4.2 Human resources
4.2.1 Planning and registration of human resources
Planning of the health workforce is not well developed, partly due to the lack of comprehensive data and analysis in this area (Domagała & Klich, 2018). According to the NIK, training of medical workers does not assure a sufficient number of medical specialists adapted to the changing health care needs of the population (NIK, 2016a). A comprehensive human resources strategy, taking into account epidemiological and demographic trends, is also lacking (NIK, 2016a). However, efforts are being made to develop strategies for health professions with particularly acute shortages. To that end, in December 2017 the government published a strategic document that sets out short-, medium- and long-term goals for the development of nursing and midwifery in Poland (MZ, 2017d).
The Minister of Health has the ultimate responsibility over the number of medical training places (for physicians and dentists). The Minister of Health, in consultation with the Minister of Higher Education, sets admission quotas for medical studies – in each academic year and for each university. Admission quotas for other health professions were abolished in 2012/2013. These quotas depend on the teaching capacities of universities (e.g. teaching staff, available infrastructure for clinical courses, etc.). Medical training for physicians used to be typically offered at medical universities; however, there were shortages of physicians, especially in voivodeships with no medical universities. In order to fill this gap, medical studies have been offered in nonmedical universities in these voivodeships (Olsztyn (since 2008), Rzeszów, Kielce, Zielona Góra (since 2015) and Opole (since 2017)). These initiatives were supported by the voivodeship self-governments and the voivodeship chambers of physicians. In 2017, physicians were trained at 17 public universities, of which 12 were medical universities. There are also three private universities providing medical training for physicians – one in Krakow (since 2016), one in Warsaw (since 2017) and one in Katowice (since 2018).
Undergraduate education is financed from the state budget, although the majority of universities also offer the so-called “extra-mural” studies, which students have to pay for. The content and form of “extra-mural” (paid) studies is the same as for regular studies, which are free of charge. In 2015/2016, there were about 3200 medical graduates (Table4.6). Dental education may be obtained at 10 medical universities.
Nurses and midwives can be trained at both public and private higher education institutions (including universities). In 2017, 54 public and 36 private higher education institutions were accredited by the Minister of Health for nurse training and 18 public institutions for training in midwifery (MZ, 2017d). In that year, 4090 students graduated with a bachelor’s degree in nursing (749 in midwifery) and 3039 with a master’s degree in nursing (444 in midwifery) (Table4.7). In 2016, 13.4% of practising nurses and 17% of practising midwives had a master’s degree.
All Polish physicians, dentists, pharmacists, nurses, midwives, laboratory diagnosticians and medical rescuers have to participate in continuous medical education (CME). This is monitored by the relevant professional chambers (by the voivodes for medical rescuers). Medical professionals who have been professionally inactive for more than 5 years must notify the relevant professional chamber and be retrained at their own expense or their right to practise will be suspended.
Registration of human resources
Polish physicians, dentists, pharmacists, nurses and midwives, laboratory diagnosticians, pharmacists and physiotherapists are associated in professional chambers (see section 2.1). Membership in a professional chamber is obligatory for all practising health professionals. Chambers maintain central registers of licensed (with the right to practise) and actively practising professionals. The national chambers collect detailed data regarding age, sex, geographical distribution and specialization of their members. The chambers are also responsible for monitoring participation in CME.
Physicians, dentists, nurses, midwives and pharmacists can apply (within their professional chambers) for certificates confirming their professional qualifications and giving them the legal right to practise in other EU countries on the basis of EU Directive 2005/36/EC.
4.2.2 Trends in the health workforce
According to information collected by the national professional chambers, about 567 000 health professionals had the right to practise in Poland in 2017. Out of these, there were 146 000 physicians (25.7%), 292 000 nurses (51.4%), 41 300 dentists (7.3%), 37 700 midwives (6.6%), 34 800 pharmacists (6.1%) and 16 000 diagnosticians (2.8%) (GUS, 2019). The numbers of actually practising health care professionals employed in health care units are presented in Table4.8. Human resources statistics are collected by several institutions and this results in inconsistencies in official statistics. It also makes it difficult to accurately assess how many health professionals work in the health care system. It is hoped that the online Medical Registers Platform, which is currently in development, will improve the situation.
According to 2015 OECD data, employment in health and social work as a share of total employment in Poland was only 5.9% compared with 10.1% in OECD countries on average (OECD, 2017). Poland has the lowest ratio of practising physicians per 1000 population among the EU countries – 2.4 in Poland in 2016 compared with 3.6 in the EU on average (2016 data; OECD, 2018a). Further, the number of practising doctors per 1000 inhabitants has remained reasonably constant in Poland, although some growth can be seen since 2013 (Fig4.3). The majority of Polish doctors are females – 56.9% in 2015 compared with the OECD average of 46.5%. According to data published by the National Chamber of Physicians, the average age of medical doctors in Poland in 2017 was 50.2 (or 54.2 for specialists). Over 26% of Polish physicians are over 60 and only about 22% are younger than 35 (NIL, 2018a).
In 2017, about 66% of Polish physicians were specialists (NIL, 2018b). Postgraduate training in family medicine was introduced in Poland in 1993.
However, family medicine is not a popular specialization (see section 4.2.4) and in 2017 only 11% of all physicians were family medicine specialists (CSIOZ, 2018b). Given the low number of such specialists, internal medicine specialists and paediatricians are allowed to work as family medicine physicians (Mokrzycka et al., 2016). According to OECD data, about 9% of all physicians in Poland work as GPs. This is low compared with the average among 23 EU countries where it is 23% of all physicians (2016 data; OECD, 2018a). Currently, development of family medicine and primary care is one of the key issues of health care reforms implemented in Poland (see section 6.1). The available data do not allow us to say what share of specialists work in ambulatory versus hospital settings and what share work in academia.
In 2016, the number of practising nurses per 1000 population was 5.2 (Fig4.4) and it was significantly lower than the EU average of 8.4 (OECD, 2018a). About a third of practising nurses were aged 46–55 (NIPiP, 2017). To offset the low number of nurses, in 2007 the profession of medical caregiver (opiekun medyczny) was introduced. Since they are auxiliary staff, medical caregivers cannot establish individual practices and be directly contracted by the NFZ and hence there is no data on the exact number of medical caregivers employed within the health care system. In spite of this, the Strategy for the Development of Nursing and Midwifery in Poland published by the Ministry of Health in 2017 found that one of the obstacles in this area was the lack of care professions supporting the work of nurses (MZ, 2017d). Other identified obstacles include insufficient regulations regarding the number and qualifications of nurses and midwives performing guaranteed services (and insufficient definition of their roles and competences in the health care system); not meeting the minimum employment standards by health care providers operating under contracts with the NFZ; and poor working conditions (MZ, 2017d).
In 2017, the number of practising dentists per 1000 inhabitants in Poland was 0.35 (Fig4.5). In 2017, 2850 dentists (20.9% of all dentists) had a specialization (CSIOZ, 2018b).
In 2017, 26 495 among the 34 797 registered pharmacists (79%) were actively practising. The number of practising pharmacists per 1000 inhabitants was 0.77 (Fig4.6). According to the National Statistical Office, 90% of practising pharmacists were working directly with patients in pharmacies (GUS, 2019). There is no information about the share of pharmacists working in community pharmacies and in hospital pharmacies.
Box4.3 and Table4.9 provide information on the geographical distribution of health workers employed in health care units.
The profile of the managerial staff in the health systems has changed significantly over the years. Currently, there are no clearly defined formal requirements regarding the qualifications of managerial staff, although they generally include a university degree, work experience and no criminal record.
Managers typically have a medical degree, although the share of managers with a medical background has been falling (Czabanowska et al., 2017), and a postgraduate degree in management studies, often specifically in health care management.
4.2.3 Professional mobility of health workers
Migration of medical staff abroad is an important problem in Poland. The main reasons for this are difficult working conditions, with low salaries, heavy workload and long hours; barriers to professional development, including problems related to postgraduate medical education (limited number of residencies for certain medical specialties, low remuneration of resident doctors undergoing specialization training). For the same reasons, Poland is not an attractive destination for foreign-trained health workers. In 2015 the share of foreign-trained doctors in Poland was only 1.8% of the total number of medical doctors compared with the average of 28 OECD countries of 16.9% (OECD, 2017). The share of foreign-trained nurses, midwives and other health professionals is even lower and is not included in the official statistics. The exact scale of health workforce migration abroad is not known due to incomplete data and does not allow for effective monitoring of the problem (NIK, 2016a; Domagała & Klich, 2018).
For physicians and nurses the scale of outward migration is estimated on the basis of the number of certificates issued by the respective professional chambers confirming professional qualifications that give legal right to practise in other EU Member States (EU Directive 2005/36/EC). Between Poland’s EU accession in 2004 and mid-2016, almost 9400 certificates were issued for physicians (about 7.1% of practising doctors) (Domagała & Klich, 2018). According to the National Chamber of Nurses and Midwives, between Poland’s EU accession and end of 2017, over 20 500 nurses obtained such certificates (NIPiP, 2018).
Many nurses undertake jobs in EU countries as medical caregivers and do not apply for certificates confirming their professional qualifications. According to data published by the destination countries, over 6500 decisions regarding the recognition of qualifications were taken between 2004 and September 2018 regarding Polish nurses (over 5300 were positive) and over 600 regarding Polish midwives (almost 450 were positive) (Rutkowska, 2018). The majority of nurses had their qualifications recognized in the United Kingdom, Germany, Ireland, Norway and Belgium, while the majority of midwives had their qualifications recognized in Germany and the United Kingdom (MZ, 2016c).
4.2.4 Training of health personnel
The standards of education for health personnel are defined by the Minister of Science and Higher Education in consultation with the Minister of Health. These standards take into account EU regulations on the requirements for education and training to practise as a medical doctor, dentist, pharmacist, nurse and midwife.
Physicians and dentists
It takes 6 years to complete undergraduate education for medical doctors (at least 5700 hours of theoretical and practical training) and 5 years for dentists. All medical graduates have to complete a postgraduate internship at an accredited hospital. This internship lasts 13 months for medical and 12 months for dental graduates and ends with the State Medical Examination (Lekarski Egzamin Końcowy, LEK) or the State Dental Examination (Lekarsko-Dentystyczny Egzamin Końcowy, LDEK). Exams are carried out by the Medical Examination Centre and are offered twice a year (in spring and autumn). Students who passed the exam and completed the postgraduate internship receive the full right to practise and can be listed in the register of physicians and dentists. They can then apply for postgraduate specialist training in the chosen discipline. However, specialization places are limited and specializations with the highest numbers of places available are not necessarily popular among physicians (e.g. family medicine). According to data from the Chief Medical Chamber, about 25% of available residency places are not filled (NIL, 2015). Foreign physicians and dentists need to obtain consent from the Ministry of Health to enter specialty training in Poland.
Until 1999, specialization training was divided into two levels: level I specialization was awarded after 2–3 years of training, and those who decided to continue were awarded level II specialization after further 2 years of training. In 1999, this two-level system was abolished and replaced by “basic” and “specific” specialization training, with specialist training for “basic” specialties, such as internal medicine or family medicine, usually lasting 4–6.5 years and “specific” training lasting further 2–3 years and covering specialties such as vascular surgery, endocrinology and geriatrics. Further changes have been implemented since October 2014: the 2011 amendment to the Act on the Professions of Physician and Dentist replaced the system of “basic” and “specific” specialties with a modular system. Specialist training in a specific area of medicine currently consists of a core module, covering basic theoretical knowledge and practical skills in a given field of medical specialization (there are five basic modules: general surgery, otorhinolaryngology, pathology, paediatrics and internal medicine) and a subsequent specialist module, corresponding to the chosen area of specialization in which physicians may continue specialist training after completing the chosen basic module (there are 41 specialties). There are also 28 specialties within uniform modules (integrating training of both basic and specialist modules). In total, there are 77 medical and nine dental specialties under the current system. Specialist training for medical doctors usually lasts between 4 and 6 years and for dentists between 3 and 6 years.
There are five ways of undergoing specialist training: residency training (it is financed from the state budget and guarantees employment during the training period), under an employment contract, training while on paid study leave (granted to hospital employees for the period of training), training as part of PhD studies and volunteering. Specialty training can be undertaken only in institutions accredited by the Ministry of Health that meet certain educational standards. In 2012 the Ministry of Health classed 16 specialties as priority specialties (anaesthesiology and intensive therapy; oncological surgery; geriatrics; oncological gynaecology; haematology; emergency medicine; family medicine; neonatology; paediatric neurology; clinical oncology; oncology and paediatric haematology; pathology; paediatrics; psychiatry of children and adolescents; oncological radiotherapy; paediatric dentistry) – this classification takes into account shortages in particular medical fields. Another response to physician shortages was increasing the total number of residency places funded from the state budget in 2015 (Table4.10).
Specialty training is concluded with the State Specialization Exam (Państwowy Egzamin Specjalizacyjny, PES), which is organized twice a year and awards a specialist diploma. The Centre for Medical Examinations is responsible for the organization of the PES and other exams related to postgraduate and continuous education (CE) programmes for physicians, pharmacists and other health professionals (see below).
Physicians and dentists are obliged to continue acquiring new skills and advancing their professional qualifications throughout their professional lives. This obligation can be fulfilled through self-education and participation in various forms of CE training, for which educational points are awarded. Physicians must collect 200 educational points within 4 years. Failure to fulfil this requirement can lead to the physician having to undertake mandatory training at their own expense.
Nurses and midwives
In 1995, the traditional study programme at nursing and midwifery colleges was replaced by a new system based on bachelor’s and master’s degrees that conform to EU standards (Directive 2005/36/EC). Nurses and midwives who had previously graduated from nursing and midwifery colleges or medical vocational schools have been able to upgrade their education in the so-called bridging studies since 2004. Completion of the bridging studies is equivalent to a bachelor’s degree.
Based on the 1996 Act on the Professions of Nurse and Midwife, nurses and midwives have the obligation to continuously update their knowledge and skills and the right to participate in different forms of voluntary postgraduate training (however, there is no minimum requirement on the number of educational points they have to acquire). Nurses can choose from 13 areas of postgraduate specialist training, midwives from two, and there are two areas of training that can be attended by both nurses and midwives (neonatal nursing and epidemiological nursing). The number of nurses and midwives who have completed their specialization training was 55 286 in 2018, which is less than 20% of the total number of registered nurses and midwives (CKPPiP, 2018). Specialist training is subsidized by the Ministry of Health. Enrolment limits and subsidies vary from year to year, depending on the demand in the various areas of specialization. Next to specialist training, postgraduate training is also available in the forms of qualification courses, specialist courses and CE courses (kursy dokształcające).
According to the 1999 Act on the Pharmaceutical Chambers, pharmacist licences are awarded to those who have graduated from 5-year university-level studies in pharmacy, completed a 6-month traineeship and obtained the professional qualification of master in pharmacy (or an equivalent diploma granted by an EU country). Graduates in pharmacy can obtain postgraduate specialist training in 12 specialties.
In 2015 the Act on the Profession of Physiotherapist was passed – the first legal act dedicated specifically to this professional group. In order to become a physiotherapist one should: complete a uniform 5-year master’s programme in the field of physiotherapy, undergo a 6-month professional practice and pass the State Physiotherapy Examination. Specialization training is available and ends with the State Specialization Physiotherapy Examination.
4.2.5 Physicians’ career paths
After completing the medical studies, passing the state examination and completing the 13-month practical training, the physician obtains the right to practise and can begin specialty training. After completing specialty training and passing the state examination, the physician obtains the title of a specialist in a particular medical discipline. Many physicians undertake PhD studies and may pursue academic career. The PhD title will also facilitate professional progression outside the academia. The prevailing model of hospital management in Poland is a system based on heads of wards. Physicians with managerial positions often undertake postgraduate studies in health care management as obtaining higher professional titles, such as head of ward, requires additional training.
4.2.6 Other health care workers’ career paths
Health care workers other than medical doctors may also advance professionally by undergoing specialty training or postgraduate studies (which entails the assumption of more responsibilities) or by assuming managerial positions. For example, nurses and midwives may be promoted to chief nurse or midwife in a ward or part of a ward, or may be promoted to hospital vice-director responsible for nursing. Promotion is based on competitive selection procedures.