Why Do Hungarian Health Workers Migrate? A Micro-Level Analysis

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The manuscript titled "Why do Hungarian health workers migrate? A micro-level analysis" that explores the migration attitudes of Hungarian health workers towards migration It employs a micro-level approach, focusing on various push-pull factors influencing the attitudes of health care workers towards migration. The study includes semi-structured interviews with practicing and inactive Hungarian health professionals, both living in Hungary and abroad. The thematic analysis of these interviews reveals factors related to wealth and income, workplace, human capital, quality of life, family, personal network, personality, geography, and life stage. The paper also discusses the importance of geographical characteristics and life stage as overarching integrative categories. Moreover, the study presents policy recommendations based on its findings.

 

The research methods used in this study are qualitative in nature. The researchers conducted semi-structured interviews with Hungarian doctors and other health workers to collect data for their analysis. The interviewees were selected non-randomly using purposive sampling and the snowball technique to ensure a diverse representation. Thematic analysis was then applied to analyze the field notes and interview transcripts, with a three-member research team involved in the coding and analysis process. The researchers identified micro-level factors that influence the migration decisions of health workers based on the subjective interpretations and reactions of the interviewees. The analysis also considered geographical factors and life cycle/stage as overarching categories that contribute to migration motivations.

The use of qualitative data collection and analysis methods may allow the researchers to uncover underlying factors and background processes that would have been challenging to capture through large-scale statistical analysis or questionnaire surveys

The study has a few notable limitations.

First, the data collection was also conducted before the Covid-19 pandemic, so the effects of the pandemic on migration attitudes cannot be analyzed.

 

Second, the effects of the most recent governmental measures or macroeconomic issues cannot be evaluated due to the timing of the data collection and the lack of longitudinal data.

Author Response

Thank you for your comments and remarks. The English text has been revised. UK English spelling were replaced with US English.

Regarding the effects of Covid-19 and recent governmental measures we added the following:

“This research aimed to reveal the general factors influencing migration attitudes among Hungarian healthcare workers. Covid-19 was an exceptional event that obviously affected these attitudes, but the durability of the effects is uncertain. At the same time, the factors identified in this research remained relevant and the challenges related to the pandemic can be classified into our categories (e.g. workplace or quality of life). […] The indirect data on migration intentions (the number of Certificates of Good Standing issued – the document that certifies healthcare qualification for working abroad) show that despite the rising wages, changing regulations or the investments made in healthcare in general, willingness to work abroad has not decreased.”

Reviewer 2 Report

Comments and Suggestions for Authors

This paper on 'Why do Hungarian health workers migrate? A micro-level analysis' makes a substantial contribution to the understanding of migration trends among Hungarian health professionals. One of its notable strengths lies in its comprehensive review of prior literature, which effectively contextualizes the challenges faced by healthcare systems in Central and Eastern European (CEE) countries due to health worker migration. Employing a micro-level approach through semi-structured interviews and thematic analysis, the study delves deeply into the multifaceted factors influencing migration decisions. Its inclusivity of various dimensions—ranging from economic aspects like income and work environment to personal and familial considerations—provides a nuanced understanding of the complex motivations driving migration. Furthermore, the paper's emphasis on geographical characteristics as an influential factor distinguishes it from previous studies, adding a novel perspective to the discourse on health workforce migration. Overall, this research offers valuable insights that not only shed light on the intricate reasons prompting Hungarian health workers to migrate but also lay the groundwork for potential policy recommendations aimed at addressing workforce shortages and sustaining healthcare systems in the region.

Comments on the Quality of English Language

Minor editing of English language required

Author Response

Thank you for your comments and remarks.

The English text has been revised.

Reviewer 3 Report

Comments and Suggestions for Authors

Dear Authors,

 

I have reviewed the manuscript entitled “Why do Hungarian health workers migrate? “A micro-level analysis”. The manuscript is relevant to the Sustainability Journal but needs to be reviewed before being considered for publication. I suggest making these changes:

 

Introduction

The introduction is very complete; however, it is suggested to include studies on sustainability seen from the European Union or, particularly, Central and Eastern Europe.

 

 

Materials and methods

The methodology is broad and clear, which allows the elements to be replicated, however, it is suggested to incorporate a diagram that allows the procedure and the inclusion and exclusion criteria to be clearer, as well as informed consent, in such a way that each of the phases and what is done in them is clear. Likewise, incorporate a section on the analysis of the discourse carried out to arrive at the results obtained.

 

Results

The results are complete, given that the most important results and reflections of some cases in each category are adequately described. However, it is suggested to mention the frequency in which the motivations or factors are mentioned in each category, so that evidence, of which were the most mentioned.

 

Discussion

The discussion is complete.

 

Conclusions

It is suggested to conclude in terms of the objectives set out in the study, in such a way that the migratory attitudes of Hungarian health workers are identified.

 

References

The references are relevant, however, it is suggested to increase the number of current references (last five years), given that 30% of its references are from 2019 to date.

 

Waiting for your suggestions to improve your manuscript, I look forward to any response from you.

 

Kind regards.

Author Response

Thank you for your comments and remarks.

The English text has been revised.

We included studies on sustainability and amended the text with this aspect as well:

Recent studies on European healthcare systems, including Central and Eastern Europe (CEE), conceptualize the sustainability of healthcare in several ways: budgetary/fiscal/financing, access [19,20], and environmental sustainability [21]. One of the causes as well as the consequences of these sustainability problems is the crisis of medical workforce (e.g. [22]. National healthcare systems in this region struggle with significant sustainability problems, partly due to the migration of health workers. In fact, too much reliance on foreign labor poses a risk to the sustainability of European healthcare systems and increases the workforce deficit in the sending countries [23]. Furthermore, policy changes can have a negative effect on the immigration of healthcare workers, thus may risk the sustainability of healthcare. For example, stricter immigration policies introduced after the United Kingdom left the European Union reduced the number of doctors arriving to the country. [24].

The following new references were incorporated:

Botezat, A.; Incaltarau, C.; Nijkamp, P. Nurse Migration: Long-Run Determinants and Dynamics of Flows in Response to Health and Economic Shocks. World Development 2024, 174, 106445, doi:10.1016/j.worlddev.2023.106445.

Ebeye, T.; Lee, H. Down the Brain Drain: A Rapid Review Exploring Physician Emigration from West Africa. Global Health Research and Policy 2023, 8, 23, doi:10.1186/s41256-023-00307-0.

Guthmuller, S.; Paruolo, P.; Verzillo, S. Positive Externalities of EU Actions on Sustainability of Health Systems. In The Sustainability of Health Care Systems in Europe; H. Baltagi, B., Moscone, F., Eds.; Contributions to Economic Analysis; Emerald Publishing Limited, 2021; Vol. 295, pp. 1–21 ISBN 978-1-83909-499-6.

Jakovljevic, M.; Cerda, A.A.; Liu, Y.; García, L.; Timofeyev, Y.; Krstic, K.; Fontanesi, J. Sustainability Challenge of Eastern Europe—Historical Legacy, Belt and Road Initiative, Population Aging and Migration. Sustainability 2021, 13, 11038, doi:10.3390/su131911038.

Milić, J.; Vuksan-Ćusa, Z.; Jakab, J.; Ćurčić, M.; Puljak, L.; Vranješ, I.M.; Miškulin, M. Tendencies towards Emigration and Their Association with Introversion and Ethnocentrism among Final-Year Medical Students from Osijek, Croatia: A Cross-Sectional Study. BMC Medical Education 2023, 23, 632, doi:10.1186/s12909-023-04611-8.

Russo, G.; Perelman, J.; Zapata, T.; Šantrić-Milićević, M. The Layered Crisis of the Primary Care Medical Workforce in the European Region: What Evidence Do We Need to Identify Causes and Solutions? Human Resources for Health 2023, 21, 55, doi:10.1186/s12960-023-00842-4.

Sikos Tomay, T.; Szendi, D. Analysing Economic and Environmentalsustainability in Hungary: How Cities with Countyrights Perform in SDGs. Urbani izziv 2023, 34, 87–97, doi:10.5379/urbani-izziv-en-2023-34-02-03.

Zapata, T.; Buchan, J.; Azzopardi-Muscat, N. The Health Workforce: Central to an Effective Response to the COVID-19 Pandemic in the European Region. The International Journal of Health Planning and Management 2021, 36, 9–13, doi:10.1002/hpm.3150.

Zatonatska, T.; Liashenko, O.; Fareniuk, Y.; Dluhopolskyi, O.; Dmowski, A.; Cichorzewska, M. The Migration Influence on the Forecasting of Health Care Budget Expenditures in the Direction of Sustainability: Case of Ukraine. Sustainability 2022, 14, 14501, doi:10.3390/su142114501.

 

A diagram (Please see attachment) on the research process was incorporated – this diagram also illustrates the analysis of the discourse. The presentation of data and methods is also amended with the following:

“In order to increase the reliability of the analysis, each member of the research team checked the quotes and their categorization. For a quote to be included in the analysis, all members had to agree on the interpretation.”

 

Regarding the frequency of motivations and factors: due to the qualitative approach of our research we have not calculated frequencies, because such a quantification could be misleading in a qualitative study. The importance of factors is determined not based on how often they were mentioned, but on the context in which they were mentioned. What kinds of wordings were used? How were they connected? The overlapping nature of the categories makes it difficult (if not impossible) to quantify the results. Thus, only the most important factors could be highlighted:

“Due to the qualitative nature of the research and the overlapping categories, it is not possible to classify the factors according to their importance or quantify the results. However, family and life cycle seem to be the most important factors influencing migration-related attitudes and decisions.”

 

The Conclusions were amended with the migratory attitudes identified in the research:

“The results show that the topic of migration affects all of the interview partners and all of them were considering the idea of moving; however, their conclusions were varying. Besides the types used during the selection of interview partners (emigrated, re-migrated, decided against migration), additional types of migration attitudes were identified during the analysis: the “hypermobile” and “determined non-movers”. Migration is an essential part of life and career for the hypermobile interviewees, while the determined non-movers have no intention to migrate at all.”

 

New references were used (see the list above) to make the literature background more up-to-date.

Author Response File: Author Response.pdf

Reviewer 4 Report

Comments and Suggestions for Authors

Great Job on the manuscript, I have a few comments:

Is it possible to classify the identified factors based on importance?  

 

Data for the current study was collected from 2019 to 2020, however, fear of COVID-19 has affected the attitude of emigrants. Don’t you think omitting this aspect will affect the internal and external validity of the study? 

 

The study explore the migration attitudes of Hungarian health workers. Based on push-pull apppracoh, the study explored key factors i.e., wealth and income, workplace, human capital, quality of life, family, personal networks and personality. Qualitative data was collected via semistructured interviews with doctors and health workers.Based on the purpose of the study purposive sampling techquire were used. Data was analysed via thematic analysis. The authors found income, work environment and family key factors migration decision.

 

Findings of the study will influences policy, theory and practices.  However, classification of identified factors based on there importance will strengthen the findings and support policy makers.   Data for the current study was collected from 2019 to 2020, fear of COVID-19 negatively affected migration decsion, addition of this aspect will contribute to study validity.

Author Response

Thank you for your comments and remarks.

The English text has been revised.

Based on the collected data (which is a consequence of the qualitative approach of our research) it is not possible to create a complete classification of factors. The importance of factors is determined not based on how often they were mentioned, but on the context in which they were mentioned. What kinds of wordings were used? How were they connected? The overlapping nature of the categories makes it difficult (if not impossible) to classify the factors. Thus, only the most important factors could be highlighted:

“Due to the qualitative nature of the research and the overlapping categories, it is not possible to classify the factors according to their importance or quantify the results. However, family and life cycle seem to be the most important factors influencing migration-related attitudes and decisions.”

 

Regarding the validity of results: the research aimed to reveal the key categories of factors that influence migration decisions. The pandemic obviously affected these decisions but on the one hand, the durability of these effects is not clear, and on the other the challenges in relation to Covid-19 are closely related to the categories identified in this research. The effects of Covid-19 could be identified in longer term thus longitudinal research is needed. Our research can be a basis for longitudinal comparisons. Answering to the remarks, the text was amended with the following:

“This research aimed to reveal the general factors that influence migration attitudes among Hungarian healthcare workers. Covid-19 was an exceptional event that obviously affected these attitudes, but the durability of the effects is uncertain. At the same time, the factors identified in this research remained relevant and the challenges related to the pandemic can be classified into our categories (e.g. workplace or quality of life). […] The indirect data on migration intentions (the number of Certificates of Good Standing issued – the document that certifies healthcare qualification for working abroad) show that despite the raising wages, changing regulations or the investments made in healthcare in general, willingness to work abroad has not decreased.”

Reviewer 5 Report

Comments and Suggestions for Authors

I really enjoyed reading the manuscript, and I appreciated the logical coherence from beginning to end. The approach from a sustainability perspective is valid.

In methodological terms, the way the data is presented manages to stand its ground in the qualitative paradigm, congratulations.

In line 992, please put a coma (,) after the word «least».

Author Response

Thank you for your comments and remarks.

The English text has been revised, the suggested changes were implemented.

Reviewer 6 Report

Comments and Suggestions for Authors

Thank you for presenting a timely and interesting article about the EU and Hungary. Learning of the internal issues concerning health professionals from this location and the push-pull representation individuals go through in making the decision to stay or leave their home of record indicates the conflict in making that decision.

 

1.     What is the main question addressed by the research?

What factors influence the migration intentions of Hungarian health professionals, and how do these factors operate?

 

2.     Do you consider the topic original or relevant in the field?

Yes, it is relevant to the field. Before the country's democratization, the migration of any professional individuals to a Westernized country was restricted and closely monitored. Now that the country is politically open, authors can compare data from earlier time frames with the country's current status and publish this material for academic purposes.

 

Does it address a specific gap in the field?

The manuscript addresses several contributing factors to the identified gap, specifically why Hungarian health professionals leave the country and the incentives for leaving. The main aim of exploring Hungarian health workers' migration intentions and motivations is to expand and deepen existing knowledge, revealing the complexity of motivating factors.

 

3.     What does it add to the subject area compared with other published material?

      During the era of state socialism, there was no shortage of health professionals, as the health

systems could develop in isolation from international processes and market mechanisms due to state paternalism. Articles discussing the sustainability of healthcare systems from the perspective of human resources often ignore the role of the individual’s micro-environment in making migration decisions

 

4.     What specific improvements should the authors consider regarding the methodology?

      Determining a specific means of target population selection in keeping with qualitative methods.

 

5.     What further controls should be considered?

            None

 

6.     Are the conclusions consistent with the evidence and arguments, and do they address the main question?         The authors were consistent in their presentation of topics. In the final paragraphs, they indicated their     identified limitations, as well as how their study answered their posed questions.

 

 

 

7.     Are the references appropriate?

Yes. This manuscript will fit well with the current literature and nicely incorporate historical information.

 

8.     Please include any additional comments on the tables and figures.

      I have no comments on the tables. They represented the thematic information.

 

Comments on the Quality of English Language

I find no real issues with this manuscript except minor noun and verb tenses. Other than this issue, I found the manuscript easy to read and understand.

Author Response

Thank you for your comments and remarks.

The English text has been revised.