4.2 Human resources
4.2.1 Health workforce trends
Even though there is no overall shortage of physicians, the current composition of human resources in the health system is unbalanced. First, there is a lack of GPs, and nurses are in short supply, which further erodes primary care in the country. Second, there are significant regional distortions as well as insufficient coverage and vacancies in some specialties. Furthermore, the health workforce is rapidly ageing, and emigration among young health professionals is persistent.
In 2015, around 120 000 people were employed in the health care sector, which represents roughly 5.5% of all full-time employees. There were 29 038 working physicians, representing an increase of 5.5% compared with the total number in 2000 (Table4.3). With 15%, or a total of 4433 physicians, working as GPs, Bulgaria is following the general trend of a rising ratio of physicians per population throughout Europe. The number of physicians per 1000 population has been steadily growing from 3.27 in 1990 to 4.16 in 2016 (Table4.4). Similar to other EU countries, the increase is the result of both a rise in the absolute number of physicians as well as the population decline (see section 1.1 Geography and sociodemography).
Furthermore, among EU Member States, Bulgaria records a relatively high ratio on a par with Austria (5.04), Portugal (4.42), Lithuania (4.30), Sweden (4.12) and Germany (4.11). In terms of the relative number of physicians, Bulgaria stood higher than the EU13 average (2.8), EU28 average (3.5), EU15 average (3.7) and selected countries, such as Poland (2.3), Romania (2.4), Croatia (3.13) and Hungary (3.3) (Fig4.4).
Even though most EU Member States struggle with an unbalanced proportion of medical specialists to general medical practitioners, in Bulgaria this ratio is exceptionally low. What is more, the number of generalist physicians decreased by 21.6% between 2000 and 2015, while the number of specialist physicians increased by 11.8%. The share of generalists to the total physician workforce has consistently been shrinking from 21% in 2000 to 16.6% in 2015, which is the second lowest ratio in the EU after Greece and far below the EU25 weighted average of 30.2%. As part of the widespread tendency towards more specialists, the ratio of specialists to generalist medical practitioners is growing, from 3.8 in 2000 to 5.4 in 2015. Within the group of the generalist physicians, the number of GPs has been steadily going down, recording a negative change of 16.2% for 15 years. Some of the reasons are the heavy administrative workload; insufficient payment and recognition; low appeal of the specialty among young physicians; and problems with training and acquiring the specialty of general medicine (Valentinova & Nedkova-Milanova, 2018).
Bulgaria has recorded the highest ratio for surgical specialists (on a par with Greece, Lithuania and Austria), above one physician per 1000 population (Eurostat, 2018).
With regard to all physicians, more than half are employed in hospitals. In the last decade this share has been steadily growing – from 47.1% in 2005 to 56.7% in 2015. Women account for 55.1% of all physicians. The generally rapid ageing of medical professionals characterizing Europe is evident in Bulgaria as well. The share of the physicians aged 55–74 years in 2015 was 44.5%; 13.3% of all physicians being between 65 and 74 years and only 10.1% were less than 35 years old (Eurostat, 2018).
There are persistent geographical distortions in health care labour supply throughout the country. The districts with medical universities and university hospitals concentrate the largest numbers of physicians and more health professionals on average per 1000 population than the other districts. For example, in 2016, in Pleven district there were 5.63 physicians per 1000 population, whereas the national average was 4.16 per 1000 population. One fifth of all physicians work in the capital, Sofia, with 5.03 per 1000 population (Table4.5). At the same time, the distribution of professionals is disproportionately low in the districts of Razgrad (2.63 physicians per 1000 population); Dobrich (2.70 per 1000 population) and Pernik (2.70 per 1000 population), which poses serious challenges to equal access. Particularly alarming are the great regional disparities in the distribution of GPs and the vacant practices in rural and remote areas. Physicians still lack significant incentives to work in underserved areas.
Similar to other EU Member States, nurses are the most numerous health professional group in Bulgaria. Unlike physicians, the number of nurses in Bulgaria has stayed comparatively stable during the last 15 years, around 31 000 nurses in total. However, in terms of the ratio of nurses to population, the country has the second lowest ratio in the EU, with 4.9 per 1000 population (Fig4.5), which surpasses only Greece (3.4 per 1000 population; Fig4.6). The number of nurses per 1000 population is considerably lower than in Romania (5.5), Hungary (6.6) and Croatia (6.1), and is below the EU28 average of 8.7 per 1000 population. Thus, Bulgaria records the lowest nurse per physician ratio of all EU Member States with 1.1 nurses per doctor, less than half the EU Member States ratio of 2.5 nurses per physician. The shortage of nurses is also characterized by regional inequities (although less accentuated than for physicians and dentists).
The number of graduating nurses has fluctuated over the last 15 years: from 828 in 2000 to 295 in 2005 and 379 in 2015. However, Bulgaria still has the lowest number of nursing graduates per capita, almost 10 times less than the average EU number (Eurostat, 2018). More alarmingly, a large number of trained nurses emigrate because of the lack of adequate job opportunities and better pay for nurses abroad (Veleva et al., 2013).
Similar to nurses, the number of midwives has stabilized at some 3200 in the last 5 years. At 0.46 midwives per 1000 population in 2016, the midwives per population ratio remains one of the highest in the EU, surpassed only by Sweden (0.75 in 2014), Poland (0.59) and the United Kingdom (0.48) (Eurostat, 2018).
Contrary to most EU Member States where the number of practising dentists per capita remained relatively stable between 2010 and 2015, in Bulgaria this ratio has been consistently growing, reaching its peak with 1.05 dentists per 1000 population (see Fig4.7). In 2015, a total of 7547 dentists were recorded, which is 11.3% more than in 2000. In 2016, this figure further increased and stood at 1.16 dentists per 1000 population (NSI, 2018d). Notably, Bulgaria recorded the largest absolute change across all EU Member States in the density of dentists for the 2010–2015 period, with an additional two dentists per 1000 population. Thus, in 2015, Bulgaria was one of two countries (together with Cyprus) with the highest density of practising dentists in the EU (Eurostat, 2018). Nonetheless, there are significant regional disparities in the distribution of dentists. Almost half of all dentists (48% in 2016) work in only three districts – Plovdiv, Varna and Sofia city (NSI, 2018d).
According to Eurostat data, Bulgaria stands in the middle of EU countries in terms of the number of pharmacists per population with 0.84 pharmacists per 1000 population in 2016. National data (Bulgarian Pharmaceutical Union) indicated a total number of 6202 pharmacists in 2018. Unfortunately, data limitations preclude a complete analysis of the development and dynamics of this professional group (see Fig4.8).
A specifically underrepresented part of the health care personnel are medical specialists in public health, with a majority employed at the RHIs. However, there has been a tendency of steady staff decrease from 3341 in 2010 to 2500 in 2015. The low remuneration places this group of professionals at a great disadvantage, resulting in highly qualified specialists with medical degrees leaving their jobs, lack of motivation of the existing staff and shortage of medical and nonmedical young specialists. In 2015, the average age of the professionals with a medical doctor’s degree working in the public health system was 54 years (NCPHA, 2017).
4.2.2 Professional mobility of health workers
Migration has been evolving as a result of democratic changes after 1989, the eastward enlargement of the EU, and economic and cultural globalization. Open borders, rapid technological development and the recognition of higher education diplomas are essential prerequisites for the intensifying of the process of emigration.
Despite the aggregated good availability of physicians and health care professionals in the country, there are enormous interregional differences. Thus, part of the migratory flows is directed from smaller towns to large settlements, which has an impact on the actual free choice of health care facility, access and adequate provision of health services. There is also migration from the public to the private sector. Health professionals can split their working time between both sectors, which causes a deterioration in public health care system performance (due to low motivation), creating disorganization (insecurities for patients being sent to private practices) and economic losses.
In 2013, 2636 physicians trained in Bulgaria were employed abroad in OECD countries (Lafortune, 2016). This exodus of medical specialists is developing into a serious problem for the Bulgarian health care system: in 2014, approximately 540 physicians left the country, whereas in the first 6 months of 2015, more than 280 physicians left Bulgaria. According to the Bulgarian Medical Association, certificates allowing physicians to work abroad were issued mostly to physicians who have taken a specialty (Yaneva, 2017). Although there are no precise statistics about nurses who left the country, migration of nurses is prevalent as well. In 2015, the MoH issued a total of 291 certificates necessary to practise as a nurse abroad. However, issuance of a certificate is only a proxy indicator – certificates are more a measure of potential emigration. According to data from the Bulgarian Association of Health Professionals in Nursing, most Bulgarian nurses work in the United Kingdom, followed by Spain, Italy, Germany, Belgium, France and Switzerland (Vasileva, 2017).
The most common reasons for leaving the country include low levels of satisfaction and lack of recognition, lower salaries compared with the destination countries, imbalances in payment by specialties, lack of modern medical equipment and failed health reforms. Some of the most important retention measures for young physicians and other health professionals in the country are the opportunities for professional development (see also section 6.1 Analysis of recent reforms).
4.2.3 Training of health personnel
As stipulated in the 1995 Higher Education Act, the CoM approves state requirements for obtaining higher education degrees and specialty titles of regulated health professions (physicians, dentists, pharmacists, nurses, midwives and all paramedical professions). Every year until the end of April, the Council also approves the number of admissions for undergraduate and graduate students according to academic capacities, and perspective needs of the professional fields and specialties of the regulated professions. The Council meets this decision based on a proposal by the Minister of Education and Science as well as suggestions by the respective universities.
Currently there are four medical universities and two medical faculties. The medical universities in Sofia, Plovdiv and Varna have four faculties: medicine, dentistry, pharmacy and public health. In 2016, the medical university in Pleven opened a new faculty of pharmacy in addition to the three faculties of medicine, public health and health care. The Faculty of Medicine in Stara Zagora was founded as a higher medical institute for training specialists of medicine within the Medical Academy of Sofia. It remained an independent institution until 1995, when it was merged with the Thracian University – Stara Zagora. On the other hand, the Faculty of Medicine, which had been a unit of Sofia University “St Kliment Ohridski” between 1917 and 1950, was restored in 2003 and became part of that university.
Undergraduate medical education lasts 6 years and includes 5 years of theoretical training and 1 year of practice. During the final year, medical graduates have to pass five state examinations. After graduation, physicians continue their study in accordance with a MoH ordinance for specializations. The duration of specialty training is from 4 to 5 years for most specialties but may last longer, whereas specialty training in general medicine takes 3 years. Once physicians have completed their residency and postgraduate qualification, they need to register with the MoH and obtain a certificate for professional qualification.
Dentistry training lasts 5 years followed by 6 months of practical training. The curriculum includes fundamental and dental disciplines, with hours on special dental subjects progressively increasing from the first to the fifth year. Students complete their studies with a state examination.
Pharmacists train for 5 years and studies are organized in three levels: the first level aims to provide fundamental professional knowledge while the second is oriented towards specific knowledge and skills for the pharmaceutical profession. Students can major in either General or Industrial Pharmacy, a choice to be made after the sixth semester. The third level is practical training and takes place in pharmacies, drugstores, pharmaceutical firms and/or pharmaceutical laboratories for drug control, which have been recognized as training centres. The degree is awarded after successfully completing the four state examinations; defending a Master’s thesis can be chosen as an alternative to one of these examinations. Medicine, dentistry and pharmacy training is offered only on a full-time basis and students graduate with a Master’s degree.
Public Health faculties at medical universities offer training in Bachelor’s and Master’s degrees in various specialties. In total, respective faculties provide 18 Bachelor and 17 Master programmes, which show a wide selection of specialties.
Presently, nurses and midwives are trained not only at medical universities and their affiliates. In recent years, the increased shortages of this type of professionals have led to the establishment of separate faculties for Public Health and Health Care within the structure of other universities. The education of nurses and midwives lasts 4 years and results in a Bachelor’s degree. These professionals can continue their studies in specific Master’s programmes.
In 2017, the Medical University of Varna in cooperation with the Naval Academy N.Y. Vaptsarov – Varna and the Military Medical Academy – Sofia, introduced for the first time in Bulgaria a joint training in two new specialties “Military Physician” and “Military Nurse”. After a full 6 years of training the military physicians obtain a Master’s degree in “Medicine” from the Medical University – Varna and a Bachelor’s degree in “Organization and Management of Military Formations at the Tactical Level” from the Naval Academy – Varna. Students in the Military Nurse programme graduate with a Bachelor’s degree.
Six medical colleges, four of which are part of medical universities, provide training for paramedical personnel (for example, assistant pharmacists, rehabilitators, medical and X-ray laboratory technicians, dental technical assistants, medical cosmetics, physician’s assistants). Those colleges offer professional Bachelor’s degrees in the field of health care and the length of training is 3 years. Some of the graduates pursue further education in Bachelor’s and Master’s degree, seeking further professional development and remuneration.
Professional specialties to be acquired by medical and nonmedical personnel in the health system are regulated by an ordinance of the MoH. A new ordinance regulating terms, conditions and financing of medical specializations was issued by the MoH in 2015. It aimed at ensuring better conditions for specialization, removing financial constraints and providing better opportunities for professional development for young physicians in Bulgaria. The new ordinance changed the residents’ status from trainees in the health care establishments to employees. Residents are now entitled to work on a full-time labour contract for the duration of their residency with a health care establishment of their choice accredited for specialization training. Thus, instead of paying fees to health care providers, the residents are now remunerated. Admission examinations to specialization training were also abolished. Capacities for training are decentralized and follow proposals of health care establishments and Medical Universities for clinical and nonclinical specializations, respectively, which are consequently approved by the MoH. At the same time, the new specialization ordinance requires the training facilities to announce the vacancies for postgraduate students throughout the year. The vacancies for specializations are announced on the MoH’s website as well to increase transparency and awareness for postgraduates. However, the new regimen has encountered some problems. The financial ability of health care providers to launch places for specialization training prompts a problem for the smaller health care establishments and especially for specialization in general medicine. Nevertheless, the new ordinance created additional incentives to complete the training in certain medical specialties, such as anaesthesiology and intensive care, general and clinical pathology, paediatrics, emergency medicine, infectious diseases and neonatology. Nurses and midwives can also specialize in accordance with the ordinance mentioned above for 1 year. All specializations require a final state examination for the State Examination Commission in Sofia.
The Bulgarian Medical Association registers and organizes the continuous medical education in accordance with the Health Act. In addition, it contracts scientific organizations, associations, pharmaceutical companies and others for individual qualifications. The contracts stipulate the terms and conditions for conducting the form of continuous qualification as well as the financial relations. The forms of training can include courses, seminars, conferences, congresses, presentations, workshops, distance learning and subscription to specialized medical issues. Physicians are qualified by their own wish and prove their qualification with a certificate issued by the Bulgarian Medical Association. A credit system is used to assess the medical specialists’ performance based on different categories. Each category (for example lectures, congresses, distance learning) recognizes a certain number of credit points for a period of 3 years.
The terms, conditions and financing of medical specializations are regulated in the Ordinance on medical specialization (see “Reforms to medical specialization system in Bulgaria” from 26/05/2015). At the beginning of 2019, the Ministry of Health issued a draft revision to this Ordinance. The proposed amendments aimed to enact some young physicians’ retention measures, to address the significant regional distortions as well as insufficient coverage and vacancies in some specialties, and to motivate young physicians to choose general medicine for their career path.
Тhe proposition envisioned a predefined set of specializations and health care establishments for which the MoH will subsidize the training period (usually three to five years). The financial incentive is available for the respective health care establishments, and the young specialist provided that after the specialization, they enter a labour contract with the same duration as the training period. The party that refuses to fulfil the contract is bound to refund the received funding. As the shortage of GP’s continues to be severe, the Ordinance envisions additional financial incentive for general medicine.
The draft proposal led to vigorous debates between the MoH and the Bulgarian Medical Association and even strikes from some young physicians. Those who oppose the changes argue that these obligations will lead to the refusal from young physicians to specialize in the fields with shortages as they will not be able to choose their employer after the specialization.
As a result from the debates, the Ordinance went through several revisions. The MoH tried to address the discontent of the young physicians, while keeping the Ordinance a useful policy tool regarding the specializations.
According to the current version of the Ordinance, every year the Minister of Health will approve the number of specialists from respective specialties for whose specialization the state would provide a financial incentive and a list of healthcare establishments from which they can choose to enter a labour contract after the training period. The young specialists are obliged to work in a health care establishment from the list mentioned above for at least three years after their training is complete. Otherwise, they will have to refund the specialization fees, covered by MoH during their training period. The number of subsidized specialists and the respective health care establishments will be determined based on the needs of the respective regions, according to the National Health Map (see “The National Health Map in Bulgaria – evolution and policy implementation “, from 10/04/2019). To ensure transparency, the information on the whole process (announcement of the available subsidized positions, the recruitment process, completion of the training period, and the fulfilment of the respective obligations) will be available on the MoH website.
Ordinance on medical specializations (first draft from 31.01.2019 in Bulgarian) - https://www.mh.government.bg/media/filer_public/2019/01/30/proekt_na_naredba_za__izm_naredba_1.pdf
Ordinance on medical specializations (motives for amendment from September 2019 in Bulgarian) - https://www.mh.government.bg/media/filer_public/2019/09/30/motivi_chetvrto_izmenenie_naredba_1.pdf
Ordinance on medical specializations (current version in Bulgarian) - https://www.lex.bg/laws/ldoc/2136417712
4.2.4 Physicians’ career paths
Once medical students have become a Master of Medicine, they usually apply for the acquisition of a specialty. After being awarded a specialty degree, physicians choose to work either in outpatient health care establishments or in hospitals. In ambulatory care, physicians can choose between individual and group practices, as well as between being employed in diagnostic-consultative centres or medical centres. Despite these opportunities, the individual private practice for specialized medical care is still the most dominant form.
A promotion during a physician’s hospital career is based on specialty and length of service. Promotion proposals are made by the heads of clinics or departments and approved by the hospital management. In university hospitals, physicians may pursue an academic career by combining clinical duties and research activities. Furthermore, a physician or other professional (for example, a person with nonmedical education) may choose to qualify for hospital management in accordance with the 1999 Health Care Establishments Act, by completing a course in health care management.
Another option for physicians is to work as medical representatives of pharmaceutical companies, which offer flexible working hours and higher salaries. However, this option is not as attractive for physicians as it was in the mid-2000s due to the development of the curative sector. In recent years, the trend of pursuing career abroad remains. First, graduates can choose to specialize abroad and second, do practice after receiving a specialty within the EU. In order to work in an EU Member State, the basic requirements for Bulgarian applicants (according to the automatic recognition of professional qualifications) are a completed medical education, a confirmation for the obtained specialty and working experience in a certain area, and mastery of the host country’s language.
4.2.5 Other health staff career paths
Registered nurses, regardless of their educational background, are entitled to take specialist training courses. Nurses and midwives with a Bachelor’s and Master’s degree with the specialty “management of health care” might participate in competitions for managerial posts (senior nurse/midwife, chief nurse/midwife). The requirements for this career path are regulated by the Health Care Establishment Act. For health professionals, a career in universities can also be an option, depending on ambitions and personal goals.
Even though the short supply of nurses in Bulgaria was developing over the last decades, recent data reveals its urgency. Bulgaria has the second-lowest ratio of nurses to population and the lowest nurse to physician ratio among all EU Member States. There are multiple factors driving the shortage, out of which a low number of graduates (6.1 per 100 000 inhabitants - a fifth of the EU average, Eurostat) and an outflow of trained nurses due to emigration remain dominant (Veleva et al., 2013). Furthermore, the average age of the practicing nurses is above 50 years which indicates a heightened shortage in the near future (Bulgarian Association of Nurses). There is growing discontent in the nursing workforce that escalated in strikes in the spring of 2019. The Strikes were supported by the nursing professional bodies, calling for fair and just remunerations, improved working conditions and more respect towards the professionals.
The Ministry of Health and the Ministry of Education and Science responded with an agreement to increase the number of nurses whose university education (mainly the tuition) will be subsidized by the government. Furthermore, the Ministry of Health proposed a new calculation base for the salaries of hospital employees in which doctors, nurses and other types of personnel are salaried proportionally. This change is expected to increase the salaries of the nurses.
These measures are yet to unfold their planned effects. However, projections suggest that they are not sufficient to reverse the current trend of nurse shortage.
Eurostat 2018, Healthcare personnel statistics - nursing and caring professionals (https://ec.europa.eu/eurostat/statistics-explained/index.php/Healthcare_personnel_statistics_-_nursing_and_caring_professionals#Health_graduates)
Veleva, N, et al. (2013). Bulgarian nursing workforce forecast (2013–2015). European Journal of Public Health, 23 suppl. 1, Oct. 2013.
Ministry of Health. Methodology for formation and proportions of the hospital employee wages (www.mh.government.bg/bg/novini/aktualno/ministr-ananiev-predstavi-proekt-na-metodikata-za-/)