Regular general practitioners who are immigrants
One in five regular GPs are immigrants
One out of five regular general practitioners included in the Norwegian GP’s patient list system is an immigrant, and more than half of these GPs are born in the EU/EEA area. Immigrants make up a greater portion of GPs in the least central municipalities and have a higher incidence of open patient lists.
In 2008, a total of 3 969 regular general practitioners were included in the Norwegian patient list system (Fastlegeordningen). Altogether, 777 of the regular GPs, or 19.6 per cent, were immigrants. This is a result of data collated from the statistics register of GP’s patient list systems owned by the Norwegian Labour and Welfare Administration (NAV) and demographic data from Statistics Norway’s system for population data and statistics (BESYS).
Immigrant is the term used for persons born abroad with parents also born abroad, and is one category in the classification Immigration category 2008. This classification consists of six categories that show different combinations of the person’s and his parent’s country of birth.
Country of birth classified according to the classification of countries and citizenship in social statistics, and usually refers to the mother’s country of residence at the time of birth.
Most regular GPs from EU/EEA countries, excluding the Nordic countries
In 2008, 32.4 per cent of the immigrants who worked as regular GPs in Norway were born in EU/EEA countries, excluding the Nordic countries, while 30.4 per cent were born in Asia, Africa, Latin-America or Oceania, excluding Australia and New Zealand, and 24.5 per cent were born in the Nordic countries.
Among the regular GPs who are immigrants, Germany, Denmark and Sweden are the countries which contribute the most. In 2008 there were 129 GPs who were born in Germany (16.6 per cent), 103 were born in Denmark (13.3 per cent) and 73 GPs who were born in Sweden (9.4 per cent). In addition, a relatively high proportion was born in Iran (6.6 per cent), Poland (5 per cent), Iraq (3.5 per cent), and Russia (3.3 per cent).
Best represented in least central municipalities
The municipalities of Norway can be classified by their centrality. The data show clear differences between GPs who are immigrants and other GPs with regard to the centrality of the municipalities they have agreed to a contract with. While 16.6 per cent of the regular general practitioners in the central municipalities were immigrants, the proportion in least central municipalities was as high as 35.5 per cent.
GPs’ patient list system and centrality of municipalities
According to the GPs’ patient list system, every municipality must engage GPs or agree to contracts with self employed GPs in order to provide a reasonable supply of services to the population. The municipality the GP has agreed to a contract which is termed ‘municipality of practice’.
The municipality of practice can be classified according to centrality. Centrality mainly reflects travel time from an urban settlement at different levels, according to number of inhabitants and available public services. When a GP has agreed to this type of contract with more than one municipality, the municipality where the GP has her main practice (most citizens listed) is defined as municipality of practice. Where there are an equal number of patients listed in the different municipalities, it is the municipality with the longest running contract that is defined as municipality of practice
Immigrants have higher incidence of open patient lists
In 2008, a total of 33.4 per cent of all regular general practitioners had an open patient list, i.e. they were available for new persons/patients to sign up. In 2002, the first full year the GPs’ patient list system (Fastlegeordningen) was implemented nationwide, the proportion of open patient lists was as high as 47.4 per cent.
There are differences between regular GPs who are immigrants and other regular GPs with regard to the proportion of open patient lists. While 56.8 per cent of regular GPs who are immigrants had an open patient list in 2008, the similar proportion for other regular GPs was 27.8 per cent. The rate of change from 2002 to 2008 shows that the proportion of open patient lists has declined in both groups, but the decline is not as strong among GPs who are immigrants as for other GPs.
Patient list status
The patient list status defines whether the GP has the capacity to admit more persons to her list. According to the current regulations, municipalities can require at contract signing that the regular general practitioner undertakes responsibility for up to 1 500 persons when employed full time in patient treatment, and a proportion of this number in the case of part-time employment.
Patient list status is defined as the number of patients agreed to in the regular general practitioner’s contract minus the actual number of patients on the list. A list is open (i.e. has available capacity) if the agreed number of patients minus the number of patients on the list exceeds 20. A list is closed if the agreed number of patients minus the number of patients on the list is less than 20.
Growing number of regular general practitioners
Both the number of regular GPs and the number of GPs’ practices has increased since the patient list system was introduced. Even though a regular GP commonly has just one practice as a GP, some GPs have signed agreements with more than one municipality to practice as a regular GP. In practice, this means that the number of GPs’ practices exceeds the number of GPs at all times.
According to the Norwegian Labour and Welfare Administration (NAV), there were 3 728 regular general practices in Norway in 2002, and the number increased to 3 983 in 2008. The number of regular GPs (persons) increased from 3 703 to 3 969 in the same period of time. The latter represents a growth of 264 GPs, or slightly more than 7 per cent.
The proportion of regular GPs born abroad by foreign-born parents has been approximately 18-19 per cent for the whole period. However, the relative increase is higher for regular general practitioners who are immigrants than for other regular general practitioners. In 2002, 688 of the regular GPs were immigrants, while in 2008 the number was 777. This gives an increase of almost 13 per cent, while the increase in GPs who were not immigrants was about 6 per cent.
Regular general practitioners and the GPs’ patient list system
As regular general practitioners (GPs), we include general practitioners who have an agreement with one or more municipalities to practice as a GP. In Norway, the GPs generally have a private practice, i.e. are self-employed, but some are employed by the municipalities.
The GPs’ patient list system was introduced for Norway as a whole on 1 June 2001.The system means that every citizen who wants to be enlisted by a regular general practitioner has a legal right to be enlisted. Each municipality agrees to contracts with general practitioners as regular general practitioners. The number of contracts agreed to is not regulated by law or by the government. Each municipality has to employ general practitioners or agree to a number of contracts in order to provide a reasonable supply of services.
International consideration - national requirement
At the international level there is a great deal of interest in elucidating the mobility of health personnel across borders. For instance, the Organization for Economic Co-operation and Development (OECD) has presented mobility among health care personnel as a topical subject in relation to the expansion of OECD Health Data. Statistics on the immigration category and country of birth of the regular general practitioners provide information about the general practitioners and their mobility across borders.
Furthermore, the World Health Organization (WHO) is focusing on mobility among health care personnel. There are at least two considerations to take into account: On the one hand that health care personnel shall be able to seek career opportunities abroad and that a global economy is based on a free flow of labour. On the other hand it is important to consider the effects on countries who supply other countries with health care personnel, and where the health care systems and the population can be suffering. In April 2004, The World Health Assembly (the executive office at the WHO) signed a resolution which asked the member countries “...to develop strategies to mitigate the adverse effects of migration on health personnel and minimize the negative impact on health systems” (WHO 2004).
The fact that one out of five regular general practitioner in Norway is an immigrant gives reason to believe that this group is essential for the recruitment of regular GPs in the municipalities and necessary for fulfilment of the aims of the patient list system. This indicates that the situation of a relatively stronger increase among regular general practitioners who are immigrants than among other regular general practitioners will probably continue in the future. There is also reason to believe that the regular general practitioners will continue to come from different regions of the world, not only the Nordic countries or the EU/EEA countries.
Country of birth:
Centrality of municipalities:
Statistics in Statistics Norway and the Norwegian Labour and Welfare Administration (NAV)
The statistics is published on Statistics Norway’s website. The purpose of these statistics is to provide information on structure and development of employment among people with a health care education, i.e. medical practitioners.
Central data about patients in general practice is published on Statistics Norway’s website. The aim of the project was to establish a system for representative statistics about activity in general practice and contact between patients and regular general practitioners. The statistics cover the year 2005, and annual statistics have not been established.
The statistics are presented on the Norwegian Labour and Welfare Administration’s website. The main purpose is to produce necessary control information for national and regional health authorities.
Bach, Stephen (2008): “International Mobility of Health Professionals: Brain Drain or Brain Exchange?”, in Andrés Solimano (ed.): The International Mobility of Talent. Types, Causes and Development Impact , Oxford: Oxford University Press, 202-235.