Overcoming obstacles along the pathway to integration for Syrian healthcare professionals in Germany.

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.