4.2 Human resources

4.2.1 Trends in the health workforce

In 2007, the total health workforce was 109 829 people, which is 4.64% of the total workforce in Slovakia. Non-state health care facilities employed 62.2% of health workers, which is 24.6% more than in 2003. This increase reflects the transformation of health care facilities owned by self-governing regions and municipalities into the non-state sector. Table 4.7 captures the numbers of health workers per 1000 population for the period 2000–2007.

Of the total number of employees working in health care facilities in Slovakia in 2007, 16.6% were physicians, 2.6% dentists, 3.0% pharmacists, 31.0% nurses, 1.5% midwives, 5.2% lab technicians, 8.7% assistants, 1.8% technicians, 2.6% other health care workers (for example physiotherapist, speech therapist psychologist) and 27.1% other workers (technical and operational personnel). Per 1000 inhabitants, these numbers amounted to 3.37 for physicians, 0.53 for dentists, and 6.61 for nurses (2007; other figures see Table 4.7). Over half – 55.5% – of all physicians were female.

A gradual decrease of the health workforce could be observed until 2005. The most significant decrease was observed in the number of nurses and professions not directly related to health care provision. In 2006, the health workforce started to increase again (Table 4.7). The decrease in the period 2000–2005 was most probably due to the restructuring of health care facilities after 2000, as well as the migration of health care workers. In 2007, the number of health workers increased as a result of the new Labour Code, which transposed the EU Working Time Directive (2003/88/EC). The providers were forced to employ more employees in order to maintain operational levels. The increase in 2007 in the number of health workers reached 2.8% for workers in state providers and 2.5% in non-state providers. This was insufficient to observe the Labour Code in the opinion of trade unions. From 2009 onwards, the implementation of minimum workforce requirements for inpatient health care facilities, which was issued by the Ministry of Health in 2008, will result in further increases in the health workforce.

Table 4.7: Number of health workers per 1 000 population in all health care facilities, 2000–2007

Table 4.8 presents a detailed division of health workers in health facilities. Public health tasks are carried out by public health experts educated in an appropriate field of expertise. Physicians specialized in epidemiology, hygiene and preventive medicine form a minority among the public health workforce.

Table 4.8: Registered number of health workers (full-time equivalent [FTE]) by category and type of facility, 2007

The health care workforce is ageing. The proportion of physicians aged 50 years and older reached 47.4% in 2007. The largest group of health workers is between 50 and 54 years. In the long-term, a gradual increase in people retiring from their jobs combined with migration of health care workers is reinforcing the shortage of health care workers. Professional mobility also poses a challenge to the health workforce. This is elaborated in more detail in section 4.2.2 Professional mobility of health workers.

Distribution of personnel in the territory of Slovakia shows large disparities (Table 4.9). The Bratislava region has 1.5 to 2.5 times more health workers on average per population as compared to other regions.

Table 4.9: Geographical differences in distribution of health workers per 1 000 population, 2007

Compared to other countries, the number of physicians per population was similar to Germany as well as the EU15 until 2001. After 2001, Slovakia witnessed a continuous fall in the number of physicians per population (Fig. 4.4), although the number remains well above the EU12 average. The number of nurses per population (Fig. 4.5) also shows a trend break in 2001. Before 2001 this number was on the EU15 average and similar to the number in the Czech Republic. After 2001, this number fell below the EU15 average but remained above the EU12 average. These changes are closely linked with the migration of doctors and nurses abroad, as well as the restructuring of health care facilities.

Fig. 4.6 shows that the number of dentists per 1000 population in Slovakia is well below the EU15 average, but above the EU12 average. Among the countries of the Visegrád Four, Slovakia is only surpassed by the Czech Republic, similar to Hungary and above Poland.

In 2008, there were 3032 pharmacists and 1406 pharmacies in Slovakia. According to the Slovak Pharmaceutical Chamber’s data, the number of pharmacies exceeded 1900 in 2009. This is the result of liberalized ownership regulation, which enables non-pharmacists to own pharmacies. Pharmacy chains are not explicitly permitted, but the same subject is allowed to establish more than one pharmacy. Currently about one-third of all pharmacies in Slovakia are part of a pharmacy chain. The number of pharmacies and pharmacists is not regulated. Fig. 4.7 shows that the number of pharmacists per 1000 population in Slovakia (0.47, number for 2007) was slightly above the EU12 average, but well below the EU15 average.

Fig. 4.4: Number of physicians per 100 000 population, 1990 to latest available year

Fig. 4.5: Number of nurses (PP) per 100 000 population, 1990–2007 or latest available year

Fig. 4.6: Number of dentists (PP) per 1 000 population, 2008 or latest available year

Fig. 4.7: Number of pharmacists (PP) per 1 000 population, 2008 or latest available tear

4.2.2 Professional mobility of health workers

Four medical faculties in Slovakia produce approximately 500 graduates annually and many of them leave the country to work abroad. The migration of highly respected specialists, motivated by higher salaries creates a problem in human resources (Beňušová, 2007). Although this is considered common knowledge, the statistical data to evaluate the decrease in the number of health staff are lacking. The registration of health care professionals in professional chambers should contain information on the location of their practice as well as information about their employer. However, professional chambers often do not have this information as health care professionals do not always fulfil their reporting requirements and the chambers do not possess effective tools to enforce this requirement.

The number of issued certificates of conformity of study, required for working abroad (see Table 4.10), provides an indication of the number of health workers leaving the country. In percentages (calculated using Tables 4.8 and 4.10) this means that, for example in 2006, 1.26% of health workers, 2.14% of physicians and 1.26% of nurses had such a certificate and may have decided to practise abroad. According to EC Directive 2005/36 on the recognition of professional qualifications, the issued certificates enable health care workers to start a recognition procedure in another Member State or Iceland, Liechtenstein and Norway. Between 1 May 2004 and 30 June 2008, the Ministry of Health issued 3972 confirmations. However, these data provide only a partial picture of the situation as the data does not show whether health care professionals have actually migrated and does not include those health workers who have decided to work in countries outside the EU or Iceland, Liechtenstein and Norway. The number of nurses leaving their jobs in Slovakia and working as caregivers in other Member States of the EU is not available. It is assumed that over 1000 Slovak physicians work in the Czech Republic.

Table 4.10: Number of certificates of conformity of study issued by the Ministry of Health to health workers

4.2.3 Training of health care personnel

A professional qualification to perform activities in various health occupations, which is called the basic qualification in Slovakia, can be obtained after completing:

• a Bachelor’s or Master’s degree in an accredited university programme
• higher vocational training
• full secondary vocational training
• secondary vocational training.

Professional qualifications to perform specialized professional activities can be obtained through a specialized course/training. Professional qualifications to perform certified professional activities can be obtained through certified training. Specialized training, certified training and continuous education of health workers are called “further education/training” in the Slovak system.

Until 2004, the Slovak Health University was the sole provider of further education. Since 2004, other institutions, accredited by the Accreditation Committee of the Ministry of Health, including medical faculties, may offer training and education for health professionals. Life-long continuous medical education is obligatory for every health professional. Relevant professional chambers perform evaluations of continuous education at five-year intervals. In case of shortcomings, the professional organization may warn the employer or may notify the HCSA. It may also investigate a health professional or impose sanctions (for example temporary withdrawal of their licence). The employers must create conditions for further education of their employees while professional organizations must participate in educational activities and quality assurance programmes.

Physicians in Slovakia must have a Master’s degree university education in a medical doctor programme. The Slovak Master’s degree in General Medicine is recognized by the EU as equal to comparable degree programmes in other EU Member States. The General Medicine degree programme has a six-year curriculum and includes at least 5500 hours of theoretical and practical study. Graduates are awarded the title of Doctor of Medicine (MD). At present, four medical faculties provide programmes in General Medicine at three universities; two medical faculties in Bratislava (Comenius University, Slovak Health University), one in Martin (Comenius University) and one in Košice (Pavol Jozef Šafárik University).

If a physician aspires to become a specialist, he or she should continue his or her education and complete a training programme in a selected medical specialty. Currently there are 96 specialized postgraduate training programmes which last at least three years. After completing the specialized postgraduate training, physicians can apply for certified programmes in relevant specializations and achieve a certificate (such as endoscopies, ultrasonography and so on). Currently there are 32 different types of certified programmes.

In addition to specialized postgraduate training programmes and continuous education, physicians can complete a PhD programme. Physicians may continue their academic career with the academic titles “University Reader” (United Kingdom) or “Associate Professor” (United States) and “Professor”, if they meet the necessary criteria.

Prior to accession of Slovakia to the EU, training for dentists was part of the study programme “stomatology”. Since accession, to ensure full compliance with EU law, dental practice requires a specialized degree in dentistry instead of a degree in General Medicine. This new programme can be followed at two medical faculties in Slovakia. To be allowed to practise, dentists who graduated under the old system as doctors of general medicine (with the title MUDr.) are obliged either to extend their education in a specialized training programme in dentistry, or to practise for three years under the supervision of a specialist. The last opportunity to enrol in the stomatology degree programme was in 2009. The relevant professional chamber issues licences for independent practice.

A shortage of nurses caused by the departure of health personnel from Slovakia was aggravated by the low numbers of nurse graduates from medical schools. The decrease in nurse graduates is a result of two factors. First, a low salary relative to the intensity of the work causes a lack of interest in this occupation. Second, since EU accession, instead of secondary vocational training at specialized high schools, nursing education is provided either as vocational training or at a Bachelor’s (Bc) level. Further education at a Master’s degree university level (Mgr) is optional, but not a condition for nurses to practise. Following this change, a rise in the number of university graduates in nursing can be observed (see Table 4.11), but the overall number of nurse graduates went down. The relevant professional organization issues licences for nurses to practise.

Pharmacists are required to complete a Master’s degree university programme in pharmacy. Their training was reformed to ensure full compliance with EU law. There are two entities offering this programme – the Pharmaceutical Faculty of Comenius University in Bratislava and the University of Veterinary Medicine and Pharmacy in Košice. The relevant professional organization issues licences for pharmacists.

Table 4.11: Number of health care oriented graduates of full-time university study, 2000–2006