Small Scale Study ll. Managed Migration and the Labour Market the Health Sector

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1 1 Small Scale Study ll Managed Migration and the Labour Market the Health Sector Swedish NCP

2 2 1. Executive summary Introduction to the healthcare sector in Sweden County councils' main task County councils' finances Levels of medical care Dental care Methodology Migration Policy and the healthcare sector in Sweden Employment of immigrants in the healthcare sector Education and training Applicants with a university degree from new EU member states Applicants with a university degree from outside EU/EES Costs of validation of foreign certification Any other aspects Future dependency burden Conclusions...16

3 3 1. Executive summary The aim of the study is to examine future migration and labour force immigration within the medical and healthcare sector. In Sweden, the 21 county councils are responsible for medical and healthcare. The aim of healthcare and medical services is to ensure good health and the provision of care on equal terms for the entire population. Care should be provided with respect for the equal dignity of all human beings and of the individual. Medical care in Sweden is largely financed by taxes and only a small part by patient charges. The basis for this study has been taken from interviews, data collection and studies of published material from a range of authorities and organisations. All immigration, including labour force immigration, is regulated by the Aliens Act and the Ordinance on Aliens. For people who are not citizens of EU/EES countries or Switzerland and who lack a permanent residence permit, the process of gaining a work permit in Sweden is relatively complicated and many are not granted a permit. Citizens of Nordic countries do not need a work permit or a residence permit to work in Sweden. Citizens of EU and EES countries do not need a work permit but they do require a residence permit for stays of over three months. A parliamentary committee has been appointed to examine the regulatory framework regarding labour force immigration, with the aim of producing a regulation permitting extended labour force immigration from countries outside the EU/EES. The committee should also analyse any consequences of increased labour force immigration. People with education from an EU/EES country can apply for certification in Sweden. This recognition of professional competence is more or less automatic. Applicants with a university degree from a country outside the EU/EES must apply for a re-examination of their foreign education as a basis for Swedish certification. The person must show that he/she has acquired sufficient knowledge of the Swedish language for the profession in question. The applicant must also complete a supplementary training programme at Swedish degree level as well as participate in a course on society and constitutional studies. The person must also carry out a practical traineeship.

4 4 2. Introduction to the healthcare sector in Sweden The aim of the study is to examine future migration and labour force immigration, an issue which has increased in importance in recent years. The study shall illustrate changes and trends in migration with a focus on the healthcare sector, regarding the regulatory framework, statistics and planned changes. The study should cover the following professions: doctors, dentists, dental nurses, dental hygienists, pharmacists, dispensers, nurses, midwives, psychologists, psychotherapists, physiotherapists, chiropractors, chiropodists. 2.1 County councils' main task Sweden is divided into 21 healthcare regions, or county councils. Central government decides on the laws and ordinances directing what the county councils are to do. The county councils are run by politicians elected directly by the inhabitants of the county. This means that citizens have the possibility to influence and control how the county councils carry out their tasks. The county councils are responsible for services that are common to large geographical areas and often require considerable resources. Their most important task is healthcare and medical services. One of the foundations of the Swedish welfare model is that all citizens have access to adequate healthcare when needed. "The aim of health and medical services is to assure the entire population of good health and of care on equal terms. Care should be given on the bases that all people have equal worth and respect the value of every individual. Priority for health and medical care should be given to the person whose need of care is the greatest County councils' finances Regional autonomy means that the county councils can adapt their activities to correspond to local conditions. Activities are largely financed by taxes, with only 3 per cent being financed by patient charges. Around 10 per cent of the income of Swedish people is paid in taxes to the county councils. Patient charges are so low that everyone should be able to afford to use healthcare services. In addition, prescription medicine is subsidised so that Swedish people on average only pay directly one fifth of the real cost of the medicine. The common financing should guarantee that all Swedish inhabitants should have the same access to healthcare and medical services of high quality. Every county council has the right to decide for itself how high the taxes should be and how the resources should be distributed. Economic conditions, such as the number of inhabitants and their average income, vary considerably between the different county councils. For reasons of fairness, therefore, there is a system for the transfer of funds 1 Health and Medical Services Act 2 (1982:763)

5 5 between county councils. The system consists of an equalisation of income and expenditure. Compensation within the equalisation system is determined and administered by central government. 2.3 Levels of medical care The whole Swedish medical and healthcare system is divided into three levels: primary healthcare, county healthcare and regional healthcare. Primary healthcare forms the foundation for the Swedish medical and healthcare system, consisting of health centres, district nurse surgeries and other GP and family doctor surgeries. Different professional groups work together at the health centres to ensure high quality care. The health centres carry out treatments that do not require the technical and medical resources found in hospitals. County councils may buy services from private care providers. In this case, a contract is signed guaranteeing the same regulations and charges that apply to the healthcare and medical services run by the county council. County healthcare is carried out at county hospitals and provincial hospitals. In principal, county hospitals should have the skills and medical equipment to cover all medical areas. Provincial hospitals are smaller and do not always offer all types of specialist surgeries. Regional healthcare is carried out at nine regional hospitals across the country. These can take care of all rarer and more complicated illnesses and injuries, often in close cooperation with the medical universities for training and research. 2.4 Dental care Dental care is not subsidised to the same extent as other forms of healthcare. County councils plan all public subsidised dental care, both private and public. The National Dental Service offers public dental care and is also responsible for specialist dental care, including the treatment of more complicated dental problems. This can include orthodontics, dental surgery, dental and oral diseases and dental injuries. The most important task for the county council's public dental service is preventative dental care for children and young persons. All those aged between 3 and 19 receive regular dental care free-of-charge. For people aged 20-29, the social insurance office pays a contribution of 106 SEK for an examination. This is also the case for people aged 65 and older. Other costs for examinations are covered by the patient. People aged between 30 and 64 pay the full costs for an examination. There is a cost ceiling in place for prosthetics and orthodontic treatments, meaning that patients receive some compensation from the social insurance office when the total cost of treatment is over SEK.

6 6 Some people with disabilities or long-term illnesses are eligible for dental care support in order to improve their quality of life and to increase their ability to take in food and nutrients. Dental care support means that essential dental care is provided at the same cost as within the open health and medical care services. People needing dental care as part of a treatment for an illness should also be able to receive this at the same cost as for general healthcare. There is a cost ceiling for dental care for people aged over 65. This means that patients themselves should pay a maximum of SEK for a prosthetic treatment. Costs for material and basic treatment are, however, additional. A committee on dental care has been appointed to examine dental care costs for adults. An interim report has been submitted with a proposal that a dental examination should not cost more than 200 SEK, the same as for a normal hospital visit. It is also proposed that patients should pay themselves for expensive treatments up to a specific amount. For treatments that are even more expensive, only a predetermined share should be paid by the patient. It is being considered whether there should be special support for extremely expensive dental care. A final report is due in December Methodology The basis for this study has been taken from interviews, data collection and studies of published material from employment offices, the National Employment Service, the National Board of Health and Welfare, the Swedish Integration Board, the Swedish Migration Board,, the Swedish Federation of County Councils, the Swedish Medical Association, the Government Offices, the Swedish Association of Health Professionals and the media. Statistics are presented in tables with the variables Swedish-born/foreignborn and country of birth. The term Swedish-born refers to people born of a mother, father or guardian who is registered in Sweden at the time of birth. This includes people born in a hospital abroad but whose parents are registered in Sweden. The term foreign-born refers to people who do not fulfil the conditions for being Swedish-born. When a person immigrates to Sweden, they state their country of birth. If this country of birth later ceases to exist or is broken up, this will not be automatically changed in the register on which the statistics are based. However, a person can apply to have their country of birth changed in the register on humanitarian grounds. This means that there are a number of people in Sweden who are registered as born in countries that have ceased to exist; the tables presented will therefore also show statistics on Czechoslovakia, for example.

7 7 Data on the number of occupied jobs for 2004 are not available and, consequently, the number of vacant jobs for 2004 cannot be presented either. To provide an idea of the situation in the healthcare sector, the table presented below shows the situation for Migration Policy and the healthcare sector in Sweden All immigration, including labour force immigration, is regulated by the Aliens Act and the Ordinance on Aliens. There are no special regulations for labour force immigration within the healthcare sector. The regulatory framework described below is applicable regardless of occupation. Those wishing to work in Sweden who are not citizens of EU/EES countries or Switzerland, or who lack a permanent residence permit in Sweden, must have a work permit in their passport before travelling to Sweden. A residence permit is also required if they will be working for longer than three months. This applies to all occupations. Citizens of many countries must also have a visa to travel to and stay for less than three months in Sweden. Work permits are granted by the Swedish Migration Board, which is also the authority that handles visas and residence permits. The Swedish attitude to labour force immigration is that the need for labour should only be fulfilled by foreign labour in cases where this need cannot be fulfilled within Sweden or EU/EES countries. Instead of using foreign labour, the needs of the labour market should be met through labour market policy measures, such as training programmes. In order to obtain a work permit, it is necessary to have a written job offer for a job in Sweden. The employer should guarantee a salary, insurance and other employment conditions, equivalent at least to a collective agreement or Swedish practice within the particular profession or industry. Housing in Sweden must be arranged before arrival. In addition, the person must be intending to leave Sweden when the employment finishes. Work permits and any visa or residence permit required should normally be applied for in the person's home country, or the country where the person is permanently resident, and should be obtained before arrival. Applications should be submitted to a Swedish embassy or consulate. If foreigners are already in Sweden, applications for work permits should be submitted to the Migration Board or the County Labour Board. Citizens of Nordic countries do not need a work permit or a residence permit to work in Sweden. Citizens of EU/EES countries do not need a work permit but they do need a residence permit for stays of over three months 23. All 2 From April 2006 these people will no longer need to apply for a residence permit but the right to be resident. 3 Ordinance on Aliens Chapter 4, 1

8 8 people, regardless of citizenship, with a permanent residence permit in Sweden also have the right to work in Sweden. 4 The National Employment Service (AMS) decides on the guidelines for the evaluation of matters concerning work permits 5. The Swedish Migration Board, which grants work permits, should consult with the County Labour Board before approving an application. The Migration Board may approve an application without consultation in special cases, based on how long the foreigner has been in Sweden, his/her personal situation and circumstances in general. 6 More detailed conditions for work permits are not outlined directly in the Aliens Act. The guidelines applied are based on provisions in different government bills. The bill on immigration and refugee policy (1983/84:144) contains much of the regulatory framework that defines the possibilities for labour force immigration. This, in turn, is based on the guidelines adopted at the end of the 1960s. Structural changes have taken place since then, in both the labour market and society in general, not least following entry to the EU and increasing internationalisation. This is why a parliamentary committee has been appointed to examine the regulatory framework regarding labour force immigration, with the aim of producing a regulation permitting extended labour force immigration from countries outside the EU/EES. This committee will also investigate the need for labour force immigration, assess the consequences of such immigration on the labour market and in general, and propose actions. The committee is expected to submit a final report on 18 October There are no regional or local ordinances regarding residence permits, visas and work permits in Sweden. All laws and ordinances apply to the whole country. Sweden has ratified all EU regulations in this area, which has resulted in greater freedom of movement for EU citizens. 5. Employment of immigrants in the healthcare sector Sweden's statistics on occupations cannot be broken down to an ISCO88 four-digit level at the same time as the division Swedish-born/foreign-born is used. To make it possible to produce statistics on occupation broken down by country of birth, occupations must therefore be grouped in this report on a three-digit level as follows: healthcare and medical specialists (doctors, dentists, pharmacists); midwives and specialist nurses; psychologists and social work professionals, etc.; physiotherapists and dental hygienists, etc; and nurses. There are statistics available for 2001, 2002 and Aliens Act Chapter 1, 5 5 Chapter 4, 6 6 Chapter 6, 8

9 9 The following tables present statistics broken down by the variable Swedishborn/foreign-born and by a selection of countries of birth. The term Swedishborn refers to people born of a mother, father or guardian who is registered in Sweden at the time of birth. This includes people born in a hospital abroad but whose parents are registered in Sweden. The term foreign-born refers to people who do not fulfil the conditions to be Swedish-born. When a person immigrates to Sweden, they state their country of birth. If this country of birth later ceases to exist or is broken up, this will not be automatically changed in the register on which the statistics are based. However, a person can apply to have the country of birth changed in the register on humanitarian grounds. This means that there are a number of people in Sweden who are registered as born in countries that have ceased to exist. Therefore, statistics relating to Czechoslovakia will also appear in the following tables. Table 1 data missing Table 2 data missing Table 3 data missing Table 4 data missing Table 5 Employees in healthcare sector 2001, all countries of birth Swedish-born Foreign-born Total Men Women Men Women Men Women Healthcare and medical specialists Midwives and specialist nurses Psychologists, social work professionals, etc Physiotherapists, dental hygienists Nurses Table 6 Employees in healthcare sector 2002, all countries of birth Swedish-born Foreign-born Total Men Women Men Women Men Women Healthcare and medical specialists Midwives and specialist nurses Psychologists, social work professionals, etc Physiotherapists, dental hygienists

10 10 Nurses Table 7 Employees in healthcare sector 2003, all countries of birth Swedish-born Foreign-born Total Men Women Men Women Men Women Healthcare and medical specialists Midwives and specialist nurses Psychologists, social work professionals, etc Physiotherapists, dental hygienists Nurses Table 8 - missing Table 9 missing Table 10 missing Table 11 - Vacancies reported to county employment offices 2004 Occupation Number of vacancies Healthcare and medical specialists Midwives and specialist nurses Psychologists, social work professionals, etc 996 Physiotherapists, dental hygienists Nurses Table 12 - Vacancies reported to county employment offices 2003 Data on the number of occupied jobs for 2004 are not available and, consequently, the percentage of vacant jobs for 2004 cannot be presented either. To provide an idea of the situation in the healthcare sector, the table presented below shows the situation for Occupation Number of vacancies Per cent of total number of jobs Healthcare and medical specialists Midwives and specialist nurses Psychologists, social work professionals, etc Physiotherapists, dental hygienists Nurses

11 11 Country Table 13a Foreign-born employees in healthcare sector by country of birth, 2001 Healthcare Midwives; Psychologists, Physiotherapists, Nurses & medical specialist social work dental hygienists, specialists nurses professionals, etc etc. Austria Belgium Denmark Finland France Germany Greece Ireland Italy Luxembourg The Netherlands Portugal Spain Sweden United Kingdom Total EU Slovakia Slovenia Poland Lithuania Latvia Malta Cyprus Czech Republic Czechoslovakia Estonia Hungary Total EU Norway Iceland Liechtenstein Switzerland Total EU/EEA Country Table 13b Foreign-born employees in healthcare sector by country of birth, 2002 Healthcare Midwives; Psychologists, Physiotherapists, Nurses & medical specialist social work dental hygienists, specialists nurses professionals, etc etc.

12 12 Austria Belgium Denmark Finland France Germany Greece Ireland Italy Luxembourg The Netherlands Portugal Spain Sweden United Kingdom Total EU Slovakia Slovenia Poland Lithuania Latvia Malta Cyprus Czech Republic Czechoslovakia Estonia Hungary Total EU Norway Iceland Liechtenstein Switzerland Total EU/EEA Country Table 13c Foreign-born employees in healthcare sector by country of birth, 2003 Healthcare Midwives; Psychologists, Physiotherapists, Nurses & medical specialist social work dental hygienists, specialists nurses professionals, etc etc. Austria Belgium Denmark Finland

13 13 France Germany Greece Ireland Italy Luxembourg The Netherlands Portugal Spain Sweden United Kingdom Total EU Slovakia Slovenia Poland Lithuania Latvia Malta Cyprus Czech Republic Czechoslovakia Estonia Hungary Total EU Norway Iceland Liechtenstein Switzerland Total EU/EEA The share of foreign-born employees in the health and medical care sectors, within the mentioned 13 occupations, has increased from 18.5 per cent in 2001 to 20.6 per cent in The greatest increase can be seen among Healthcare and medical specialists. The number of foreign employees born in an EU/EES country increased by 8 per cent between 2001 and A strong increase in the number of employees within the Swedish healthcare sector has been seen from two countries of birth in particular, Germany and Norway. The number of foreign-born people working within the healthcare sector who were born in Germany increased by 40 per cent from 2001 to The corresponding figure for Norway is 14 per cent. 6. Education and training Those with education from an EU/EEA country or Switzerland can apply for certification in Sweden. For occupations that are regulated by sector directives (doctors, dentists, nurses, midwives and pharmacists), it is

14 14 generally not necessary to translate foreign degree certificates; these can be submitted in the original language. For other occupations, a translation is sometimes required into Swedish or English. Applications for certification must always be accompanied by a certificate from the appropriate authority in the applicant's home country confirming that the professional qualification has not been limited or withdrawn. Such a certificate (certificate of good standing) should not be more than 3 months old. Doctors and dentists also have specialist qualifications that can be covered in the relevant directive. Nurses with specialist areas of expertise can receive recognition on the basis of the general directives. Only those who have received Swedish certification can apply for the right to be called a specialist nurse. Because recognition of professional competence within the EU/EEA or Switzerland is more or less automatic, there are strict requirements for the attestation of copies. An organisation, institution or authority must confirm that the copies correspond with the original documents. Attestation by private persons is not accepted. 6.1 Applicants with a university degree from new EU member states Applicants from the ten new member states must also attach one of the certificates listed below. The certificate must be issued by the appropriate authority in the country where the education was carried out. This certificate is required when the Swedish Board of Health and Welfare have not received the necessary information from the new member states. Certificate of compliance with the relevant EU directive Certificate of equivalence Certificate of earned privileges (confirming three years professional practice during the last five-year period - in some cases, five years practice during the last seven-year period) All documents should always be accompanied by a translation into English or Swedish, carried out by an authorised translator. 6.2 Applicants with a university degree from outside EU/EES Applicants with a university degree from outside the EU/EES countries must apply for a re-examination of their foreign education as a basis for Swedish certification. This applies to all the occupations discussed in this study. This re-examination cannot be offered to all those wishing to work in Sweden due to the lack of resources. In principle, only people who have been granted a residence permit by the Migration Board on political, humanitarian or family grounds are accepted. People who have completed education for a certified occupation in a third country must show that he/she has acquired sufficient knowledge of the

15 15 Swedish language. In order for the National Board of Health and Welfare to assess occupational competence, applicants must complete a supplementary training programme at Swedish degree level. A course and test on society and constitutional studies is also given. After this, a practical traineeship is arranged. The traineeship should be carried out under supervision and be assessed by a certified supervisor. Only after this is completed can a formal application be submitted to the Swedish Board of Health and Welfare. 6.3 Costs of validation of foreign certification For citizens with training from an EU/EES country, the validation of certification is free-of-charge. For citizens with training from a third country, the National Board of Health and Welfare charges SEK for the validation of degrees awarded to doctors and psychologists. The cost for other occupational groups is 600 SEK. These people must also undertake a traineeship within the Swedish health and medical care sector. During the traineeship period, the person will receive a salary according to the relevant agreements for trainees. These people must first take a course in Swedish for immigrants. This course is free-of-charge and is available to all people registered in Sweden. People who are registered in Sweden as refugees receive a daily allowance during the course. Other people on the course do not receive a daily allowance but can apply for social assistance. After completing the Swedish course, the person must undertake a course in healthcare-related Swedish. This course is run by the public employment office and is also free-of-charge. The actual costs of validating foreign certification are thus considerably higher than the cost paid by the private person. These costs are covered by municipalities and central government. 7. Any other aspects Many Swedish county councils have successfully recruited doctors from countries such as Poland and Germany. Recruitment in Poland had already started before Poland's entry into the EU, making use of the temporary work permits that can be granted to citizens outside the EU/EES for an 18-month period to cover temporary shortages in the workforce. The AMS has in several cases granted exemptions so that the period for which a work permit is granted has been extended to 36 months. Many doctors surgeries have had problems with recruitment and retaining staff, and these took part in a countrywide recruitment project led by Kalmar county council. Documented shortages in the workforce were a prerequisite for recruitment from Poland.

16 Future dependency burden 7 The dependency burden, i.e. how many need to live off what is produced by the working share of the population, will not change very much until It will then increase slowly until So if the employment forecasts are correct, there should not be a sharp increase in the dependency burden in the years leading up to 2010, as was previously expected because those born in the 1940s were expected to retire during this period. It has become clear that the share of people born during the 1940s was not as high as had been feared. The number of people of working age will increase until 2014 when there will be around more than today. The total will decrease after this but there will still be around more in 2020 compared with today's figures. Over and above the developments in the population, there is the question of how many people will be actively working. The number of people working is also affected by changes in the pension system and the participation in studies, with more students and longer study programmes, etc. 8. Conclusions The number of persons aged will increase over the next years. The retirement of people born in the 1940s will be compensated by the baby booms of the 1990s. The real problem can be expected to hit during the 2020s, when the large number of people born in the 1960s will retire and be replaced on the labour market by younger age groups. The existing shortage of people working with training in the healthcare and social sectors will increase and be very extensive in the long-term. At the same time as access to medical care personnel decreases, the demand for medical care will increase due to the ageing population. There will primarily be a shortage of people with healthcare education from upper secondary school but shortages can also be significant among occupations such as nursing. The increase in demand will mainly be seen in care for the elderly but, to some extent, also in the general health and medical care sectors. Access to personnel with upper secondary care education will decrease by one third in the period up to Over and above these population developments, participation in the labour market also plays a significant role in the supply of labour in the future. There has been a downhill trend for both men and women since the 1990s. One issue that can also be important is whether the new pension system will mean that more people will opt to work longer in order to secure a good pension. The new system of student aid, involving a raise in grants and a tightening of the repayment rules, introduced in 2001 can also be of significance. People with foreign backgrounds have often encountered great difficulties when trying to establish themselves on the Swedish labour market. The ability to communicate is important and therefore knowledge of the Swedish 7 Trends and Forecasts 2002, (2003)

17 17 language is essential. This adds to the difficulties of entering the workforce, especially for immigrants who have arrived in Sweden in recent years. Immigration to Sweden has changed since the 1960s. In those days, immigration largely consisted of labour immigration from the Nordic countries and from Western and Southern Europe. To a great extent, Nordic immigrants were already able to communicate in Swedish at the time of immigration. This labour immigration has now been replaced by refugee and family immigration from the third world and Eastern Europe. Language problems and religious and cultural traditions have made the integration of immigrants more difficult, both into society in general and into working life in particular. The economic crisis at the beginning of the 1990s made it even harder for immigrants to establish themselves on the labour market 8. Forecasts from the National Board of Health and Welfare 9 show that the number of midwives employed in health and medical care will decrease by slightly over 25 per cent. The National Board of Health and Welfare further comments that the number of midwives with foreign qualifications who have received Swedish certification and then started to work in the Swedish health and medical care sector is limited. The very low numbers of midwives immigrating to Sweden means that, in principle, the inflow of midwives only comes from domestic training programmes in Sweden. The number of nurses employed in the health and medical care sector is expected to increase by around 10 per cent until Net migration is expected to be on the level of around 200 nurses annually, which only represents 0.2 per cent of those employed. The number of certifications issued to nurses with foreign education increased during the period 1995 to 2003, from around 150 to slightly over 500 annually. The largest training countries are Finland and Germany. The future immigration of nurses educated in the Nordic countries or in other EU/EES countries is completely dependent on the employment situation, both in Sweden and in the other EU/EES countries. The inflow of nurses from EU/EES countries outside the Nordic region has been steady but has shown a tendency to increase in recent years, primarily relating to persons with German education. Immigration of nurses educated in third countries is harder to assess as this is largely related to refugee and family immigration. The National Board of Health and Welfare considers that immigration of nurses from third countries will correspond to 150 to 200 nurses annually in the coming years. The number of doctors employed in the health and medical care sector is expected to change relatively little and should be on the same level in 2020 as in Net migration is expected to be insignificant. The development of 8 These analyses are taken from Trends and Forecasts 2002, (2003) 9 Forecast of employment in the health and medical care and dental care sectors , National Board of Health and Welfare

18 18 migration is, in principle, dependent on the labour market in Sweden and the rest of the EU and also, to some extent, on the various flows of refugees across the world. The labour market situation for doctors in Germany and Denmark will probably have the greatest impact on the immigration of doctors to Sweden. The number of certifications issued to doctors with foreign education increased during the period 1995 to 2003 from around 200 to close to 900 per year. The largest individual training countries are Denmark and Germany. However, it is not certain that those who have been issued Swedish certification actually work in the Swedish health and medical care sector, or even in Sweden. The inflow of doctors with foreign education to the Swedish health and medical care sector until 2002 came primarily from third countries. Whether the increase of newly certified doctors with foreign education reflects a general increase in the number of employed persons in the Swedish health and medical care sector has not been determined. The training of doctors in the new EU countries has been approved by the rest of the EU. It seems however unlikely that emigration from these countries to Sweden will increase to any great extent. It is possible that such an effect can be seen in the short-term, as a number of doctors may have awaited EU membership to apply for Swedish certification. In its forecast, the National Board of Health and Welfare anticipates an annual inflow of 100 to 150 doctors with education from EU/EES countries outside the Nordic region, plus an annual inflow of 100 to 150 doctors with education from third countries. The number of dental hygienists employed in the dental care sector is expected to increase and reach the level of around in 2020 compared to in Net migration is expected to be insignificant. During the period 1996 to 2003, only nine dental hygienists with foreign education have received Swedish certification, which is why a forecast of this group is not possible. The number of dentists employed in the dental care sector is expected to decrease considerably to reach a level of in 2020 compared to in Some net migration can possibly be expected, both of dentists with foreign and Swedish education. However the National Board of Health and Welfare considers that this inflow will not affect more than marginally the future access to dentists employed in the dental care sector. Foreign dentists who received Swedish certification, and who were employed in the dental care sector in Sweden the following year, increased from one person in 1996 to 38 persons in Even if more dentists with foreign education who have received Swedish certification also begin to work in dental care in Sweden, the number remains limited. The National Board of Health and Welfare estimates that there will be an annual immigration of 20 to 30 dentists.

19 References Published: SOU Directive Review of the legislation for labour immigration Trends and Forecasts 2002, Guidelines from the Labour Market Administration for the handling of work permit applications Forecast of employed persons within healthcare, medical and dental care, National Board of Health and Welfare Government authorities: Labour Market Administration Swedish Migration Board Validation delegation Sweden's county councils and regions Swedish Medical Association Laws and ordinances: 1989:529 Aliens Act SFS 1989:547 Aliens Ordinance

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