Care drain in the Balkans

Nikica Martić and his family are looking forward to a new life in Germany. The 33-year-old doctor has been waiting for the “right moment” to leave Croatia in search of better pay and working conditions, and there are many more like him.

Since Croatia joined the European Union in 2013, Croatia’s National Medical Council has received more than 1300 requests for certificates to work abroad. At least 550 doctors have left the country, many fed up with dead-end jobs, forced overtime and abusive patients.

“You hear stories from people working abroad. About better working conditions, better education, higher wages,’’ says Martić, who worked for six years in an emergency unit in Istria after graduating from medical school in Zagreb. Typically young doctors get stuck working in “ER” for years.

“My wife is a nurse and we decided together to go abroad as a family. We chose Germany, because there is a large Croatian diaspora, and our contacts there told us it wasn’t difficult to find a job,” Martić tells Equal Times.

Although some have tried their luck in the United States or the Gulf countries, most doctors seek fresh starts in western European countries such as Germany, Austria, the United Kingdom or Sweden.

Europe’s breeding ground for “free” doctors

The “care drain’’ is not just a Croatian issue: it is taking place across the former Yugoslav republics. In addition, large numbers of doctors from EU member states like Poland, Bulgaria, Romania and Greece have also migrated west.

In socialist Yugoslavia, university education was entirely state-funded. After the breakup of the country, the education remained mostly free, meaning that many Balkan states in effect “subsidise” the healthcare systems of western EU countries, says Harun Drljević, president of the National Medical Council of Bosnian Federation.

“EU countries are getting ‘ready-made’ medical doctors, without investing anything in their education and training. Ready-made, and for free! This is a great gift for health systems of the EU countries,” he says bitterly.

Last year alone, the Federation of Bosnia and Herzegovina lost around 300 doctors to migration abroad. These figures do not include junior doctors who often leave the country after graduation.

In Slovenia, the National Medical Council receives up to 300 requests for certificates every year: they estimate that around five per cent of these applicants end up going abroad. The National Medical Council of Serbia has been issuing more than 1000 certificates each year.

There are no accurate figures for Kosovo, but the Kosovo Federation of Health Workers claims the country lost 400 medical staff in 2013 alone, and the trend has continued to grow ever since.

It is also estimated that about 300 doctors left Macedonia in 2013 and 2014.

In Germany, one of the main migration destinations for medical staff from the Balkans, different programs and agreements have made it easier for skilled healthcare workers from Bosnia and Kosovo to immigrate.

Drljević also highlights the presence of different foreign employment agencies scouting for talented medical doctors in these country. In Serbia, local media reported the opening of a German job agency specialised in medical staff.

A Serbian doctor working in a clinic in Germany claimed, in the Serbian newspaper Blic, that they receive a bonus of €2000 (US$2300) for every doctor or nurse they bring in from Serbia.

In every country of the former Yugoslavia, higher salaries, better professional development and greater possibilities for promotion are mentioned as the main reasons why medical doctors move abroad.

Drljević notes that the medical doctors in his country “often have to face hard working conditions that don’t fulfil even the basic professional standards. Often, patients can become physically abusive towards physicians.”

“Slave contracts”

In Croatia, the average age of doctors who leave the country is 37. Among junior doctors who decide to leave, many do so before starting their specialty training.

Amongst them is 27-year-old Stella Miloš, a graduate from the Faculty of Medicine of Zagreb. She gets angry just by mentioning the specialty training system in Croatia. “They are making us sign ‘slave contracts’,” she says.

After they graduate, junior doctors in Croatia who have successfully completed their mandatory six-month internship usually apply for a specialty training. But the available posts are scarce and often attributed in a non-transparent way, so junior doctors often end up working in emergency units for years.

Once they finally get a residency, they are required to work at the institution where they initiated their training, or face a fine of €30,000 (US$35,000) per year of “non-completed contracted work”.

“After six years of university education, one is often unsure what to do next. I did not want to be forced to remain in one place, doing something I maybe didn’t want to do for 10 years, or pay a lot of money to leave,” explains Miloš.

She now lives in Austria, where she obtained a specialty-training contract in urology a year and a half ago.

Fixing the system

As junior doctors such as Miloš and Martić migrate west, they are leaving behind an ageing sector in dire straits.

“What is important to emphasise is that it is not only a struggle to keep doctors, but also a struggle to keep the social security system of Croatia. The service will ultimately become less accessible and of lower quality,” explains Trpimir Goluža, president of the National Medical Council of Croatian Physicians.

The effects of the care drain are already being felt, since waiting lists for medical examinations are getting longer and longer, while doctors work a number of overtime hours that “are not even legal”, he claims.

Moreover, an ever-increasing elderly population is expected to put even more pressure on the health care services.

To tackle the problem, Croatia has increased the number of university admissions for medical school and has increased the optional retirement age. Last year’s tax reform is aimed at highly skilled employees with higher incomes, doctors included.

But it is “not enough”, according to Goluža.

“If doctors continue to leave, then there is something in the system itself that is wrong. These are all mere ‘cosmetic measures’, while the necessary hasn’t been done,” he points out.

He says doctors need better opportunities for promotion and a reform in the way specialty training is attributed to junior doctors so that it becomes more transparent. And better loan conditions, so that doctors can afford to purchase houses.

But even these measures wouldn’t persuade Stella Miloš to return.

“I don’t think I’ll go back anytime soon…Someday, maybe, when I retire,’’ she says. “It’s nice to come to Croatia only on holidays, with your wallet full of foreign currency.”