HEALTHCARE

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HEALTHCARE

• Istvan Szilvasi
• Higher Education and Labour Market
• Seminar
• 2 December 2008
• Budapest

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Basic Dilemma

• Increasing costs of healthcare
• technological development
• diagnostic and therapeutic
• increasing demands
• ageing of society
• Limited resources

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Basic problem of the Society

• Health care is part of the social security
• Governments, chambers, organizations
  (professional, trade-unions, etc.) are concerned
  about the healthcare service (even in the USA)
• Reforms (?) are permanent
• Increasing costs of medical service in
  industrialized countries press the governments to
  continous health care reforms

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BUT

• Reform needs money !
• number of beds and capacities can be
• but number of patients can not be
• reduced by the governments
• (at least in short-term)

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Bermuda Triangle of Healthcare
EVERYBODY
MONEY
HIGH QUALITY
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Responsibility of the State

• All Hungarian citizens has the right to the
  highest possible level of physical and mental
  health
• (declared in the Constitution)
• Solution is not by the market
• Active role of the State is indispensable
• among others
• sufficient manpower!

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CPME statementon Health Services

• healthcare is a case apart from other services
  and cannot therefore be treated as a mere
  economic/commercial service.
• Health services have specific characteristics
  that should be recognised and protected.
• As they deal with citizens lives and well-being,
  health services need stricter controls and
  regulation than most other services.

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CPME statementon Health Services

• It is essential that Member States take
  responsibility for guaranteeing the quality and
  equal availability of healthcare for their
  citizens in all circumstances.
• Member States remain responsible for offering the
  best possible care for their citizens.
• recognize the specificity of healthcare services
  and to guarantee equal access and sustainability
  of healthcare systems.

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Therefore we need
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GDP Per Capita (PPP US)
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Health Expenditure Per Capita (PPP US)
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Physicians (Per 1,000 Population)
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TOTAL NUMBER OF PHYSICIANS IN EU COUNTRIES, 2002
Figures 1 and 2 show comparative data of the EU
individual countries
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NUMBER OF PRACTICING PHYSICIANS / 1000
INHABITANS In OECD 2005 Greece 4.4
Italy 4,1 Belgium 3.9 Iceland 3.9 Switzer
land 3.6 Czech R. 3,5 Austria 3,4 France 3,4
Germany 3,4 Portugal 3,3 Sweden 3.3
Hungary 3,2 Spain 3,2 Estonia 3.2 Norway
3,1 Netherlands 3,1 Slovakia 3,1
Denmark 2.9 Luxembourg 2,7 Ireland 2,6 Fin
land 2,6 Poland 2,5 UK 2,2 Turkey 1,4
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Shortage of manpower isnot a Hungaricum

• General shortage
• Physicians
• earlier anaestesist, pathologists, etc.
• today almost all specialties
• Nurses
• Non-medical professionals (physicists, chemists,
  informatics, biologists, engineers, etc.)
• Age
• Regional distribution

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Causes of Shortage

• Low income in some countries
• Physical and psychical stress (burn-out) duties,
  night work
• Increased demand of the society - frustration
• Unfriendly media in some countries
• Decreased prestige of the profession
• Misconduct lawsuits in some countries

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Causes of Shortagein Hungary

• Low income
• Physical and psychical stress (burn-out) duties,
  night work
• Increased demand of the society - frustration
• Unfriendly media
• Decreased prestige of the profession
• Blamed by

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SURVIVE of the HEALTHCAREMANPOWER -
INFRASTRUCTURE
Hungary
OECD
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SALARY SURVEY HUNGARY53 sectorswww.merces.hu
2008 November

• The 4 best-paid Average Brutto HUF (Euro)
• Leasing 352 000 1300
• Informatics 352 000 1300 Pharma
  industry 315 000 1200 Banking 313 000 1200
• The 4 worst - paid Average Brutto
  HUF Restaurants, catering 158 000
  610 Healthcare 157 000 610 Public
  education 155 000 610 Textil industry 147
  000 550

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Specific for Education of Physicians

• In Europe
• - Higher education of physicians
• is not in the Bologna Process
• - Education periode is too long
• 6 5 11 years (specialization)
• 2. In Hungary
• Specialization is competence of the Ministry of
  Health
• Financing only in the first two years of
  specialization
• Hospitals have no resources to employ young
  doctors
• (they can not work alone by law) for training

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AND The Working Time Directive

• Council Directive 93/104/EC, 2000/34/EC of the
  European Parliament and of the Council
• Protect the health and safety of workers.
• Limiting of the maximum length of a working week
  to 48 hours in 7 days, and a minimum rest period
  of 11 hours in each 24 hours.
• Right of the patient to a non-tired doctor !
• Opt-out of the 48 hour working week in order to
  work longer hours (duties) ?
• It needs Money and Doctors
• Rich countries import them !

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And more

• Membership of the European Union
• Mutual (automatic) recognition
• physicians, dentist, pharmacists, nurses,
  midwives
• Consequence migration (toward developed
  countries)
• - migration of healthcare professionals

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Towards OECD countries
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Estimates of expatriation rates of nurses and
physicians from selected European
countriesworking in OECD countries around 2000

• COUNTRY NURSES DOCTORS
• Hungary 2117, 2.4 2538, 7.2
• Poland 9153, 4.6 5821, 5.8
• Romania 4440, 4.9 5182, 10.9
• After accession
• a WHO report published in 2006 and based on
  country case studies noted that, while there
  were some indications of increased out migration
  of health professionals from Estonia, Lithuania
  and Poland, the numbers were not as large as had
  been anticipated, perhaps because surveys at the
  time had overestimated the intent of many health
  professionals actually to leave.
• But
• continously increasing

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Physicians' migration in Europe

• FROM EU12 TOTAL ABROAD in EUROPE
•      Romania 42,538 4,397 1,523 9.4
•      Hungary 32,877 2,461 1,043 7.0
•      Poland 95,272 6,568 3,130 6.4
•      Slovakia 17,172 888 888 4.9
•      Czech R. 35,960 1,809 900 4.8
•      Slovenla 4,475 44 44 1.0

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Survey of the Young Physicians(Hungarian
Residents Association)

• 2/3 of them are considering working abroad
• 15 have prepared (contacts)
• 80 because of low salaries
• other reasons
• infrastructure
• living conditions
• working conditions

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Hungarian Chamber of Physicians

• Between 2004 2006
• 1925 Hungarian physicians asked for
• Certificate of Good Standing
• (necessary to work abroad)

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Import of Hungarian speakinghealthcare workers

• 3-4 million Hungarians are living in the
  surrounding countries (Romania, Slovakia, Serbia,
  Ukraine)
• Immigration in the last decade of last century
• ca. 2000 physicians came to Hungary
• Compensating effect
• But has stopped (even reverse?)

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Immigration of doctors from Transylvania BALÁZS
PÉTER, 2005
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Foreign doctors in medical groups () BALÁZS
PÉTER, 2005
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Number of Romanian specialists BALÁZS PÉTER,
2005
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BALANCE Hungary is a netto exporter of
physicians and nurses to Western-European
countries Increasing shortage of healthcare
workers is getting a severe problem of the
society, because health care is part of the
social security.
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Migration is an international issue

• OECD Report on migration of health workers 2007
• In 2004-2005 4 million healthworkers
• Main targets USA, UK, Canada
• In OECD countries every 9. nurses and 6.
  physicians are from developing countries
• Ethical question of recruitments !

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A Comparative Examination of the Migration
of Physicians and Nurses into and out of Canada,
the U.S., the U.K., and Australia Ivy Lynn
Bourgeault, Ph.D. Canada Research Chair in
Comparative Health Labour Policy Health
Studies/Sociology McMaster University Canada
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Health Labour Migration in High Income
Countries. Highly saturated with immigrant health
labour are the U.S., the U.K., and Australia.
These three countries are among the top active
recruiters of immigrant health care providers
from developing countries. US Roughly one
quarter of the U.S. physician workforce. Subspecia
lize at a disproportionately high rate. The
primary source are India, the Philippines and
Mexico. UK Most of the candidates were graduates
from developing countries and Eastern Europe.
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Current situation in Hungary

• Hungarian Hospitals Association
• there is a need for about 1.000 physicians
• 12 of vacancies are impossible to cover
• Hungarian Chamber of Physicians
• 100 general practices are permanently vacant in
  the country
• Hungarian Chamber of Healthcare Workers
• there is a need for about 8.000 nurses

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Aging

• Hungarian Chamber of Physicians
• 20 of practicing family doctors are over 65 yr
• 15 of practicing phycicians are over 65 yr

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Internal medicine Number of physicians by age
and gender
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Family doctors
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Radiologists
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Specialists in Hungarian hospitals by age
groups Hungarian Hospital Association
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Regional inhomogeneityNumber of specialists
/100.000 inhabitants by regionsÁdány R., 2007
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Solution of manpower shortage

• Basically is NOT an issue of higher education
• Income (should be) 2-2.5 times higher
• if we want to have
• a high-quality
• solidarity-based
• public health system
• for everybody
• This is the very question
• It needs common consensus of the society

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Contribution of Higher Education I.

• Sufficient number of medical students (financed
  by the Government)
• Four medical universities
• 1.000 physicians / year
• 1.400 / year is necessary
• Good cooperation of Ministries of Health an
  Education !
• BUT capacity? foreign (paying) students?

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Contribution of Higher Education II.

• New BSc and MSc, because of the technological
  developments (physiotherapists, imaging
  technologists, dieteticians, social workers,
  etc.)
• More non-medical graduates (informatics,chemist,
  biologists, physicists, management, etc.)
• Harmonization of competencies is a must!
• (upper secondary, post-secondary, tertiary
  education) clearly defined - not easy !
• BUT we need more healthcare workers (e.g.
  nurses) without higher education as well!

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The National Authority is responsible for
developing a manpower planning policy at national
level which aims at balancing demand and training
for medical specialists in the EC member state
concerned. UEMS, 1995
MANPOWER PLANNING European Training Charter of
Medical Specialists
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Continuing Medical Educationalso for majority of
healthworkers

• Europe-conform (UEMS)
• Obligatory (licence)
• Well-organized system
• Controlled
• BUT who pays the expenses!?
• medical industry (good and bad)
• pharmaceutical and intrumentation

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FINALLY THE OUTLOOKSby Bureau of Labor
Statistics, 2007

• As the largest industry in 2006, health care
  provided 14 million jobs13.6 million jobs for
  wage and salary workers and about 438,000 jobs
  for the self-employed.
• 7 of the 20 fastest growing occupations are
  health care related.
• Health care will generate 3 million new wage and
  salary jobs between 2006 and 2016, more than any
  other industry.
• Most workers have jobs that require less than 4
  years of college education, but health diagnosing
  and treating practitioners are among the most
  educated workers.
• Wage and salary employment in the health care
  industry is projected to increase 22 percent
  through 2016, compared with 11 percent for all
  industries combined.

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BUT

• IN HUNGARY ???
• budget cuts in public health service !?

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Healthcare ?
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It is true

• Not the number of physicians is low
• But the number of patients is high
• and it is true
• Not the number of physicians is too high
• But the sum of money is too low

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Last minutesManpower !
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THANK YOU
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• European Training Charter of Medical Specialists
• Each Member State shall recognize the diplomas,
  certificates and other evidence of formal
  qualifications in specialized medicine awarded to
  nationals of Member States by the other Member
  States
• UEMS

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Healthcare ProfessionalsCrossing Borders
ProjectProgress Report No. 5Friday, 26 August
2005

• Recommendations The European Framework for a
  Certificate of Good Standing Information
  exchange, reactively and/or proactively, when
  professionals are subject to restrictions to
  practice or are under investigation for serious
  issues European Web Portal of Competent
  Authorities.

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Summary Key factors explaining migration
patterns include the demands of the service
economy in high income countries, their
cultural, political, military, and economic
hegemony over low income countries, and
immigrants experience of uncertainty over their
futures in their native land. The ethical issues
resulting from the migration of health care
providers from poorer to richer nations have
become critical. Both the EU and WTO have urged
national governments to reduce or eliminate
requirements and regulatory devices that impede
or block the movement of goods and services. The
EU's and WTO's facilitation of enhanced
international trade in services may weaken the
autonomy and authority of nationally-based
professional authorities.
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FEMINISATION (Physicians)
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Healthcare workers in Hungarian hospitals by age
groups Hungarian Hospital Association
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Non-medical workers in Hungarian hospitals by age
groups Hungarian Hospital Association
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