Table 1

Challenges faced by Syrian healthcare workers in joining the German healthcare workforce

Challenges faced
Obtaining proof of degrees and accreditationMany 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 diplomasSome applicants presenting their diplomas to German embassies for ratification have difficulties proving that they are not fraudulent documents.
BureaucracyThe 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 registrationThe 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 willThere 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 languageSome 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 workersMany 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
RetrainingSome 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 statusSome 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 patientsStudies 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 refugeesDue 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.