4.2 Human resources
4.2.1 Health workforce trends
There is a health workforce shortage in Estonia due to ageing health care workers, professional migration and inadequate training volumes in the past. In the early 1990s, when health care reforms were planned and implemented in Estonia, there was a general perception that there was an oversupply of doctors. This was true in a historic perspective and for certain specialties, but not for the total number of doctors active in clinical practice (Kiivet & Asser, 2006). At the same time, the main problem in the supply of health care personnel – the shortage of nurses – was not recognized and has yet to be solved. Between 1991 and 2000, the total number of doctors decreased by 18% (from 5500 to 4500), and the number of nurses decreased by 12% (MoSA, 2002). Since then, the number of physicians per 100 000 population has increased slightly reaching 342 in 2015, but since 2009 falling behind the continuously increasing EU average, which in 2014 was 350 (Fig4.3). The shortage of nurses is even more worrisome. The number of nurses has stagnated with a slight downward trend at 641 per 100 000 population in 2014 (Fig4.4), which is only 75% of the European average (864 per 100 000). In 2014, in Estonia, the ratio of nurses to doctors was, on average, 0.5 less compared to the EU average (1.93 and 2.47 respectively), which is hindering task-shifting from doctors to nurses (Fig4.5). The need for lower level specialists, i.e. nurse assistants and nonclinical specialists such as nutritionists, dieticians and so on, has so far received less attention, but in the coming years their role in the health system and training opportunities should be enhanced, especially in the light of the increasingly overweight population (see section 1.4 Health status).
The Estonian health workforce is ageing; 45% of doctors are older than 55 years (NIHD, 2018) and among family doctors this share is even higher (58%). Furthermore, in 2015, 24% of physicians and 16% of nurses working in health institutions were older than 65 years, i.e. past retirement age (NIHD, 2018). A unique feature of the Estonian health workforce is the high proportion of female doctors, which, at 74% is the highest among OECD countries (OECD, 2018).
The shortages of health care personnel differ across categories and locations. Medical specialties where the workforce shortage is acknowledged and seen as an obstacle in service provision are the psychiatric specialties, especially those specializing in addictions, and family physicians. The shortage is most acute in general hospitals in rural and remote areas where visiting doctors from regional or central hospitals are being used to fill the gaps. A subsidy was introduced to motivate young specialist doctors, including primary care doctors, to start their careers in locations where it has been difficult to find qualified specialists. Table4.3 shows health personnel numbers in different categories. The number of dentists per 100 000 population in Estonia (92.4 in 2014) is above the European average of 67.9 (Fig4.6), but the number of pharmacists active in Estonia (67.6 in 2014) is well below the European average of 85.0 (Fig4.7).
4.2.2 Professional mobility of health workers
Estonia only started to formally register health care personnel in 2003, and since 2004 the Health Board has collected information on the number of doctors, nurses and other health care professionals working in Estonia, as well as about those wishing to work abroad. At the request of a registered health professional, the Health Board issues certificates of conformity of studies for employers and national regulatory bodies in other EU Member States. As shown in Fig4.8, the number of certificates issued for both physicians and nurses started to rise during the economic crisis and peaked during 2010–2012, after which there has been sharp decline. However, these data might be misleading in terms of how many health professionals are actually working abroad because the Health Board does not have any data on whether the health professional concerned has actually left and started to work in another Member State (Saar & Habicht, 2011).
The main recipient country of Estonian doctors and nurses is neighbouring Finland, where, in 2014, 1276 Estonian doctors and 659 nurses were working, according to OECD data. Mobility is caused by higher salaries, close proximity, and active recruitment of students as well as a similar cultural environment and language. In addition, young Estonian doctors without residency training are allowed to work independently in Finland but not in Estonia. Furthermore, the close proximity between Tallinn and Helsinki (two hours by ferry) even enables part-time working both in Estonia and in Finland. Mechanisms or incentives to slow the migration are lacking.
Until recently, despite the lack of health workers there was no migration of health workers from abroad to work in Estonia because of the very conservative work permit policies and strict requirements for knowledge of the Estonian language, which is very difficult to learn outside Estonia. So far, the few doctors and nurses who have come to work in Estonia are citizens of the Russian Federation, Ukraine and other states of the former USSR. According to the OECD, in 2015, only 3% of all Estonian physicians are foreign-trained. At the time of writing (late 2017) the regulatory system for foreign-trained doctors, including registration and recognition of qualifications, is being amended aiming to clarify the processes and requirements.
4.2.3 Training of health personnel
The vast majority of physicians, dentists and pharmacists working in Estonia are graduates from the Faculty of Medicine, University of Tartu, which is the only medical school in Estonia. Nurses and midwives are graduates from health colleges located in Tallinn and Tartu. These two health colleges also teach the other health professionals who are not regulated by the EU Directive 2005/36 (European Commission, 2005a): laboratory assistants, pharmacy assistants, radiology technicians, optometrists, physiotherapists and specialists in environmental health and health promotion.
The curricula of the four regulated professions (physicians, dentists, pharmacists and nurses) were rearranged to meet EU requirements during 2002–2004 in anticipation of EU accession. This was more a technical issue, as the length and content of teaching had always followed the traditional European structure. As there is a natural monopoly of training of regulated health care professionals in Estonia, evaluation of these programmes is carried out by international peer review and accreditation mechanisms. As a result, the training and education of health workers are well recognized internationally, which is illustrated by the high recruitment rates of Estonian physicians and nurses abroad.
It takes six years of study to become a medical doctor authorized to practise medicine, and five years to practise dentistry or pharmacy. The Ministry of Education sets admission quotas for publicly funded undergraduate or postgraduate medical training positions (also section 2.8.3 Registration and planning of human resources). Although the admission quota to the medical faculty has been gradually increased, from 100 in 2000 to 185 in 2018, it still falls below the level that would cover the estimated future needs, which the Ministry of Social Affairs estimates at 200 admissions. To overcome the shortage of family doctors, caused by ageing and the increased need for primary care due to the demographic and epidemiological transition, it was estimated that from 2016 and for the next 10 years, Estonia should train 50 family doctors instead of 35 per year (De Maeseneer, 2016). In addition, since the early 1990s, the University of Tartu has admitted 20 foreign students annually (mainly from Finland) to study medicine in English, all of whom have returned to work in Finland and do not contribute to health care in Estonia.
A major change was introduced in the 1990s in the training of specialist physicians in Estonia and since 1995 a postgraduate residency programme of three to five years has to be completed in order to be licensed as a specialist doctor. In Estonia, doctors of family medicine (general practice) are also defined as specialists, and it takes three years of residency training to become a family doctor. There is a recent initiative led by the Society of Family Doctors to prolong the family medicines residency training by a year.
Postgraduate specialist medical training (residency) is separately financed from the state budget through the Ministry of Social Affairs and is not part of the regular health care budget. The University of Tartu runs residency programmes, and the admission quotas for state-funded residency positions are formalized by a contract between the University and the Ministry of Social Affairs. The resident physicians have fixed employment contracts with the teaching hospitals and they have to rotate as specified in the residency programme. In this way, residents serve specified terms in different hospitals and hospital departments in order to obtain maximum experience to fulfil their future responsibilities.
The Tallinn and Tartu Health Colleges provide basic training for nurses and midwives in compliance with EU requirements. The durations of nursing and midwifery training are 3.5 and 4.5 years, respectively, out of which 40–50% is training. The training comprises theoretical studies and comprehensive practical clinical instruction, which is conducted in teaching hospitals under the supervision of the colleges. The nursing profession was incorporated in Estonian legislation only in 2001 and since then there are four main nursing specialties. These include primary care (family medicine) nursing, clinical nursing, intensive care nursing and mental health nursing; these require a 1-year postgraduate theoretical and practical training course, provided by the two health colleges.
Although the admission quota for nurses has been increasing in recent years from 350 in 2014 to 400 in 2016, the gap with actual need, which is 700–800 new nurses annually, is still striking (Kerner, 2016). In November 2016 a consensus agreement between stakeholders was reached to increase nurse training capacity to 517 in 2020. As practical training forms a considerable share of the nursing curricula, the hospitals have agreed to offer placements, bear the cost and assure the availability of the supervisors required. The training capacity for midwifery has remained stable at 55 persons annually.
Since 2001, the University of Tartu Faculty of Medicine has also offered a Master of Science programme in public health (Master of Science in Health Sciences), with options to specialize in epidemiology, health management or environmental health. The University of Tallinn provides a master level degree on organizational culture, specializing in health care organizations as well as a doctoral level programme on health behaviour and well-being.
Since 2005, the training possibilities for public health specialists have been expanded. In 2007, a curriculum for health promotion specialists was opened in Tallinn Health Care College and, in 2008, in Haapsalu College, Tallinn University. This training takes three years and after graduation, students obtain a higher education degree allowing them to continue their studies in a master’s programme.
In 2005, the Estonian Health Insurance Fund started to fund esta family physician’s advisory line with the main aim to increase access to medical services outside of working hours in order to reduce volumes in emergency rooms and ambulance care. Every 4 years, the service provider is chosen through a public procurement process. The volume of calls has been continuously rising, from 139,000 calls in 2006 up to 235,000 calls in 2019.
The medical doctor or nurse on the advisory line will help the patient decide whether to go to the emergency department, visit their family doctor or provide medical advice on how to solve the health issues at home. Patients can use a short number 1220 when calling from Estonia or +372 634 6630 when calling from abroad. The advisory line is free of charge except [WE1] for small co-payments depending on the mobile operator. The advisory line is open for 24 hours a day, including weekends and public holidays, providing services in Estonian, and Russian [WE2] [KK3] and English language support is also available on certain times during the day. The service is available to everyone and does not depend on an individual’s insurance status.
Starting from 2020, patients can contact the family physician’s advisory line and receive advice based on their medical data available in the national e-health system’s personal medical records, if the patient provides consent. The patients need to identify themselves with a Mobile-ID or Smart-ID system, which allow people to use a mobile phone as a form of secure digital ID, before placing the call. Following identity verification, the advising clinician can add the information about the advice given to the national e-health system. This improves the quality of advice provided to the patients and also enables better cooperation between different health care service providers, especially with the patient’s family doctor. There are still ongoing discussions whether to give the advisory line also rights to renew prescriptions and start a patients’ official sick leave.[WE4]
[WE1]I assume this is the case but please adjust if not!
[WE2]I’m not sure, is the Russian service available 24 hours or also only during certain times?
[KK3]Est and Rus is 24/7 and engl is certain times during the day
[WE4]This would be convenient!
Starting from 1. January 2020, the Estonian Health Insurance Fund will be responsible for covering the salary of all medical students in residency training. Previously the costs were covered by the Ministry of Social Affairs. The changes in financing were agreed during a recent health financing reform (see also update from 23/05/2018 „A five-year transition plan to broaden the health insurance revenue base started in 2018“). The ministry continues to cover the costs of teachers and a grant for the service providers who offer residency training for medical students.
The changes in financing also led to developments in organizing the training process. Starting from 2020, every program has to have a validity period, which means that the Tartu University is obliged to renew the residency programs regularly. Furthermore, starting from April 2020, the residents are also allowed to complete their residency training working part-time. This increases the flexibility for medical students to divide their time between completing their residency program and contributing to their PhD studies. These changes were highly anticipated and supported by the Estonian Association of Young Doctors.
4.2.4 Career paths for doctors
After the completion of their medical degrees, physicians have the following career options:
- to work in a health institution as a physician without the right to work as an independent provider or to open a private practice;
- to continue in postgraduate specialist medical (residency) training;
- to continue academic studies for a doctorate (PhD); or
- to leave health service provision to work as a civil servant or public employee in the field of health care management in health institutions or governmental bodies or in the pharmaceutical sector.
The majority of medical graduates enter residency training in Estonia, which is the direct path to becoming a specialist. In fact, the career path to become a clinical specialist has become so strong a driver that the medical faculty has difficulty recruiting PhD students from among medical graduates, and the higher administrative positions in health are filled by nonmedical staff.
The majority of doctors are salaried employees whose contracts are negotiated with hospital management. The hospital management has the power to determine salaries and individual career paths for the physicians they deem important for the provision of specific services. There are no specific governmental regulations on salaries and the workload of health workers despite efforts of trade unions. Considerable differences exist between the salaries of health workers in similar positions and specialties even in the same health institution. In certain fields (gynaecology, psychiatry, ophthalmology) there are a number of independently working providers.
In order to bring health professionals who are working outside the health sector back to clinical work, the Ministry of Social Affairs has initiated targeted projects. The first project was meant for doctors who had the required training but who were not in the health care workers’ registry. Those wishing to be registered as doctors had to undergo practical training and take a general physician exam. The project resulted in 35 doctors entering the residency programme. Starting from 2015 the project targeted nurses instead of doctors. During the first year, 21 nurses completed the course, and many started working in the health sector. Due to its success the project was continued in 2016 and 2017, and re-launched for doctors in 2018.
4.2.5 Career paths for other health personnel
Graduates of nursing have the same career options but are also sought after outside the health sector, especially in the pharmaceutical and beauty industries and in other areas where the skills of the nursing profession are valued.
In December 2018, parliament approved the amendments in the regulatory system for foreign-trained (outside European Economic Area or Switzerland) doctors, dentists, nurses and midwives. The amendments aim to clarify the processes and rules for registration and recognition of qualifications, including the verification that qualification requirements have been met.
Starting from the 1st of September, 2019, the above-mentioned health professionals must complete an aptitude test in Estonian on both theoretical concepts and practical training before obtaining their license to practice as a health care worker in Estonia. The Health Board, University of Tartu and health care colleges from Tartu and Tallinn will participate in the process of verifying qualifications. The educational organizations are responsible for arranging the theoretical exams and practical training placements. During the practical training, the administration costs for the educational organizations as well as reimbursement for mentoring will be covered by the state budget through the Ministry of Social Affairs (MoSA).
According to the MoSA, on average around 60 foreign-trained doctors and one to two nurses apply for the permission to work in Estonia every year.