Summary box
Germany faces a shortage of doctors with conservative estimates suggesting a shortfall
of 15 000 doctors; this could rise to 111 000 by 2030.
Over 1 million refugees have arrived in Germany of whom several thousand are healthcare
workers; however, few studies explore their registration process and integration into
Germany’s health system.
We discuss challenges faced by Syrian healthcare workers in Germany to enter the workforce,
such as cultural and linguistic barriers, decentralised bureaucratic processes and
long delays in obtaining and ratifying diplomas.
We suggest policy recommendations including collaboration and leadership from German
doctors’ associations, healthcare workers and policymakers to support the successful
integration of Syrian healthcare workers into Germany’s federal health system.
Successful integration of Syrian healthcare workers into the German healthcare system
could be cost-effective and could support the provision of culturally and linguistically
sensitive healthcare to Arabic-speaking and Kurdish-speaking populations in Germany.
Introduction
The Syrian war has resulted in over 5.6 million refugees, the majority of whom reside
in the neighbouring countries, including Lebanon, Jordan and Turkey.1 Since 2015,
over 1 million refugees, the majority of whom are from Syria, entered Europe through
Greece in the hope of transitioning to Northern European countries to seek asylum.
Germany was the favoured destination for many refugees due to its welcoming policies
for integration, which include liberal asylum laws, healthcare and educational advantages
and pre-existing familial links.2 As of December 2018, there are nearly 700 000 Syrians
living in Germany, a large increase from 2016 due to positive decisions on asylum
claims as well as resettlements.3
A significant number who sought asylum in Germany hold professional qualifications
and university degrees, including medical doctors, dentists and other healthcare workers.4
Although there are no official numbers, the German Medical Association states that
the largest influx of foreign doctors in the past year are from Syria, with nearly
737 Syrian physicians entering the German workforce in 2017.5 They also estimate that
there are more than 3370 Syrian doctors working in Germany, including those who arrived
before the onset of the Syrian conflict.4 However, this likely underestimates the
true number as it omits those who have German citizenship or are completing their
registration. In general, there is sparse information on the number of qualified healthcare
workers among Syrian refugees. This may be due to the lack of data collected from
new arrivals on entry to Germany; although occupation is included in the Refugee Resettlement
Form used by the United Nations High Commissioner for Refugees (UNHCR), it is not
included within the minimum data collected through the emergency UNHCR registration
process.6 7 This limits the ability of host countries to estimate the proportion of
healthcare workers among their refugee populations and to support them to integrate
into the local healthcare workforce.
Historical precedents whereby refugee healthcare workers have been integrated into
host countries exist.8 After the Second World War, the UK welcomed refugee healthcare
workers into the National Health Service; similarly, in the 1950s, Egypt permitted
Palestinian refugee healthcare workers to practise.8 More recently, Sweden launched
Snabbsparet, a fast-track initiative to help new immigrants have their licenses accredited
for the health sector following negotiations between associations and trade unions.9
Some governments have been under political pressure from their medical associations
to prevent Syrian healthcare workers from integrating into the workforce (Jordan,
Lebanon),10 whereas others such as Turkey have opted for the retraining of doctors
and limiting their practice to working in Migrant Health Centres.11
Though Germany is among the most advanced countries in Europe in their support of
integrating refugee doctors into their workforce, the process remains challenging,
particularly for refugees from non-European Union (EU) countries. Integrating healthcare
workers into any host system is challenging due to the rigorous training and examinations
required to obtain certification. This is compounded by language and cultural barriers,
differences between the health systems of different countries and, in the case of
Germany, different registration requirements across different states (Bundesländer)
due to the decentralised federal system.4 12
Challenges
The process by which refugee healthcare workers can enter the German healthcare system
can be bureaucratic and expensive with long delays at each step.13 For Syrian refugees
to obtain a license to practise in Germany, the process requires: an accepted asylum
application, ratification for licenses obtained outside of the EU, European Economic
Area (EEA) or Switzerland, proficiency and aptitude tests and proof of proficiency
in German medical language.13 For doctors trained outside of countries in the EU,
EEA or Switzerland, a license to practise medicine (Approbation=full license, Berufserlaubnis=temporary
license) must be issued by the state health authorities of the individual federal
states (Approbationsbehörden).13
For the basic medical diploma to be recognised, the applicant must contact the competent
Federal State authority; some Federal states have one registration authority (Approbationsbehörde),
while others have several.14 Specialty certificates need to be recognised by the State
Chamber of Physicians (Landessärztekammer) and depends on the geographical area.14
If it is demonstrated that there is insufficient evidence for equivalence, the applicant
is required to perform a proficiency test (Kenntnisprüfung). An aptitude test (Eignungsprüfung)
is required if there are major differences in medical training, or if training occurred
outside of the EU. Proof of language skills is required for either a full or temporary
license to practise. As of 2014, a German medical language proficiency examination
(C1 level of Common European Framework of Reference for Languages) is required and
is carried out by the State Chambers of Physicians in the majority of federal states
with costs of up to €487.14
Syrian refugee healthcare workers face challenges at each of these steps including
obtaining proof of previous training or certificates (particularly if they have been
destroyed or lost during the conflict), learning medical German and understanding
the new culture of delivering healthcare.4 15 Furthermore, navigating the different
requirements in each of the states and potential long delays between each step. For
many, outstretched waiting periods and bureaucratic procedures can take a toll on
their mental health despite some support being available.15The table 1 explores the
challenges faced by Syrian healthcare workers in Germany in more depth.
Table 1
Challenges faced by Syrian healthcare workers in joining the German healthcare workforce
Challenges faced
Obtaining proof of degrees and accreditation
Many refugees left Syria suddenly during active conflict and took perilous routes
to Europe; this often meant that any official documents they had were either left
behind or lost en route. For accreditation, official replacements are required from
the Syrian government. This is challenging for those who have fled persecution in
Syria and could be placed at risk when requesting official documents from the government
or from the Syrian Embassy in Germany. Alternative methods of verifying qualifications
could be introduced.
Ratifying Syrian diplomas
Some applicants presenting their diplomas to German embassies for ratification have
difficulties proving that they are not fraudulent documents.
Bureaucracy
The bureaucratic processes in Germany are very different from those in Syria, where
bureaucratic procedures are centralised. As Germany is a federal state, there are
decentralised processes among different states. These bureaucratic mechanisms can
prove complicated for Syrians who may move often between states in their first few
years in Germany.
Time to full registration
The time for the full registration process can be long, with several months delay
between each step. Time between examinations (often months) may also be long causing
further delays.
Political will
There is a perceived lack of political will to streamline the process of entering
the workforce, to making it faster and easier to navigate. Additionally, some Syrian
healthcare workers call for a central (transfederal) assessment body to ratify foreign
documents in way that is efficient, fair and transparent.
Culture and language
Some healthcare workers find achieving a sufficient standard of medical German challenging.
This is particularly the case outside of main cities where professional-level German
language classes, including those specific to medical professionals, may not be available.4
Some find that the cultural aspects of practising medicine and interacting with patients
differ significantly from their practice in Syria. This is pertinent given the very
different roles that doctors and other healthcare workers have in Syria compared with
Germany and differences in patient interactions, expectations and the different skills
that doctors in Germany may have.15 In Syria, healthcare workers may continue to deliver
a paternalistic style of caring for patients, whereas in Europe this has become less
prevalent. Expanding opportunities for cultural and language classes and observerships,
particularly outside of main cities could support Syrian healthcare worker integration.
Mental health of healthcare workers
Many of the Syrian healthcare workers practised during the war seeing trauma patients;
many would have lost family members, been imprisoned or been threatened by various
groups. Furthermore, the period of uncertainty in Germany to obtain ratification and
the stress associated with building a life in a new country and entering the work
force is also likely to contribute to increased stress and associated morbidities.20
Retraining
Some Syrian healthcare workers, particularly those who are specialists or who are
later in their career, find the prospect of retraining and taking further examinations
challenging. Doctors who were refugees in transit (eg, in Lebanon or Jordan) may have
faced legal restrictions to working and thus may have faced substantial interruption
to their clinical practice.10 Those who worked often did so in the humanitarian sector,
often in non-clinical roles. Bridging classes and observerships could support the
retraining of Syrian healthcare workers.
Refugee versus migrant status
Some Syrian healthcare workers came to Germany on either a working or student visa.
Once this expires, they have the option of seeking asylum or returning to Syria. For
some who still have family in Syria and who can travel back and forth to Syria, achieving
refugee or asylum seeker status would mean that they could not return to Syria in
the short term. Furthermore, the temporary nature of migratory status and achieving
legal refugee standing can serve as a barrier when applying to jobs and thus hinder
the ability of both refugees and migrants from partaking in the health workforce.21
Acceptance by colleagues and patients
Studies exploring the challenges faced by foreign-born doctors in Germany found that
they often received negative comments from patients, colleagues or supervisors and
reported feeling negative preconceived notions of their capabilities.22 23 Stakeholders
(including local and foreign-born healthcare workers, administrators, politicians,
advocacy groups) interviewed in these studies were reportedly critical of foreign-born
doctors’ skills, professional attitudes and behaviours which were felt to waver from
an ideal attitude, behaviour or ability expected from a doctor in Germany.22 23
Changing attitudes towards refugees
Due to the rapid increase of refugees into Germany, particularly between 2015 and
2017, attitudes towards refugees have shifted. An increasing number of Germans consider
refugees to be a threat to German culture and to be responsible for increasing crime.24
This is combined with anti-immigrant, anti-Muslim and anti-European stances, which
has become more prominent on the back of the refugee crisis.24 Alongside this, the
scale of numbers of asylum seekers has required tremendous resources from the government
in terms of: social integration, integration into the labour market, health and education.
In 2015, social welfare payments amounted to 5.3 billion euros (169% more than in
2014) and in 2016, the figure was 21.7 billion euros for refugee-associated expenditure.25
This could contribute to resentment towards refugees including healthcare workers.
Opportunities
Despite challenges, there are social and economic benefits to the integration of refugee
healthcare workers into European healthcare systems.4 16 Many European countries have
a shortfall of doctors and nurses; this is driven by an ageing population, retiring
healthcare workers, an increase in part-time working and insufficient numbers being
trained. In Germany, a conservative estimate of the shortfall is 15 000 doctors, though
some suggest it may be up to 27 000 with notable shortages in General Practice in
the East of Germany.12 The shortfall is estimated to rise to 111 000 by 2030 with
one in seven doctors (around 51 000) predicted to retire in the next 5 years.4 The
shortages are greatest outside of the three major cities in Germany, with specialities
like General Practice and General Medicine particularly affected; foreign-born physicians
can alleviate this shortage.4 Germany has set an important legal precedent for countries
receiving refugees. Restrictions on the rights of refugees to work are often regulated
by law; however, structured legal changes can facilitate refugee healthcare workers
to enter the workforce. For example, in 2015, Germany passed a law that allows refugee
medical doctors to work alongside licensed doctors in refugee centres, a move which
supports refugee doctors, refugees and the host country.4
Supporting the entry of Syrian healthcare workers into the German healthcare system
can encourage the provision of culturally sensitive healthcare (including linguistic
and gender-related sensitivity) for the more than 1 million Arabic and Kurdish speakers
in Germany, with whom they may share language and cultural backgrounds. Most have
fled conflict in Syria and Iraq, whereas others come from Morocco, Tunisia, Mardin
in Turkey and Lebanon. Studies suggest that specifically language differences, negatively
impact refugee patients’ access to healthcare and communication with health providers.17
Moreover, Syrian physicians working in Germany are key to rebuilding Syria’s decimated
health system as demonstrated by Syrian diaspora groups in Europe and the USA.18 Lastly,
there is economic benefit to supporting the entry of qualified healthcare workers
into the host country workforce as it is more cost-effective than training doctors
from medical school through to postgraduate training. Enabling foreign-born healthcare
workers to contribute will additionally reduce their dependence on the state. The
International Monetary Fund estimated in 2016 that the macroeconomic benefit from
the influx of refugees and migrants into the labour market impact the overall EU gross
domestic product (GDP) and increase the GDP by 0.5%–1.1%.19
Recommendations
Streamlining the process by which Syrian healthcare workers are integrated into the
German healthcare system is key to successful and efficient integration. Although
Germany has led the way in supporting the integration of Syrian healthcare workers
and has invested in structures which enhance the learning of the German language and
cultural understanding, the process of registration is slow and bureaucratic; this
has led to frustration among Syrian healthcare workers in Germany.4 Standardising
the process among federal states (Bundesländer) through a central assessment body
to ratify foreign documents in a way that is efficient, fair and transparent could
alleviate and expedite some of the challenges faced. For integration to be successful
political will, prioritisation of this issue, collaboration and leadership from doctors’
associations, healthcare workers and policymakers in Germany is fundamental. This
could provide increased support and opportunities for refugee healthcare workers to
improve their medical German language and cultural understanding, understand the German
health system and provide more opportunities for observerships during the registration
process, particularly outside of major cities.
Conclusions
The process of integration for Syrian healthcare workers into the German healthcare
system presents challenges as well as opportunities. Successful integration will benefit
not only the Syrian healthcare workers but also support the shortfall of healthcare
workers in Germany and provide economic advantage. This does invariably require political
will and increased support from German Physicians’ Associations with prioritisation
to support successful integration. Given the number of refugees and refugee healthcare
workers in Germany and the already positive initiatives that Germany has initiated
to support Syrian healthcare workers, lessons learnt through the German experience
will be important in other European and non-European contexts where Syrian and other
foreign-born refugees or migrant healthcare workers can enter the workforce.