Public-private and dual-practice workforce dynamics in small countries: findings from a Small Countries Initiative consultation across the WHO European Region.

BACKGROUND: Public-private workforce dynamics, including dual practice and movement between public and private sectors, are widespread in European health systems. In small countries they interact with thin professional pools, concentrated services and constrained administrative capacity to produce disproportionate system effects; evidence for the twelve Member States of the WHO Small Countries Initiative (SCI) is limited. OBJECTIVE: To describe the shape, drivers, perceived impacts and governance of these dynamics across SCI Member States and identify priorities for cooperative action. METHODS: We analysed responses to a cross-sectional consultation conducted ahead of the SCI Ministerial Meeting (Riga, 2026). Ten of twelve Member States responded through nominated ministerial officials. Descriptive frequencies were combined with thematic synthesis of open-text responses. RESULTS: Employment structures are heterogeneous: four of ten responding Member States describe predominantly public systems with limited dual practice, while the remainder describe public-private dynamics as structural rather than marginal. Where dual practice is substantial, it concentrates among medical specialists (9). Salary is the dominant driver (8). Five of ten reported disproportionate service-delivery effects when small numbers of professionals depart. Respondents cluster into four profiles - pre-authorisation, public-dominant, restrictive and data-deficit; priorities converge on governance of simultaneous employment, public-private collaboration for surge capacity, and minimum data and monitoring systems. CONCLUSIONS: Public-private workforce dynamics in SCI Member States require responses calibrated to four typological profiles. Governance, collaboration and data form a coherent policy architecture with retention as a cross-cutting concern; regional cooperation is a fit-for-purpose response to the shared constraints identified.