Doctors in eastern Europe prepare to walk out over pay

Abstract

Medical staff across eastern Europe are on a collision course with their governments, as disputes over pay and conditions threaten to hit frontline services. Ed Holt investigates.Thousands of Czech doctors are threatening to resign en masse, as frustration grows over working conditions. Doctors' unions say that unless doctors get higher wages, better hospital working conditions, and the government starts an overhaul of health sector funding, at least 2500 of 16 000 doctors working in Czech hospitals will quit by the end of the year. They say the move could leave some already chronically understaffed hospital departments unable to function, but that they have been left with no choice. “There is a serious problem with medical staff in the Czech Republic being undervalued and underpaid. Instability in the health-care system is already beginning to show by the large numbers of doctors and nurses leaving for work abroad every year. This is a significant sign of a serious problem and it must be dealt with”, Zdenek Mrozek, vice-president of the Czech Doctors' Chamber (CLK), told The Lancet.The threatened resignations—which have already been carried out at one hospital in which an entire department resigned—come amid increasing discontent among health-care workers in several countries across eastern Europe. Medical staff are striking, doctors are leaving for western Europe and North America in substantial numbers, and some senior medical figures have warned patient care is being put at risk because of staff and funding shortages. But governments across the region, some of which have already started or are planning drastic public sector spending cutbacks, say they simply cannot meet the demands of some doctors as they struggle with public finances in the wake of the financial crisis.In the Czech Republic, the Doctors' Trade Union (LOK) has appealed directly to newly elected politicians to earmark an extra €117–157 million for doctors' salaries per year. They say that higher salaries and better working conditions are the only way to keep doctors in the country and maintain present standards of patient care. Newly graduated doctors earn a basic salary of slightly more than €650 per month, the CLK says. The country's average monthly wage is about €900. It adds that some junior doctors also get paid only a part-time wage of €235 per month, but in reality work full-time hours.The CLK says that roughly 250 doctors leave the country to work abroad each year, most of whom are in their 30s and 40s and at the peak of their career potential. The poor state of post-graduate medical education means that many young doctors are leaving to take up work in other countries as soon as they finish medical school. Hospitals say that there is already an acute shortage of doctors in internal medicine, surgery and anaesthetic, and resuscitation wards. Mrozek, whose chamber is supporting the mass resignations of doctors, told The Lancet: “we are greatly concerned about the situation in departments at hospitals with a lack of specialised doctors. This is becoming a very big problem. In some cases that we know of there is only one senior qualified doctor for the whole department, so if he is away from the department at any time or sick there is no senior qualified doctor available. With regard to the proposed mass resignations—the situation at some places is so bad at the moment that just a few resignations could cause huge problems for a hospital.”One Czech doctor, who asked not to be named, told The Lancet that the lack of staff was already putting patients at risk. “Patients are already in danger. It is happening now and will go on until something changes”, he said. CLK president Milan Kubek presents an even more damning picture of the situation. He was quoted in local media in June as saying hospital staff numbers had been so decimated in some places that “anyone who knew about it would not go there to get treated”.The situation in other eastern European states is little better. Earlier this year Polish nurses went on strike, warning the situation in their profession was critical and that nursing in the country could soon become extinct. The All-Poland Trade Union of Nurses and Midwives (OZZPiP) said low wages and poor conditions had led to thousands of nurses leaving Poland to work abroad over the past 6 years since the country joined the European Union. In Romania, according to the Romanian College of Physicians, more than 4000 doctors, or almost 10% of all doctors, have emigrated since 2007, while in Hungary, more than 2600 doctors have left to work abroad since 2004. Data from the Hungarian Chamber of Doctors from 2008 showed that 8% of all Hungarian-trained doctors practised abroad, and of these, 10% left for work outside Hungary straight after graduation. Earlier this year legislation was drawn up to try and force graduate doctors to practise in Hungary for 4 years or repay part of their state-financed education fees.In the Baltic states, wages for health staff are also low, and specialist surgeons often earn no more than €800 per month. In January this year, the Latvian Medical Association said that the number of doctors taking up work abroad had increased by three times. Bulgarian Health Minister Anna-Maria Borissova told local media in April this year that the country had only half the number of nurses it needs and that “one doctor leaves the country to work abroad every day”—an exodus she said was a catastrophe for Bulgarian health care. In Poland, however, doctors say their situation has improved greatly since laws were passed in 2006 to guarantee doctors' wage levels. This saw doctors in most hospitals suddenly receive a 40% increase in pay. Marel Balicki, former Polish Health Minister and now head of Wolski Hospital, told The Lancet that the average salary for specialised doctors is about €2424. He added that doctors had just been given a 10% pay rise at his hospital. He also explained that over the past 2–3 years fewer doctors had been leaving the country to work abroad following the wage rises, since the salaries on offer in the west were now only nominally higher but had much lower purchasing power because of the higher cost of living.Many doctors and nurses complain not just of low wages, but of a general chronic underfunding of health care. In Romania, where the past decade has seen repeated strikes by medical staff over pay, conditions, and poor funding, and where doctors have previously admitted that some underfunded hospitals are so poorly equipped that they have had to buy medicines and basic equipment like syringes and bandages from their own money, health-care spending was just over €362 per person in 2009—the lowest of any EU member state. State spending on health care in eastern Europe was 3% of GDP on average, compared with the western European average of about 8%. Some countries have already begun or are planning to overhaul their health-care financing. In the Czech Republic, where the CLK says that the 7% state spending on health care needs to be raised to at least the western European average, controversial charges for patients' visits to doctors have been introduced in a bid to raise some of the money needed.Similar charges are part of a raft of reforms to the health sector in Romania that are due to take effect in the second half of the year, and which also include decentralisation of hospitals to local authorities in a bid to improve fiscal efficiency. The cash-strapped country, which has been forced to take a multi-billion Euro loan from the International Monetary Fund, has also announced plans for massive public sector pay cuts, including in the health sector. Ambulance workers, for example, are facing a 25% pay cut this year.With the global financial crisis still putting a stranglehold on public spending, experts say governments have little room for manoeuvre on health-care spending, and almost certainly do not have what some estimate would be tens of billions of Euros needed to raise wages to the levels wanted by medical staff. In the Czech Republic the health ministry has said that the doctors demands are unreasonable, and spokesman Vlastimil Srsen told Czech media last month that workers in the health sector needed to “realise that we are going through a crisis”. But doctors say they have had enough of waiting for higher wages and reforms that they were calling for years before the financial crisis broke. And they reject the ministry's claims about funding being under pressure because of the financial crisis, arguing that spending on capital projects and expensive drugs could be redirected to raising salaries. “There is so much money given to the health-care sector which goes into building and reconstruction projects and facilities and equipment, but not into doctors' wages. So the problem, or at least a main part of it, is to do with distribution of money in the health sector”, Mrozek told The Lancet.Meanwhile, some doctors have put their resignation threats into practice. At the Sokolov Hospital in western Czech Republic the entire internal medicine department resigned on July 1, with a 2-month notice period. The doctors complained of terrible working conditions, unbearable patient loads, poor pay, and a lack of qualified doctors. It is likely many more resignations will follow. “It will be interesting to see how many do leave. 2500 have said they are ready to give in their notices, but it will not take that many to go to cause serious problems”, said Mrozek. Medical staff across eastern Europe are on a collision course with their governments, as disputes over pay and conditions threaten to hit frontline services. Ed Holt investigates. Thousands of Czech doctors are threatening to resign en masse, as frustration grows over working conditions. Doctors' unions say that unless doctors get higher wages, better hospital working conditions, and the government starts an overhaul of health sector funding, at least 2500 of 16 000 doctors working in Czech hospitals will quit by the end of the year. They say the move could leave some already chronically understaffed hospital departments unable to function, but that they have been left with no choice. “There is a serious problem with medical staff in the Czech Republic being undervalued and underpaid. Instability in the health-care system is already beginning to show by the large numbers of doctors and nurses leaving for work abroad every year. This is a significant sign of a serious problem and it must be dealt with”, Zdenek Mrozek, vice-president of the Czech Doctors' Chamber (CLK), told The Lancet. The threatened resignations—which have already been carried out at one hospital in which an entire department resigned—come amid increasing discontent among health-care workers in several countries across eastern Europe. Medical staff are striking, doctors are leaving for western Europe and North America in substantial numbers, and some senior medical figures have warned patient care is being put at risk because of staff and funding shortages. But governments across the region, some of which have already started or are planning drastic public sector spending cutbacks, say they simply cannot meet the demands of some doctors as they struggle with public finances in the wake of the financial crisis. In the Czech Republic, the Doctors' Trade Union (LOK) has appealed directly to newly elected politicians to earmark an extra €117–157 million for doctors' salaries per year. They say that higher salaries and better working conditions are the only way to keep doctors in the country and maintain present standards of patient care. Newly graduated doctors earn a basic salary of slightly more than €650 per month, the CLK says. The country's average monthly wage is about €900. It adds that some junior doctors also get paid only a part-time wage of €235 per month, but in reality work full-time hours. The CLK says that roughly 250 doctors leave the country to work abroad each year, most of whom are in their 30s and 40s and at the peak of their career potential. The poor state of post-graduate medical education means that many young doctors are leaving to take up work in other countries as soon as they finish medical school. Hospitals say that there is already an acute shortage of doctors in internal medicine, surgery and anaesthetic, and resuscitation wards. Mrozek, whose chamber is supporting the mass resignations of doctors, told The Lancet: “we are greatly concerned about the situation in departments at hospitals with a lack of specialised doctors. This is becoming a very big problem. In some cases that we know of there is only one senior qualified doctor for the whole department, so if he is away from the department at any time or sick there is no senior qualified doctor available. With regard to the proposed mass resignations—the situation at some places is so bad at the moment that just a few resignations could cause huge problems for a hospital.” One Czech doctor, who asked not to be named, told The Lancet that the lack of staff was already putting patients at risk. “Patients are already in danger. It is happening now and will go on until something changes”, he said. CLK president Milan Kubek presents an even more damning picture of the situation. He was quoted in local media in June as saying hospital staff numbers had been so decimated in some places that “anyone who knew about it would not go there to get treated”. The situation in other eastern European states is little better. Earlier this year Polish nurses went on strike, warning the situation in their profession was critical and that nursing in the country could soon become extinct. The All-Poland Trade Union of Nurses and Midwives (OZZPiP) said low wages and poor conditions had led to thousands of nurses leaving Poland to work abroad over the past 6 years since the country joined the European Union. In Romania, according to the Romanian College of Physicians, more than 4000 doctors, or almost 10% of all doctors, have emigrated since 2007, while in Hungary, more than 2600 doctors have left to work abroad since 2004. Data from the Hungarian Chamber of Doctors from 2008 showed that 8% of all Hungarian-trained doctors practised abroad, and of these, 10% left for work outside Hungary straight after graduation. Earlier this year legislation was drawn up to try and force graduate doctors to practise in Hungary for 4 years or repay part of their state-financed education fees. In the Baltic states, wages for health staff are also low, and specialist surgeons often earn no more than €800 per month. In January this year, the Latvian Medical Association said that the number of doctors taking up work abroad had increased by three times. Bulgarian Health Minister Anna-Maria Borissova told local media in April this year that the country had only half the number of nurses it needs and that “one doctor leaves the country to work abroad every day”—an exodus she said was a catastrophe for Bulgarian health care. In Poland, however, doctors say their situation has improved greatly since laws were passed in 2006 to guarantee doctors' wage levels. This saw doctors in most hospitals suddenly receive a 40% increase in pay. Marel Balicki, former Polish Health Minister and now head of Wolski Hospital, told The Lancet that the average salary for specialised doctors is about €2424. He added that doctors had just been given a 10% pay rise at his hospital. He also explained that over the past 2–3 years fewer doctors had been leaving the country to work abroad following the wage rises, since the salaries on offer in the west were now only nominally higher but had much lower purchasing power because of the higher cost of living. Many doctors and nurses complain not just of low wages, but of a general chronic underfunding of health care. In Romania, where the past decade has seen repeated strikes by medical staff over pay, conditions, and poor funding, and where doctors have previously admitted that some underfunded hospitals are so poorly equipped that they have had to buy medicines and basic equipment like syringes and bandages from their own money, health-care spending was just over €362 per person in 2009—the lowest of any EU member state. State spending on health care in eastern Europe was 3% of GDP on average, compared with the western European average of about 8%. Some countries have already begun or are planning to overhaul their health-care financing. In the Czech Republic, where the CLK says that the 7% state spending on health care needs to be raised to at least the western European average, controversial charges for patients' visits to doctors have been introduced in a bid to raise some of the money needed. Similar charges are part of a raft of reforms to the health sector in Romania that are due to take effect in the second half of the year, and which also include decentralisation of hospitals to local authorities in a bid to improve fiscal efficiency. The cash-strapped country, which has been forced to take a multi-billion Euro loan from the International Monetary Fund, has also announced plans for massive public sector pay cuts, including in the health sector. Ambulance workers, for example, are facing a 25% pay cut this year. With the global financial crisis still putting a stranglehold on public spending, experts say governments have little room for manoeuvre on health-care spending, and almost certainly do not have what some estimate would be tens of billions of Euros needed to raise wages to the levels wanted by medical staff. In the Czech Republic the health ministry has said that the doctors demands are unreasonable, and spokesman Vlastimil Srsen told Czech media last month that workers in the health sector needed to “realise that we are going through a crisis”. But doctors say they have had enough of waiting for higher wages and reforms that they were calling for years before the financial crisis broke. And they reject the ministry's claims about funding being under pressure because of the financial crisis, arguing that spending on capital projects and expensive drugs could be redirected to raising salaries. “There is so much money given to the health-care sector which goes into building and reconstruction projects and facilities and equipment, but not into doctors' wages. So the problem, or at least a main part of it, is to do with distribution of money in the health sector”, Mrozek told The Lancet. Meanwhile, some doctors have put their resignation threats into practice. At the Sokolov Hospital in western Czech Republic the entire internal medicine department resigned on July 1, with a 2-month notice period. The doctors complained of terrible working conditions, unbearable patient loads, poor pay, and a lack of qualified doctors. It is likely many more resignations will follow. “It will be interesting to see how many do leave. 2500 have said they are ready to give in their notices, but it will not take that many to go to cause serious problems”, said Mrozek.