Landscape after the battle

Doctors on strike in the V4

29 September 2013

The system is about to collapse!” The doctor sighed, apologized and turned back to my results before continuing: “It’s going to collapse. I myself don’t care that much. I’m going to retire soon, but what about my colleagues? The nurses are even worse off, with the day and night shifts, overloaded with work and underpaid, and I can’t imagine what might ease the burden they carry.”

Disregarding how embarrassed my allergist made me during the examination, he is far from alone in his profession. Indeed, in recent years many doctors have expressed increasing desperation about the state of health care and future of public hospitals.

A similar story is playing out in practically all the countries of the V4: exhausted, overworked doctors and nurses, working lengthy shifts with extra hours for pitiful compensation. Students of medicine have a distorted image of their prospects and patients are losing trust, as the health service has not improved reasonably since 1989. Only the costs have raised and the problem of informal payment is still on the table. Substantive structural changes have not taken place and health care has entered a period of crisis – budgets are tight, hospitals are indebted and thousands of doctors leave their countries each year for material reasons.

In this apparent dead-end, doctors have begun a series of campaigns to improve work conditions and raise salaries, with the eventual goal of reaching two times the national average for young doctors, and three times that for specialists. Still far below the “Western standards”, this would nevertheless be enough to keep them at home. Like a rolling strike, with the wave moving across countries rather than sectors or units – strikes began in Poland in 2006 and continued through 2007 and 2008. In 2010, massive campaigns kicked off in the Czech Republic, where thousands of doctors deposited a dismissal notice. This was followed by a similar action in Slovakia in late 2011 and finally in Hungary. Drawing on the similarities in these post-communist countries, the unions of the V4 decided to support each other in the campaigns and negotiations.


Pushing and pulling

After the fall of socialist regimes, the field of medicine was burdened by relics of the authoritarian past, particularly damaging was the baggage of low wages and anti-competitive conditions. Toward the end of the 90’s, doctors in Central Europe not only earned considerably less than their Western colleagues, but also lagged behind other occupational groups within their home countries. This resulted in new waves of emigration, reaching a peak after accession to the EU. Open borders and simplified administrative procedures have attracted tens of thousands of health care professionals from the region – surgeons, psychiatrists, anaesthesiologists, obstetricians and professionals from other areas. The most popular destinations are the UK, Germany and Scandinavia. Even France, Austria, Spain and Switzerland (otherwise restrictive concerning emigrant workers) welcomed doctors from the former Eastern bloc, attempting to fill shortages in small towns and marginal regions, expand weekend hours and increase their respective supplies of specialists.

The reasons for leaving are generally pragmatic. To quote the Hungarian psychiatrist Dr. Edina Sugár: “When I decided to leave, my monthly salary was about 120-122 000 HUF, while the balloon payment for my apartment had gone up to 112 000 HUF.” Doctors’ salaries in Hungary are the lowest in the V4. But even Czech doctors can make 4-5 times more in neighbouring Germany or Austria. Besides issues of compensation, poor working conditions are also responsible for the massive healthcare exodus. Citing Dr. Sugár once more: “In our hospital we had regular shifts of 8-hours, but we were obliged to provide attendances of 16 hours plus administration, after a regular work day, which made shifts as long as 26-28 hours. A physician can be obliged to take up to two attendances a month, but we were encouraged to “volunteer” for further attendances. Moreover, the payment for an attendance is 70% of the regular salary. I was the only person who didn’t sign this – I was not about to offer extra work for 1 Euro/ hour. Not that it mattered – I had to do it anyway.”

The problem with working hours is also well known in Slovakia. Jana, a student of medicine, describes the state of affairs at Comenius – considered the finest medical university in Slovakia: “There is a lack of staff, the working hours are long and our professors don’t have enough time even to teach us!” The Slovak Doctors’ Union (LOZ) warns that while the EU directives suggest no more than 192 extra hours per year, Slovak doctors face approximately 500-600 additional hours each year, a situation that puts both doctors and patients at risk.

Beyond working hours and wages, the movement of doctors is also motivated by better conditions and the opportunity to gain professional experience. An instructive example in this case would be the migration of Slovak doctors to the Czech Republic. While there are minimal differences in wages between the two countries, the Czech Republic is home to better facilities, including a higher number of large and well-equipped hospitals. In Western Europe and Scandinavia, physicians are given better supplies and provisions – there is no threat of a shortage of appropriate medications and hospitals do not need to cut costs on available examinations. In short, in these regions doctors do not need to consider financial implications when ordering tests.

If a physician decides to go abroad, they usually turn to one of the numerous recruitment agencies specializing in health care. The procedure is rather simple – the basic condition is a diploma in medicine. It is easier to get a job as a specialist but this is not a requirement. It is preferable that the candidate has good language skills – usually an intermediate level of English or German is sufficient. The first interview takes place on location, and after having received a positive review the candidate is generally invited for a second interview, already at the prospective hospital of employment. If necessary, a language course will be organized. The agencies also provide free language courses for spouses, as well as help with administration, obtaining accommodation or organizing schooling for children.

There are rarely problems with acceptance in the foreign country, among patients or colleagues – as the flood of Eastern European doctors is neither exceptional nor new. As Dr. Sugár explained: “There are three psychiatrists in our hospital – one Norwegian, one Polish and me – I mean specialists, because the resident doctors are usually Norwegians. Otherwise, we have a Hungarian dermatologist in the hospital, one of the anaesthesiologists is Austrian, another is Hungarian and there are two Serbs. The paediatrician is Polish – what can I say, they’re used to it.”

Physicians usually leave in their 30s-40s, at the beginning or peak of their careers, and they are rarely interested in returning. The doctors who leave with their families are welcomed into the safety net of Western European or Scandinavian social systems and it is unlikely they would return to the same conditions once they have escaped.


Rolling campaigns

The reactions of respective governments have been criticized as shifting recklessly between denial and rage. Handling a complex economic and social problem as a matter of individual choice has pushed the question of responsibility aside. By the time the campaigns of the unions began to unfold, it was already too late, and talks look increasingly like battles rather than negotiations.

Polish health professionals went on strike in 2006. In the years following, the doctors joined the national strikes of public employees, embracing teachers, bus drivers and coal miners. The union reported strikes in 230 of Poland’s 800 hospitals. Nurses occupied the territory in front of the Prime Minister’s office in 2007. They managed to put up 150 tents and demonstrated under a very telling banner: “Stay Healthy, We’re Leaving!” In Poland, the outflow of medical staff started in the late 90s, which led to a severe lack of human resources in hospitals. At the same time, the country was also a destination for doctors from the former Soviet Union, especially Ukraine. But this influx slowed after accession to the EU, as Anna Stradza, head of a Polish recruitment agency explains: “The procedure of recognition of a Ukrainian doctor’s diploma has become more complicated and time consuming.” The discrepancy between incoming and outgoing physicians continued to expand, at least until the doctors managed to negotiate better payments in 2008-2009.

The Czech union leader, Martin Engel, blames corrupt political leadership, citing this factor as the primary reason why his union is opposed to the privatization of hospitals. In the Czech Republic, the campaign was preceded by dramatic statistics in 2007-2008, showing about 300 doctors leaving the country each month, primarily for Germany and the UK. In early 2010, Czech doctors launched their massive campaign “Thanks, We’re Leaving”, where more than 3800 doctors, that is about one fourth of all hospital doctors declared their resignation and put together a list of 13 reasons for their exodus. And the government finally agreed to raise doctors’ salaries by 5000-8000 KC/ per month, with promises of further raises.

Angry rhetoric also characterised the campaign of the Slovak doctors’ union, which has employed clear references to regime change – claiming that it wants to dismantle the current, malfunctioning social security system, just like the corrupt and malfunctioning authoritarian regime was dismantled in 1989. The Slovak minister of health care, Ivan Uhliarik, accused LOZ of taking patients as hostages. The response came quickly and simply: “It’s the political elite that has been doing so [taking hostages] for years”. During the 2 months of the campaign, “Let’s Rescue Healthcare”, about 2500 doctors (including half of all the doctors in Bratislava and 100% at a particular ward in Nitra) signed a resignation notice. At the dramatic height of events, Ivan Uhliarik agreed with LOZ to raise the salaries of doctors in several steps and to stop the privatization of state hospitals.

The Hungarian situation did not look much more promising – the Health Portfolio proposed that doctors would be obliged to stay at the hospital where they received their specialization for four years, in order to prevent them from leaving the country. This plan did not make it through, and no agreement has been reached in the meantime. Following their Slovak colleagues, the Hungarian doctors also decided to organize a joint “quit and leave” action, with more than 2200 individuals joining the campaign “For Viable Healthcare” by early December. These figures are but the logical extension of an ongoing process, considering the data of earlier years – in 2006, 520 doctors asked for their certificates for employment abroad at the Doctors’s Chamber, while in 2009 and 2010 this number rose to 1500.


Visegrad on the move

Recognizing the similarities between the problems of health care in the V4, the unions decided to work out common strategic plans for co-operation. In fact, the campaigns in Slovakia and Hungary were to a large extent inspired by these frameworks and the previous successes of doctors in Poland and the Czech Republic. As Dr. János Bélteczki, leader of the Hungarian Doctors’s Union, explained: “There is a lot we can learn from the Czechs. They already worked out strategies for campaigning and public appearances and can advise us in the deadlocks and the various stages of our actions.” In October of 2011, the unions of the four countries established the Visegrad Charta, which sets out basic principles, including plans for action (see Box article). A concrete step in this co-operation was the call by Czech and Hungarian unions for solidarity with the Slovak doctors during their strike, which meant, in practical terms, a denial of help to hospitals affected by the “quit and leave” campaign.

The results of the uncompromising stances and actions taken by Visegrad doctors are already reflected in the statistics. In Poland, wages for doctors in the public sphere were raised, in some cases, by 60%, and the outflow of doctors dramatically slowed. During the first year after the EU accession, 2800 doctors left Poland, but by 2010 this number had dropped to 325. By the first half of 2011, less than 150 certificates for leaving were issued. Even if there are specialists willing to go abroad, the recruitment agencies are rather busy finding short-term occupations, such as weekend shifts and locum jobs.

It is important to note that payment issues are not fully sorted out andthere are still worries that the promised improvements will not be achieved. It also needs to be stressed that the results still don’t cover the whole of the health sector and that the doctors are a group with significantly better representation. Nurses, assistants and other employees did not necessarily benefit from the actions. On the contrary, five nurses in Poland went on a hunger strike in the spring of 2011, for example. However, the brain drain and uneven movement of health workers is slowing down and the prospect of better earnings and work conditions may potentially keep health specialists at home, thereby raising the level of trust amongst partners – health care employees, the government and – not the least of which – the patients.

The author is a cultural anthropologist writing her dissertation on post-socialist urban movements.

The article was originally published in Visegrad Insight vol. 1 (1) 2012.