychiatry trainees training in Italy. Methods. A cross-sectional survey was disseminated to Psychiatry trainees in Italy. Results. The vast majority (84.2%) of the trainees had ‘ever’ considered leaving Italy, and more than half (60.4%) considered leaving the country ‘now’. Only a quarter (25.3%) had taken ‘practical steps’ towards migration. Male trainees were more likely to have ‘ever’ considered leaving Italy. Trainees without children were more likely to have ‘ever’ considered leaving and more likely to consider leaving ‘now’. More southern Italian trainees were considering leaving the country ‘now’ compared to those from the centre-north. ‘Academic’ and ‘work’ reasons were the two most cited factors given both as a reason for wanting to leave Italy and as conditions that should be improved in the country. The main reason cited to remain in the country was personal. Conclusions. Several Psychiatry trainees in Italy consider migration as a possibility, mainly driven by work and academic reasons. The main factor keeping trainees in Italy was personal reasons. Highlighting the reasons why trainees leave is crucial to facing these issues and either finding ways to encourage trainees to remain or finding other solutions for the medical shortage. parolechiave - lingua - vke_key_id Key words. Brain Drain, Italy, medical shortage, migration, psychiatry trainees. title - controlla_titolo - art_title Il fenomeno della migrazione degli specializzandi in psichiatria: una prospettiva italiana. abstract - art_abstract Riassunto. Introduzione. Per decenni, la psichiatria è stata colpita dal fenomeno del “Brain Drain”, caratterizzato dalla migrazione di professionisti da Paesi con reddito più basso a Paesi con reddito più alto. Sebbene l’Italia si interfaccerà a breve con la carenza della forza lavoro in psichiatria, si conosce poco sugli elementi che influenzano la migrazione dall’Italia degli specializzandi in psichiatria. Obiettivo. Esplorare le tendenze di migrazione dall’Italia degli specializzandi in psichiatria. Metodo. È stato effettuato uno studio trasversale divulgando un questionario tra gli specializzandi italiani in psichiatria. Risultati. La maggioranza (84,2%) degli specializzandi ha pensato di lasciare l’Italia “almeno una volta” e più della metà (60,4%) ha considerato di lasciarla “adesso”. Solo un quarto (25,3%) ha preso “iniziative concrete” verso la migrazione. Soprattutto gli specializzandi di genere maschile hanno considerato di emigrare “almeno una volta”. La probabilità di aver pensato di lasciare l’Italia “almeno una volta” e di partire “adesso” è risultata maggiore negli specializzandi senza figli. Gli specializzandi provenienti dal Sud si sono mostrati maggiormente intenzionati a lasciare il Paese “adesso” rispetto a quelli provenienti dal Centro-Nord. Le motivazioni maggiormente indicate sono state quelle “accademiche” e “lavorative”. La ragione principalmente menzionata per rimanere in Italia è stata quella “personale”. Conclusioni. In Italia, numerosi specializzandi in psichiatria considerano la migrazione come una possibilità, spinti soprattutto da ragioni lavorative e accademiche. Il motivo principale per cui rimangono in Italia è legato a fattori personali. Evidenziare le cause connesse alla migrazione degli specializzandi è fondamentale per affrontare questo fenomeno, al fine di incoraggiare i nuovi medici a rimanere nel loro Paese e poter contrastare la loro carenza. keyword - lingua - vke_key_id Parole chiave. Brain Drain, carenza di medici, Italia, migrazione, specializzandi in psichiatria. testo - art_testo Introduction The ‘Brain Drain’ is a longstanding phenomenon1,2. Physicians moving countries contributes to the misdistribution of healthcare workers, with a loss of the healthcare workforce in the donor country, and a gain for the host country3,4, usually from lower-income to higher-income countries5. Psychiatry has been affected by Brain Drain with workforce shortages which have been recognised for decades6. This is of particular concern as the global burden of mental illness is rising and predicted to continue to grow7. In 2008 the World Psychiatry Association set up a task force to examine the Brain Drain phenomenon in relation to mental health professionals, highlighting it as a critical issue for low- and middle-income countries8. Factors that are thought to affect migration in psychiatry include professional isolation, lack of resources for appropriate patient care, and wanting to seek better training opportunities abroad8. Italy, a high-income country, had 5.98 psychiatrists per 100,000 population in 2017, which is lower compared to the average of 11.87 psychiatrists for other high-income countries9. This may be related to changes following the Basaglia Law, a reform introduced in 1978, decreeing that there would be no admissions to psychiatric hospitals from the end of that year. This led to a transfer of focus to community services, but also to a decrease in staff employed in Psychiatric services and a decrease in spending in Psychiatry compared to other high-income countries10. Importantly, there is a difference of staffing levels (both medical and nursing) within the country, with fewer employees in the centre-south compared to the north of Italy11. Within the country, there is a clear difference between the centre-north and the south of Italy in terms of emigration in the general population12. Most Italian citizens emigrating abroad in 2019 came from the centre-north of the country (total of 78,000 residents), compared to the south of Italy (43,000). The top three contributing cities are the large urban centres of Milan and Rome in the centre-north and Naples in the south12. At present, to address the shortfall of doctors in certain areas, such as in the rural region in the south of Italy, adverts have been placed asking for retired doctors to return to work to fill the health worker gap13. Whilst Italy’s number of psychiatrists is below the global average9, the number of Italian medical doctors per 1000 population (3.9) still remains slightly above the European average (3.4)14. Psychiatry as a specialty is associated with significant stigma15 and this is also likely influencing recruitment in Italy. Historically, the Italian national health service has been graduating more doctors from medical schools than there are training places available14 and this lack of training places is also thought to have been driving trainees abroad16. However, research conducted in 2021 by the Italian National Association for Hospital Clinicians (Associazione Nazionale Aiuti e Assistenti Ospedalieri - ANAAO) reported that the number of training places has increased by 21% from 2019 to 2021, and that Italy faces a shortfall of doctors in the future; it estimates that in 2026-2027 there will be a shortfall of 19,800 training places across all medical specialties, not accounting for clinicians leaving or considering currently empty roles (estimated at 5-10%)17. This is likely to lead to changes in Italian recruitment in the coming years. A 2020 study on medical migration in Italian doctors, with both trainees and consultants, disseminated through Facebook found that factors encouraging migration include inadequacy of medical infrastructures (83%), inadequate wages (80%), and uncertainties associated with a medical career (79%) in Italy18. García-Pérez et al.19 estimated in 2007 that 3.4% of doctors in training in Italy were practising abroad. Italy also faces an aging doctor population, with 54% of doctors aged 55 years or older, and the retirement of these older healthcare workers is likely to exacerbate the staff shortages14. A national Italian study of hospital physicians found that 2.9% of hospital medics decided to leave their job; quitting outright or going into retirement20. This same study found that over 3000 medics have preferred to work in the private sector or in the community compared to the public inpatient setting20. Research by the ANAAO in 2019 has predicted that for Italian NHS Psychiatry doctors between 2018-2025 there will be a shortfall of about one thousand doctors due to retirement16. Whilst previous reports have described the overall patterns of migration of doctors in Italy, little is known about the specific reality of Psychiatry trainees in Italy and their attitudes towards migration. Method Study design and instrument This study is part of an international cross-sectional survey of Psychiatry trainees developed by the European Federation of Psychiatric Trainees (EFPT). The questionnaire consisted of 61 self-reported items, asking participants: demographics, short-term (3 months up to 1 year) and long-term (more than 1 year) mobility experiences, and the attitudes towards migration. A translated version in Italian was used in Italy. The survey was conducted according to the principles of good scientific practice, which was supported by a national ethics commission consent in Switzerland in the Basel cantonal ethics committee (ref 144/13). Data collection The questionnaire was disseminated in 2013 to 2014, both as an online survey and as paper questionnaire. The inclusion criteria was being a Psychiatry trainee, undertaking training in Italy. All participants provided informed consent before initiating the questionnaire. Statistical analysis The statistical analysis was conducted using the Software Package for Social Sciences for Windows v. 22 (SPSS). Demographics were reported with frequencies and percentages for the categorical variables and with the mean value and the standard deviation for the continuous variables. Missing data were omitted, and only valid percentages are reported. Satisfaction with income was recorded to an increasing five-item Likert scale (1=very dissatisfied; 5=very satisfied). In the sub-group analysis, gender and geographic differences were tested through the chi-square test. Statistical significance was set at p<0.05. To test gender differences, we considered male and female trainees. To test the geographical differences, we selected trainees from the centre-north and south based on the city where they were originally from. We considered the political division of Italy in centre-north and south, as foreseen for the electoral districts. Results Demographics A total of 121 psychiatry trainees in Italy participated in the study (60.5% response rate, out of 200 contacted). The majority of trainees (n=119, 98.3%) were working in adult psychiatry, others (n=2, 1.7%) worked in joint adolescent and adult psychiatry, and drug abuse psychiatry. Most (n=75, 64.1%) identified as female and the rest (n=42, 35.9%) were male. The mean age was 30.09 years (SD 2.97 years), with a minimum age of 25 and maximum of 48. The majority (n=119, 98.3%) had sole Italian nationality, whilst the rest (n=2, 1.7%) had dual citizenship from Italy and the United States of America (USA). More than half (n=63, 53.4%) were from the south of Italy and the rest (n=55, 46.6%) were from the centre-north. The majority of the trainees (n=94, 80.3%) were in a relationship and fewer (n=23, 19.7%) were not. There were more women in relationships (n=66, 88%) compared to men (n=28, 66.7%) (p=0.005). There was no significant difference in relationship status comparing trainees from the centre-north and south of Italy. The majority (n=100, 85.5%) did not have children, while some (n=17, 14.5%) had children. There was no significant difference in having children between men and women; more trainees from the centre-north had children (n=12, 22.6%) compared to those from the south (n=4, 6.6%) (p=0.014). The majority (n=104, 89.7%) of trainees earnt between € 1,500-1,999/ month with some (n=10, 8.6%) earning less (€ 1,000-1,499) and only a few (n=2, 1.7%) earning more (€ 2,000-2,499). There was no significant difference in salary comparing male and female trainees or between trainees from the centre-north and south of Italy. Some trainees (n=13, 11.2%) had an additional income. Half of the trainees (n=58, 50%) were either ‘very satisfied’ or ‘satisfied’ with their income, and the rest were either ‘neither satisfied nor dissatisfied’ (n=35, 30.2%) or ‘dissatisfied’ or ‘very dissatisfied’ (n=23, 19.8%). Women (n=44, 59.5%) were more satisfied (‘very satisfied’ or ‘satisfied’) with their income compared to men (n=14, 33.3%) (p= 0.026). Migration tendency Only some (n=21, 17.4%) trainees had short-term mobility experience (living abroad between 3 months and 1 year), with an even smaller number (n=3, 2.5%) having had long-term mobility experience (living abroad for more than 1 year). From the very small number of trainees (n=3, 2.5%) that had emigrated from Italy, all moved to London in the United Kingdom (UK), and all were women. For both short-term and long-term mobility experience there was no significant difference comparing gender, relationship status, parenthood and being from the centre-north compared to the south. The short-term mobility experience influenced the attitudes towards migration in the vast majority of these participants (n=20, 95.2%), with all these influencing attitudes in favour of migration, all being ‘satisfied’ or ‘very satisfied’ with their experience. Regarding long-term mobility experiences, most (n=2, 100%) were either ‘satisfied’ or ‘very satisfied’ with their experience. The top reason they gave for immigrating to the new country was for academic (n=1, 33.3%) reasons. The vast majority (n=101, 84.2%) of trainees have ‘ever’ considered leaving the country they currently live in (table 1). More of the male trainees (n=40, 95.2%) had ‘ever’ considered leaving Italy compared to female trainees (n=59, 78.7%) (p=0.017). Parenthood did influence having ‘ever’ considered leaving the country, with most trainees (n=88, 88%) without children having ‘ever’ considered leaving the country, compared to those with children (n=11, 64.7%) (p=0.014). There was no significant difference comparing relationship status, residency within Italy and origin within Italy. More than half (n=61, 60.4%) of the trainees considered leaving the country ‘now’ (table 1). Similarly, parenthood affected whether trainees were considering leaving the country ‘now’, with most of those without children considering leaving ‘now’ (n=55, 62.5%), compared to those with children (n=5, 45.5%) (p=0.046). More trainees originally from the south of Italy were considering leaving the country ‘now’ (n=40, 71.4%) compared to those from the centre-north (n=20, 46.5%) (p=0.041). There was no significant difference when comparing gender, residency within Italy and relationship status. Only one fourth of the trainees (n=21, 25.3%) had taken ‘practical steps’ towards migration (table 1). There was no significant difference when comparing gender, residency and origin within Italy, relationship status and parenthood. With relation to their 5-year plan, almost half of the trainees (n=53, 44.2%) considered it would be most likely to be living in the country they currently lived in, over a fourth (n=31, 25.8%) were considering living within Europe, some (n=19, 15.8%) were considering anywhere in the world and only a few (n=7, 5.8%) were considering living in their home country. The top reasons trainees gave to leave Italy included academic (n=38, 24.2%) and work (n=31, 19.7%). Less important reasons included cultural (n=21, 13.4%), financial (n=20, 12.7%), personal (n=16, 10.2%), social (n=14, 8.9%), political (n=13, 8.3%), religious (n=3, 1.9%) and other (n=1, 0.6%) (figure 1). By contrast, the most cited reasons to stay in the current country included personal (n=62, 51.2%), followed by academic (n=16, 13.2%), financial (n=10, 8.3%), political (n=9, 7.4%), religious (n=8, 6.6%), work (n=8, 6.6%), social (n=4, 3.3%), cultural (n=3, 2.5%) and other (n=1, 0.8%) reasons (figure 2). With regards to their views on the features of an attractive job (figure 3) most participants ‘strongly agreed’ that the most important factors were a pleasant work environment (n=47, 44.3%), opportunities to progress professionally (n=52, 43.3%) and having a good work-life balance (n=48, 40.0%). Other important factors included having a ‘job related to my studies or other previous experience’ (n=36, 30.0%), good welfare and social security (n=42, 35.0%), being acknowledged for their efforts (n=34, 28.3%), high salary (n=34, 28.3%), supervision and support from senior staff (n=32, 26.7%), working in an international environment (n=28, 23.3%), and ability to contribute to the community (n=25, 20.8%). Less important reasons were the ability to work independently (n=13, 10.8%), and less workload (n=2, 1.7%). With regards to the conditions that should be improved in Psychiatry in Italy (figure 4), the most important factors were academic and work conditions, (both n=91, 75.2%), followed by professional networks (n=68, 56.2%) and financial conditions (n=56, 46.3%). Very few (n=2, 1.7%) reported that no improvements were necessary. Discussion Key findings This study presents a profile of Psychiatry trainees in Italy and their attitudes towards migration. The majority of respondents were female, and more women were in relationships, and women were also more satisfied with their income. The wide majority (84.2%) of the trainees in Italy had ‘ever’ considered leaving the country, with more than half (60.4%) considering leaving ‘now’. More male than female trainees had ‘ever’ considered leaving the country, but there was no difference when asked about leaving the country ‘now’ or having taken ‘practical steps’ towards migration. Parenthood had an effect as well as gender on having ‘ever’ considered leaving Italy, with the wide majority (88%) of those without children having ‘ever’ considered leaving, compared to 64.7% of those with children. This was also seen in those having considered leaving the country ‘now’, with 62.5% without children considered leaving ‘now’, compared to 45.5% with children. The most cited reason in the whole sample for wanting to stay in Italy was personal. The main reasons reported for wanting to leave Italy were academic and work-related. This is reflected in that the most cited features of an attractive job were related to the above reasons, including a pleasant work environment, opportunity to progress professionally and a good work-life balance. This is further emphasised by the fact that the conditions that should be improved in Italy in Psychiatry were mostly academic and work. Looking at differences between trainees from the centre-north and south of Italy, there were no differences in having ‘ever’ considered leaving the country, but there was a significant difference in looking at those having considered leaving the country ‘now’, with 71.4% of southern trainees having considered leaving at the time, compared to 46.5% centre-north trainees. Strengths and limitations To the best of our knowledge this is the first study on migration tendencies of Psychiatry trainees in Italy, which is its main strength. The response rate was over half (60.5%). The main limitations are that the nature of the study is a self-reported questionnaire, which is subject to reporter bias. Comparison with the literature In this sample from Italy all the trainees had Italian as a nationality, and this contrasts with the overall Brain Drain study results, which show that 13.3% of the trainees across the whole European sample were immigrants at the time of the study21. The UK is reported as the only destination for those trainees who had previously moved abroad. Similarly, the UK was also a popular destination in the findings from the Brain Drain study in Spain, where most of the trainees with short-term mobility experience had gone to English-speaking countries, mostly in the USA, followed by the UK and Australia22. In the UK Brain Drain sample 37% of trainees held a non-UK nationality, including both sole or dual citizenship23. This is reflected also in the percentage of immigrant trainees both in the pan-European study, where it was found that the UK had the third highest percentage of immigrant trainees (27.7%), following Switzerland and Sweden21, and also in other studies looking at doctors working in the UK, including estimates that 31% of doctors in the UK are born overseas24 and the UK having 28.3% international medical graduates5. In the Swiss sample the major destination was not the UK, but they were other English-speaking countries including the USA and Australia (the other major destinations for short-term mobility experience included Germany, Switzerland and France)25. In the overall findings of the Brain Drain study, 72.0% of the trainees had ‘ever’ considered migration, 53.5% were considering migration ‘now’, and 28.6% had taken ‘practical steps’ to migrating21. Comparing this to the Italian sample, a higher percentage of Italian trainees had ‘ever’ considered migration (84.2%), and were considering leaving ‘now’ (62.5%), but a smaller percentage had taken ‘practical steps’ (25.3%). Previous research on the Italian medical population found that perceived barriers to moving abroad from doctors in Italy included, in order of importance: working in a foreign language (64%); concerns over earning appropriate wages (53%); appropriateness of professional skills (48%); family integration in the new country (35%); integration in the foreign environment (33%); and obtaining appropriate housing (31%)18. In the study looking at European trends in general, the biggest push factor for emigration was financial21, whereas in the Italian sample it was not as important. Financial reasons can be looked at alongside income satisfaction. In the Italian sample that this article reports, 50% trainees were either very satisfied or satisfied with their income, and only 19.8% were either dissatisfied or very dissatisfied. Comparing it to other countries in Europe, levels of dissatisfaction were similar to the UK, where only 13% reported dissatisfaction with their income23, compared to the Baltic states where 40% of trainees were ‘dissatisfied’ or ‘very dissatisfied’ with their income26. This is at odds with previous literature suggesting that, as seen overall in Europe, that Italian Psychiatry trainees are motivated to emigrate due to inadequate wages18. The joint top reasons for Italian trainees to want to leave Italy were given as work and academic-related reasons. This is in line with Italian doctors having previously reported that inadequate medical infrastructure was the top reason for encouraging migration18. It is interesting to note that for the pan-European study the second most cited reason for leaving was personal reasons, but in both this Italian study and in the pan-European study it was also the most cited reason for wanting to stay in the home country. The mean age of Psychiatry trainees in Italy in this study (30.09 years) is lower than the average found in the pan-European study (31.17). This might be explained by differences in training pathways and by the cultural context. For example, in the UK, an individual must be 18 to start medical school, which is a minimum of five years. This is followed by two years of Foundation training before one can start Psychiatry training, which is a minimum of six years in length. Thus without any breaks the earliest one can be a consultant is age 31. However, career breaks are common, especially an ‘F3’, a break following the Foundation Programme27; the UKFPO 2019 F2 Career Destinations Survey showed that 13.6% of respondents reported taking a career break here28. By comparison in Italy, secondary school ends at 19 years old, followed also by a minimum of five years of medical school, after which one used to have to do a year of internship (true at the time of the study, this is no longer necessary at the time of writing) and then can start Psychiatry training, which was a minimum of five years at the time of the study (four years at the time of writing). Thus at the time of the study an Italian trainee could reach consultant level by age 30, and currently by age 28. As for career breaks, there is no data to suggest such a culture in Italy. Looking at differences between trainees from the centre-north and north of Italy, there were no differences in having ‘ever’ considered leaving the country, but there was a significant difference in looking at those having considered leaving the country ‘now’, with 71.4% of southern trainees having considered leaving at the time, compared to 46.5% centre-north trainees. This is at odds with the current trends in Italy that suggest that most emigration comes from the centre-north of the country12. Implication of the findings for practice, policies and research This study highlights the reasons that drive Italian Psychiatry trainees away from their home country and the key factors that encourage them to remain. These are key to understand and to tackle this loss of skilled clinicians. The most cited reasons for wanting to leave were academic and work-related. Key avenues that were reported as needing to be improved in Italy for Psychiatry trainees were in line with work: including a pleasant work environment, opportunities to progress professionally and a good work-life balance. These are not easy avenues to tackle, and speculatively reflect both an ingrained work culture, but also professional frameworks. Previous studies suggest that the Italian medical population is aging and that there will be a shortage soon due to retirement13,14. Since this study focused only on young psychiatrists in training, it did not cover the established clinicians that have completed training. Therefore, future research should also investigate the migration tendencies of consultant psychiatrists in Italy. Considering that the main reason given to remain in Italy was personal reasons, it would be interesting to characterise this further, for example through qualitative research that could further explore what these personal reasons entail. Whilst it is a cultural stereotype that in the general population Italians are more family orientated and live closer to ‘home’ compared to other nationalities29, it should be investigated whether doctors or mental health professionals corroborate this profile. Whilst this study highlights important reasons affecting attitudes towards migration, it was gathered during the financial crisis in Europe, and this may have influenced both views and actions on migration. Considering the UK is highlighted in this study as the only destination for the sample of Italian trainees studied here it is important to consider the context of this now. Since this study was carried out the UK has left the European Union, and the implications of this are likely to affect Psychiatry trainees in Italy, and the rest of Europe, moving to the UK in the future. It is important to evaluate migration from Italy to the UK in the light of this recent change. Language knowledge and skills were beyond the scope of this survey, but it is an interesting feature to consider in future research, as English-speaking countries are popular destinations for migration, and not speaking English is likely a barrier to moving to an English-speaking country. This study did not highlight many significant differences between trainees from the centre-north and north of Italy. Considering the small sample size of 121 trainees it is possible that this is not reflective of the Psychiatry trainee sample of Italy as a whole, and a larger sample size might be needed to look at whether the trends of migration seen at the country-level differ in different Italian regions. However, it is possible that migration trends seen in the general population in Italy are not reflected in the medical samples. Conclusions Psychiatry trainees in Italy consider migration as a possibility, mainly driven by work and academic reasons. The only significant difference between Italian trainees in the south and centre-north of the country was that more trainees from the south were considering leaving ‘now’ compared to the centre-north. The main factor leading them to want to remain in Italy was personal reasons. Italy is faced with a shortage of medical professionals, which is only predicted to worsen, and so highlighting the reasons why trainees leave is crucial to facing these issues and either finding ways to encourage trainees to remain or finding other solutions for the medical shortage. Conflict of interests: the authors have no conflict of interests to declare. Acknowledgements: the authors would like to thank the European Federation of Psychiatric Trainees (EFPT) for their support to this research project. biblio_titolo - ignora References bibliografia - art_bibliografia 1. Bhagwati J, Hamada K. The brain drain, international integration of markets for professionals and unemployment: a theoretical analysis. J Dev Econ 1974; 1: 19-42. 2. Mejia A. Migration of physicians and nurses: a world wide picture. Int J Epidemiol 1978; 7: 207-15. 3. Aluttis C, Bishaw T, Frank MW. The workforce for health in a globalized context - global shortages and international migration. 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