HEALTH CARE WORKFORCE

Transcription

1 IMPACT OF AGEING ON CURATIVE HEALTH CARE WORKFORCE COUNTRY REPORT SLOVAKIA MAREK RADVANSKÝ AND GABRIELA DOVÁĽOVÁ SUPPLEMENT F TO NEUJOBS WORKING PAPER D12.1 SEPTEMBER 2013 Demographic trends and ageing are one of the main factors influencing future trends in the socioeconomic development of all European countries included in significant changes in labour market structure. Presented country report provides information and overview about the current situation of the Slovak health care system, utilization and expected needs of workforce and its structure over next decade. Main driver of expected changes in demand and utilization represented by NEUJOBS tailor made demographic projection by friendly and tough scenarios. Estimation of labour demand at the health sector is based on an utilization method and main focus is related to estimation of demand for labour at sector 86 human health activities. Together with estimated labour supply based on topdown approach we will estimate expected match / shortage of health related occupations, especially nursing care personnel and doctors. Report shows, that despite the expectations about future increased demand for care, declining scenario still exists, although is less likely. Better utilization of health care services, shortened hospitalizations and technical progress could lead to decline in required workforce. On the other hand, expected level of public expenditures is still higher than nowadays. When considering also the replacement demand, a significant shortage of doctors and nurses was illustrated in following years across all scenarios. Low wage competitiveness of Slovak health sector together with simplification of specialist movement due implementation of the Bologna process in Europe and relatively low number of graduates will lead to tension in providing health care services. Most probably, the future development will lead to increased employment in selected sectors together in line with expected increase of expenditures. NEUJOBS Working Documents are intended to give an indication of work being conducted within the NEUJOBS research project and to stimulate reactions from other experts in the field. The views expressed in this paper are those of the author and do not necessarily represent any institution with which he is affiliated. See the back page for more information about the NEUJOBS project. Available for free downloading from the NEUJOBS website ( Radvansky,Dovalova, Institute of Economic Research, Slovak Academy of Sciences, 2013

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3 CONTENTS 1. Introduction Current situation of health care system and employment Characteristics of the Slovak health care system Regulations and conditions influencing the demand on health care services and the needed employment Regulations and conditions influencing the supply of services and employees Health care coverage and expenditure Employment in health care sector Overview of personnel in curative health care Characteristic of employment in hospitals Characteristics of personnel in rehabilitation institutions Current shortage of health professions Impact of demographic change on health care demand Utilisation of hospital health care Utilization of rehabilitation health care Ambulatory health care utilization Forecast of population and labour workforce (2025) Population scenarios Changes in labour force participation Impact on Health care demand and needed health workforce Impact on ambulatory utilization and workforce Impact on hospital utilization and employment Impact on public spending Demand for labour in health care related sectors Overview of demand for care professions in medium scenario Calculation of labour supply in health care in Situation of the health labour market (demand and supply-gap) Conclusions List of tables and figures Statistical appendix Bibliography

4 2 RADVANSKÝ M., DOVÁĽOVÁ G. IMPACT OF AGEING ON CURATIVE HEALTH CARE WORKFORCE IN SLOVAKIA MAREK RADVANSKÝ, GABRIELA DOVÁĽOVÁ SUPPLEMENT F TO NEUJOBS WORKING PAPER D Introduction The health and social care sector is an important employment sector employing approximately 160 thousand workers (almost 7 % of total working population), from which more than 106 thousand are directly employed in health care and other related occupations 1. Many changes have been adopted in order to transform the sector to economically more effective system which would generate reasonable costs of services and access to health care. Making a long-term forecast of healthcare utilization and workforce is a rather difficult task, mainly because there are too many factors influencing population health status. On the demand side there are factors such as age structure and average health status of the population, income and its distribution as well as accessibility of health care. On the supply side aspects such as technological changes and infrastructure have to be taken into account. At the national level there is no clear evidence about existence of more or less sophisticated models used by national authorities for estimation of the impact of population ageing on the employment in health care sector. Partial analysis was elaborated under ANCIEN project (Kvetan, V., Páleník, V., Mlýnek, M., Radvanský M., 2006), but it was more related to population health status and expenditures. Findings show that total health care expenditure will increase to 7 % of GDP by 2060, which is already bellow current level of expenditures. Higher growth of expenditures in this forecasting period will be mainly caused by the population ageing. There is no unified system of workforce planning in health care sector in Slovak Republic. Issues of providing health care and the state administration are regulated by specific legal enactment. In terms of workforce planning one of the most important enactments is connected with minimum requirements for personnel, material and technical equipment for various types of health care facilities that are set by Ministry of Health. Ing. Marek Radvanský, PhD., Ing. Gabriela Dováľová, PhD.: Researchers in Institute of Economic Research, Slovak Academy of Sciences, Šancova 56, Bratislava, Slovakia, Marek.Radvansky@savba.sk 1 According to Health Statistics Yearbook of the Slovak Republic, 2011.

5 IMPACTO OF AGEING ON CURATIVE HEALTH WORKFORCE IN SLOVAKIA 3 This paper focuses on the curative health care sector. Chapter 2 provides an overview of regulation and conditions influencing the demand and the supply of health care services and employees in this sector. Also size and characteristics of health care employment in Slovakia in curative health care sector is discussed. In the last part of this chapter authors focus on the impact of demographic change on health care demand. Third chapter is dedicated to expectations about future population development and its possible effect on labour market. Two scenarios which differ by the assumptions about future socioeconomic development (friendly and tough) are taken into consideration. In some cases, national demographic forecast was used to illustrate the most probable development between these positive and negative scenarios. Demographic changes as well as education structure will influence the demand for health care and its utilization. Information about supply side (Chapter 4) of Slovakian healthcare sector based on results of the Neujobs project is rather limited. Based on forecast of labour supply and demand estimation of current and future needs for employees in sector was created. Future needs by particular professions (doctor, nurses) are also presented. 2. Current situation of health care system and employment The transformation of health care system from formerly central planned to system compatible with market economy is still on-going process with various achievements, starting with the private practices for most pharmacies and ambulatory physicians in the early 1990s. Despite that until the 2000s almost all hospitals were in the state ownership and suffered both from lack of investment and oversupply of personnel and beds at the same time. Except necessary changes in legal conditions, there is evident pursuit, sometimes struggle for higher efficiency in the economy of health care (wages, purchasing of health care and health care spending) and the need to find solutions for new challenges as for example the ageing of population Characteristics of the Slovak health care system In Slovakia health care is provided as: Outpatient care (provided to a person whose health condition does not require the permanent health care provision for more than 24 hours) General for adult as well as for children and adolescents Specialised gynaecological and dental care Other specialised Emergency medical service Inpatient care Pharmaceutical care

6 4 RADVANSKÝ M., DOVÁĽOVÁ G. According to Act 576/2004 on Health care, services related to the provision of health care and on the amendment and modification of some other laws, general outpatient care is provided by a doctor with specialisation in the specialised field of general medicine and a doctor with specialisation in the specialised field of paediatrics assigned by the provider and a nurse with pertinent professional qualification assigned by the provider and specialised outpatient care is provided by a doctor with specialisation other than general medicine assigned by the provider, a dentist or a medical worker with pertinent professional qualification. Emergency health care is provided to a person in a case of a sudden change of the health condition directly endangering life potentially seriously endangering his/her health if not provided fast, causing a sudden and intolerable pain or provoking sudden changes of behaviour and action under influence of which the person directly endangers themselves or surroundings. Emergency care is healthcare provided in the case of a birth as well. Inpatient care is provided via hospital network described in following chapter Regulations and conditions influencing the demand on health care services and the needed employment The Ministry of Health is the key policy-maker and regulator of health care system and it is responsible for the regulation of health care providers. Health care in Slovakia is offered by public but also by private health care providers (physicians, dentists, hospitals, pharmacies). According to Act No. 578/2004 on Health care providers, health workers and professional organizations in the health service on the amendment and modification of some other laws medical profession is carried out: 1. within the employment relationship, 2. on the basis of a permit to operate health care facility or permit issued under a separate regulation, 3. under a license to operate the independent medical practice, 4. under the Certificate of Trade Authorisation. Physicians obtain license to perform independent medical practice from Slovak Medical Chamber, which is non-governmental and non-political autonomous organization acting in Slovakia. Chamber issues licences to a doctor after meeting following legal conditions: legal capacity, medical competency, professional competency, impeccability and provided registration. Another condition for obtaining a licence which should be accomplished is a credibility of a doctor, which means that within past two years his licence should not have been cancelled. Competences for issuing permits to operate health care facility are divided between state bodies (the Ministry of Health) and self-governing regions. Competent authority issues permit after fulfilling following legal conditions: having licence for providing medical profession, having own or rented premises in which the health care will be provided, these premises have to meet the requirements in term of health guarding. A general practitioner (GP) is the first in contact with patient except for the emergency care. 2 GP acts as a gatekeeper to other types of care (specialists and hospital care). There is a free choice of general practitioner and he can be changed by patient every six months. Selection of the GP is based on mutual agreement between the 2 It is also possible to directly visit dentist and gynaecologist.

7 IMPACTO OF AGEING ON CURATIVE HEALTH WORKFORCE IN SLOVAKIA 5 patient and GP. In general, GP has also territorial reference and is obliged to service the patient from his area. The system of obligatory referrals by general practitioner for patients wishing to attend medical specialist was re-introduced after two years in April There is still possibility to visit some specialists, such as psychiatrist, gynaecologist, dentist, dermatologist and ophthalmologist (only for prescription glasses) without any referral (i.e. exchange card). Furthermore, there are exceptions for urgent cases and for those suffering from chronic diseases. This system should improve quality of health care and serve as prevention from duplicity examinations as well as contradictions in cases where many medications interact and should not be used together by the same patient. In other words, GP should serve as a care coordinator and should provide appropriate treatment after previous consultation with the patient (patient has a right to choose a therapeutic procedure). Referral for admission to hospital can be made by any physician (GP or medical specialist). 4 The free choice of provider (general practitioner, medical specialist, hospital) should lead to improvement in performance of providers. According to Act No. 576/2004 Coll. on health care, health-related services and on the amendment and supplementing of certain laws, a provider may refuse proposal agreement on health provision only if: conclusion of such agreement makes him go beyond its bearable workload, a personal relation of a provider and the patient being provided with the healthcare cannot guarantee objective assessment of health condition of the patient or health care provision is averted by personal belief of respective medical worker. Due to the exceeding acceptable workload provider cannot refuse a patient who has permanent or temporary residence in his so called health district. In practice, patient with referral from GP or specialist is usually navigated to relevant health district hospital or specialist. Patient can contact any other health care provider, but in some cases (mainly due overload) this provider can deny to provide the service Regulations and conditions influencing the supply of services and employees System is based on mandatory health insurance system, where main purchasers of health care in Slovakia are health insurance companies. Health insurance companies are allowed to sign contracts directly with health care providers but they must respect the condition of a minimal public network related to demographic situation in regions. All insurance companies are obliged to have contract with network of hospitals and 3 This system was introduced in 2008 and abolished in It is a combination of choice and referral system, which means that the patient can choose GP, can choose the specialist following a referral (GP gives to a patient a referral for a specialist within his territorial area who cannot refuse this patient, but it is a free of choice of specialist, but out of this area a patient may not be accepted) and he can also choose a hospital in case that hospitalization is needed.

8 6 RADVANSKÝ M., DOVÁĽOVÁ G. specialists to cover needs of all insured. Health insurance companies negotiate with health care providers the amount of payments (or services) for the given year. In 2008 the state owned health insurance company General Health Insurance Company (Všeobecná zdravotná poisťovňa - VšZP) applied selective signing of contracts with health care providers for the first time. These criteria are of different weight and they include such parameters as minimal public network, workforce, material and technical equipment, quality indicators, price for health care services and transportation of biomedical material. Health insurance company can contract health care provider in case of securing prescribed criteria at least at the level of 90%. The General Health Insurance Company contracts each provider of pharmaceutical care, and each health care provider who is licenced to operate emergency medical services. There are 37 health care providers which have guaranteed contracts with health insurance companies and which belong to terminal minimum network. Beside state owned General Insurance Company there are two other private insurance companies (Dôvera a Union) 5. Health care contributions are same for all insurers, are based on salary and there is limited ceiling for health care insurance (maximum contribution of employee is 4 % from 5 average wages (3930 Euro and there is also contribution of employer - 10 %). All insurance companies provide similar mandatory and regulated standard healthcare service and there is lack of any private insurance scheme to cover service in higher standard, or co-payments. The minimal public network /the minimal number of providers in a given specialization and geographical area/ is set by Ministry of Health and it is monitored by Health Care Surveillance Authority and also by local self-government authorities. 6 In primary care, GP is entitled to a contract with insurance company as soon as a patient registers with him. Primary care is mainly financed by capitation 7 and the fee-for-service principle is applied for specialists. The amount of capitation payment depends on factors as patient age or insurance company, sometimes on the quality of medical care provided. According to data from Health policy institute (HPI) 8, an average amount of capitation for GPs for adults is as follows: for age group Euro, for age group Euro, for age group Euro, for persons older than Euro. 5 It is not possible to have a private health insurance in the sence as it is known in foreign countries, because it is not explicitly defined in law what is standard and what is above standard in health. Current effort of government is to reduce insurance system to single state insurance company. 6 Insurance companies are not penalized if minimal network is not met. 7 General practitioner can also receive additional payment for services e.g. preventive care, vaccination, direct payment from patients etc. 8

9 IMPACTO OF AGEING ON CURATIVE HEALTH WORKFORCE IN SLOVAKIA 7 There are no exact data, but about 10 % of total revenues of general practitioners come from patients direct payments (mainly different administrative fees) and 90 % are payments of insurance companies, from which 80 % are based on capitation and 10 % come from additional services being mainly preventive care. An average number of insured patients per GP is around 1,600. This number, however, is not limited, which makes quantifying potential shortage in health care workforce more difficult. In case of patient overload there is decrease mainly in preventive care services. Medicine prescriptions are covered by health insurance. There is system of copayments, although there should be without fee, or very limited co-paid option for every diagnosis. Significant change to prescription bound only to active substance has been in use since As a consequence, more responsibility on which medicine will be used now lies on druggist. Co-payments are restricted to 45 Euro per 3 months for pensioners and to 30 Euro per 3 months for disabled persons, but in certain conditions to use of cheapest available drugs to related diagnosis. In Table 1 international comparison of salaries of health care personnel is displayed. It compares salaries of general practitioner and hospital nurse relating to the sample of V4 countries and adjusting salary data to purchasing power parity /PPP/ in US dollars /US$/. Remuneration data for specialists are not available for Slovakia. The breakdown of data in the table below is limited by availability of data from these countries. Between 2000 and 2010, salaries for general practitioner in Slovakia increased from 15,195.3 to 38,393.9 expressed in PPP USD and for hospital nurses increased from 7,285.4 to 17,762.1 also expressed in PPP USD. 9 Table 1 International comparison of remuneration of health professional in V4 countries; salaried, income (US$ PPP) A HU : : : 26, , , , , , , ,324.5 Pl : : : : : : : : : : 45,592.9 SR 15, , , , , , , , , , ,393.9 B CZ 10, , , , , , , , , , ,850.4 HU : : : 13, , , , , , , ,601.2 Pl : : : : : : : : : : 23,219.5 SR 7, , , , , , , , , , ,762.1 Source: OECD; A remuneration of general practitioners, B remuneration of hospital nurses; data for remuneration of specialists are not available, Notes : data not available According to data from Statistical Office of the Slovak Republic, average gross monthly wage of physicians /including all bonuses, extra charges/ was 1,240 Euro, which means around 1.61 of the average wage in national economy. This means that in the last decade their salary position does not change, because in 2000 their average 9 For broader overview we provide wages (in Euro) according to type of health establishment are in statistical annex

10 8 RADVANSKÝ M., DOVÁĽOVÁ G. gross monthly wage was around 586 Euro, which represents about 1.55 times of the national wage level. According to the same source, dentists gross salary slightly decreased during the same period in comparison to average wage in national economy, from 1.71 to 1.21 in 2010 /around 928 Euro/. There is evidence that data about remuneration in health sector differ according to the source. These data also include only sources from health insurance companies /they exclude direct payments from patients, payments from pharmaceutical companies/. From this reason, real salary should be significantly higher, especially in dental care with high share of copayments. Currently there is neither available relevant official information about the salaries of physicians according to their proficiency nor information about the gross profit of private physicians resp. about physicians salaries in private and public providers of health care (Goliaš, P., 2011). Classification of wages by the type of establishment can be found in appendix table A1. In hospital, especially public one, there is similar situation about remuneration. Generally there is still in use the table remuneration system based on education level and years of experience similar to the state administration. Table 2 Average monthly gross wage of physicians in Euro / / Physicians /except dentists/ ,099 1,162 1,240 proportion of average monthly earnings in national economy Dentists proportion of average monthly earnings in national economy Source: Slovak Statistical Office Health care coverage and expenditure According to OECD (2012) health care coverage enables access to medical goods and services and provides financial security against unexpected or serious illness. For international comparison, we usually use the share of the population with health insurance coverage. Health care in Slovakia is mainly financed through mandatory health insurance. It stems from the fact, that the Slovak health care system is based on compulsory social health insurance scheme, which covers all residents. Contributions are income related and are shared between employers (10 %) and employees (4 %) 10. The contribution for the self-employed, who are responsible for the whole payment is on the level of 14% and the contributions for all unemployed (but not voluntary unemployed) and inactive persons including dependents, elderly, soldiers and the disabled are paid by state. On January 1st 2013 the amendment to the Act No 580/2004 Coll. on Health Insurance came into force, which brought some changes e.g. health insurance rate was increased from 10% to 14% for an insured persons who have an income from the dividends, the obligation to pay social security and health insurance 10 These percentages are reduced by half for people with severe disabilities.

11 IMPACTO OF AGEING ON CURATIVE HEALTH WORKFORCE IN SLOVAKIA 9 contributions also extends to individuals working based on agreements on work performed outside an employment contract 11, the maximum monthly assessment base for health insurance is increasing to 5-times the average monthly salary reported 2 years ago (for 2013 it means 3,930 Euro), the minimum assessment base for health insurance of self-employed individuals is increasing to 50% of the average wage reported 2 years ago. Such measures should provide additional financial sources. There are three health insurance companies responsible for the collection of the health insurance contributions and for its redistribution: The General Health Insurance Company (VšZP), which covers the majority of the population and two private health insurance companies, Dôvera and Union. According to National Health Information Centre, total number of insured persons by these three insurance companies was 5,150,054 in Citizens can change insurance company until 30 September each year, but in fact there is little competition between the insurance companies. According to decision of The Government of the Slovak Republic, as of January 2014 the unitary health insurance system is planned to be re-established. 13 Initiation of DRG (diagnosis related group) system, which was postponed several times, is currently under preparation and testing phase is planned from 2016 and it is based on German G-DRG system. Table 3 - Expenditure on health Total expenditure on health as % of GDP Total health expenditure per capita (PPP int. $) Public expenditure on health, % of total expenditure on health Public health expenditure per capita (PPP int. $) Out-of-pocket expenditure on health, % of total expenditure on health Out-of-pocket expenditure on health per capita (PPP int. $) Source: OECD OEC D ,057 1,140 1,351 1,619 1,862 2,066 2,090 3, ,082 1,261 1,357 1,351 2, In Slovakia, the healthcare expenditures to GDP ratio increased from 5.5 % in 2000 to 9 % in 2010, still lower than the average of 9.5 % in OECD countries. Healthcare expenditures per capita was around 2,096 USD in 2010 (adjusted to 11 There are some exceptions for students, pensioners and individuals with irregular income from work based on an agreement. 12 According to OECD (2012) in 2010 only a small share of the population, i.e. 5.2% was not covered mostly because of having insurance in other EU Member State. Small portion some of them should pay the insurance by themselves but they do not so. 13 The unitary system of health care insurance should be realized by the voluntary buyout of the shares of private health insurance companies, in other case the expropriation can be considered.

12 10 RADVANSKÝ M., DOVÁĽOVÁ G. purchasing power parity) which was also relatively lower in comparison with an OECD average of 3,265 USD. Public sector still remains the main source of health funding as health spending financed by public sources represented around 65 % of total sources in From 2000 to 2010, decreasing tendency in the share of public expenditure can be observed and it is currently below the OECD average. Out-ofpocket payments 14 are the main source of health care financing right after the public finances. The share of out-of-pocket payments increased by nearly 15 percentage points between 2000 and 2010, nowadays representing share around 26%.This poses the highest increase in all EU27 countries. Table 4 provides information on overall health care costs broken down into outpatient, inpatient and pharmaceutical health care. In 2011 the share of current expenditure on outpatient health care slightly exceeded 40 % of overall health care costs; share of expenditure on inpatient health care was just under 25 %. According to our statistics there are no exact data about share of expenditure on long-term care. According to K. Repková et al (2011) in 2008 total expenditures on health care represented 3,131 mil. Euro (4.65 % GDP) from which only 41 mil. Euro represents long term health care expenditures for people older than 60 years (social care and nonhealth services are not included). Table 4 Overall costs for the provided health care / / Overall costs Euro Index 2011/2010 Euro Index 2010/2009 Overall health care costs in thousands 3,393, ,518, Outpatient health care 1,374, , General outpatient health care 144, , Specialised outpatient health care 1,098, , Other specialised outpatient health care 18, , First aid medical service 23, , Medical resource service 88, , Financial grant provided by health care insurance for health care settlement Inpatient health care 835, ,506, Hospitals 783, ,459, Sanatoriums 19, , Hospices 1, , Natural health spa and spa sanatoriums 31, , Nursing home Financial grant provided by health care insurance for inpatient health settlement 152 Pharmaceutical care 1,102, ,112, Source: National Health Information Centre 14 Include direct payments, informal payments and cost-sharing payments.

13 IMPACTO OF AGEING ON CURATIVE HEALTH WORKFORCE IN SLOVAKIA Employment in health care sector Transformation of health care system in SR during the years highlighted workforce shortages especially among the specialists such as pathologists, paramedics, general practitioners, dentists, nurses, midwives, anaesthetists, psychiatrists. These shortages are result of several factors, especially unfavourable demographic structure of the healthcare workforce (Schultz, 2013), low numbers of educated professionals and also workforce turnover in the system, as well as within the EU. During late 2000 s, the significant increase of working migration was observed. After implementing of Bologna process, the migration of medical personnel has become easier within European countries. There has been significant increase in migration of medicine graduates who mainly target Czech Republic (mainly due to significantly higher initial salary and conditions, relatively little language barrier) and Germany. From the other qualifications, there is significant migration of personal care-givers and nurses to Austria (proximity). The statistical data which could cover this migration patterns and shortages over qualifications are missing. Health care sector is still an important segment of the economy in Slovakia from the employment point of view. The share of health and social work employment on total employment in Slovakia was about 6.9 % in 2012, which means that about 161,300 people were employed in this sector. From longer-term viewpoint women seem to be more dominant in this sector compared to men, while the share of women working in this sector on total women employment was on the level of 12% almost the whole time during the period (Figure 1). Figure 1 Share of health and social work employment on total employment in Slovakia (%) 14% 12% 10% 8% 6% 4% 2% 0% Source: Slovak Statistical Office Men Total Women Overview of personnel in curative health care The total numbers of employees in health care went down in This is reflected also in selected occupations shown in the Table 5 below. Overall the trend exposes growing numbers, the only exemptions being dentists, technicians, other

14 12 RADVANSKÝ M., DOVÁĽOVÁ G. health occupations, but also nurses. In 2011 Slovakia had on average 3.3 practicing physicians and 5.9 nurses per 1,000 inhabitants. In comparison with EU27 and OECD countries the average number of nurses in Slovakia is insufficient in contrast with the average numbers of physicians which are approximately the same as in developed countries. Table 5 Number of selected occupations per 100,000 population Year Health occupations 1,405 1, , , , , Physicians Dentists Pharmacists Nurses Midwives Lab. Technicians Assistants Technicians Other health occupations Other occupations Source: National Health Information Centre. Note: In other occupations are included technical and economic employees, working-class occupations and operating employees, educational employees, employees of science, research and development and state-employed occupations. In particular there is the middle generation of doctors who leave for better salaries and working conditions abroad, especially into Czech Republic, where the Slovaks have almost no language or cultural barriers. According to the president of Slovak Medical Chamber, shortages of doctors is manifested mainly in surgery or radiology and in smaller towns but the total numbers of physicians per 1,000 population are about the OECD or EU average. Besides the lower numbers in some occupations there is another challenge for future employment, namely the age structure and the fact, that health-care workforce is getting older. Concrete data are presented in the appendix (Table 7A-9A and Figure 1A). Table 6 Age structure of health-care workforce Age Younger than 55 Older than 55 Year Number % of total Number % of total , % 17, % , % 5, % Source: National Health Information Centre Ageing population is manifesting especially among the dentists, with the alarming proportion of dentists in the age 55 years and over standing at % in 2009, comparing with only % in the year This is also the main reason for decline in the number of dentists, and dentist coverage in some regions is thus very unfavourable. Especially worrying is aging development in the category of nurses,

15 IMPACTO OF AGEING ON CURATIVE HEALTH WORKFORCE IN SLOVAKIA 13 with declining total numbers and growing percentage of 55 years and older nurses on total health care workforce in this category. According to the President of the Slovak Chamber of Nurses and Midwives situation is very complicated. Every year 1,200 to 1,600 nurses retire, but the schools release only 500 new graduates, with at least 200 new nurses leaving the country to work abroad. Age of nurses is therefore increasing and situation is become unsustainable from long-term perspective. Figure 2 Stagnant total numbers and rising ratio of 55 years and older nurses % 14% 12% 10% 8% 6% 4% 2% 0% ratio of 55+ aged, right axis nurses, total, left axis Source: National Health Information Centre, own calculation, In 2011 about 10,060 health facilities provided outpatient health care in Slovakia with about 11,283 work positions (in FTE full time equivalent). There were 21.7 physicians posts per 10,000 inhabitants providing ambulatory care. There were 10.2 physicians posts in outpatient units providing general health care for children and adolescents and 4.6 physicians posts for patients older than 18 years. From total 23,735 work positions of independent health care professionals, about 47.5 % belonged to outpatient health care, 39 % to institutional care including out-patient units and about 12 % to pharmaceutical care. Within out-patient health care majority of work positions were created by specialized out-patient units as well as by general out-patient care units (Table 7). In 2011 there were 15,251 out-patient units in Slovakia with total 27,461 working posts of which 11,732 were job positions for physicians and dentists and 12,276 for nurses and midwives. In comparison with 2009, number of units as well as number of total working positions for physicians, dentists and nurses, midwives are slowly moving downward. Development of employment in selected specializations from 2009 to 2011 can be seen in Table 8. Decrease in specializations such as general care for children and adolescents (decreasing number of newborns), stomatology, general care etc. can be observed, while gynaecology and obstetrics, orthopaedics, physiotherapy, balneology and medical rehabilitation etc. have been on the rise.

16 14 RADVANSKÝ M., DOVÁĽOVÁ G. Table 7 Employment in out-patient health care by facility in 2011 Types of health care facilities Health service providers who operate a given type of facility Number of Health care facilities Work positions of independent health care professionals Beds Total 12,180 13,051 23, ,073 Out-patient health care, including: 9,300 10,060 11, x * General out-patient care unit 2,809 2,941 2, x * Specialised out-patient care unit 5,719 6,132 6, x * Emergency out-patient unit x * Facility providing day care x * Residential health care unit x * Health care centre x * Nursing care service x * Examination and curative components x * Mobile hospice x * Out-patient medical first aid service unit x Institutional care including out-patient units, including: , ,073 * General hospital , ,075 * Specialised hospital , ,142 * Sanatorium ,446 * Hospice * Nursing care facility * Natural healing spa ,880 * Curative spa ,239 * Biomedical research institution Pharmaceutical care 1,631 1,665 3, x Hematology and Transfusiology Facility x Others 1,072 1, x Source: National Health Information Centre, 2011

17 IMPACTO OF AGEING ON CURATIVE HEALTH WORKFORCE IN SLOVAKIA 15 Table 8 Personnel in outpatient health care facilities by occupations, Selected specialization Out-patient unit Total Working posts Physicians dentists and Nurses and midwives Total 15,251 15,621 27,070 27,461 11,732 12,225 12,276 12,845 Internal medicine , , Neurology Psychiatry Paediatrics General care for children and adolescents 1,141 1,149 2, , , , , , Gynaecology and obstetrics , , Surgery Orthopaedics Stomatology 2,346 2,516 4,758,2 4, , , , , General care 2,129 2,219 4, , , , , , Physiotherapy, balneology and medical rehabilitation Clinical immunology and allergology Cardiology Diabetology, metabolic disorders Clinical psychology Haematology and transfusiology Clinical immunology and allergology Rheumatology Gastroenterology Jaw orthopaedics Nephrology Endocrinology Source: National Health Information Centre Characteristic of employment in hospitals Patients requiring urgent medical care are hospitalized in hospitals of terminal network, which have defined standards for composition of inpatient departments, personnel and material equipment and geographical availability on the district level. In general we distinguish between general and specialized hospitals. Permits for specialized hospitals and facilities of biomedicine research and facilities providing institutional health care for more than two autonomous regions are issued by the Ministry of Health, while issuance of permits for other facilities of institutional health care (e.g. spas, hospices) is in the competence of autonomous region. In 2012 there were 142 hospitals 15 in Slovakia, from which 23 % were private Share by founder: Ministry of health (66%), private domestic (14%), private with foreign partner (1%), ownership of associations, political parties and churches (8%), autonomous region (11%).

18 16 RADVANSKÝ M., DOVÁĽOVÁ G. When concerning the fees for hospitalization, it is necessary to distinguish whether it is hospitalization for urgent medical care which is fully covered by the health insurance plan, or it is not an emergency health care, and in that case there may be certain services related to the provision of health care covered by public insurance only partially. At the end there could be more expensive hospital stays hence it is possible to charge insured persons for extra services. Lump sum payment from the insurance company is made for terminated hospitalization irrespective of the number of days. It depends on the type of hospital department and not directly from the diagnosis, while the DRG system is about to be introduced in Hospital employment is growing particularly for categories of physicians or doctors and caring personnel. While also in growing trend, numbers for professional nurses and midwives were in 2010 only slightly higher than in 2005, highlighting some problems of health care labour market in this segment. Table 9 Health personnel employed in hospital (FTE) Total hospital employment 38,778 37,726 39,743 38,672 40,322 41,401 Physicians or doctors 7,485 7,363 8,080 7,770 8,219 8,420 Professional nurses and midwives 22,236 21,560 21,913 21,153 22,058 22,450 Caring personnel 5,575 5,438 5,797 6,783 6,252 6,784 Other health service providers employed by hospital 3,482 3,366 3,953 2,967 3,794 3,746 Source: Eurostat When looking at the numbers of physicians and dentists, the development of employment in these categories is different depending on the type of health care facility. Full time equivalents are rising especially in general hospitals, both for physicians and dentists, while physicians are doing better also in specialized outpatient care units and in specialized hospitals, in contrary to the dentists, whose full time equivalents are decreasing in this type of facilities. Table 10 Number of physicians and dentists by type of health care facility Number of physicians (FTE) General out-patient care unit 3, , , , , , , Specialised out-patient care unit 3, , , , , , , General hospital 6, , , , , , , Specialised hospital , , Number of dentists (FTE) Specialised out-patient care unit 2, , , , , , , General hospital Specialised hospital Source: National Health Information Centre 16 From this 32 private hospitals there were 13% limited companies, 23 % joint stock companies, 48 % non profit organizations, 17 % alowance organizations.

19 IMPACTO OF AGEING ON CURATIVE HEALTH WORKFORCE IN SLOVAKIA Characteristics of personnel in rehabilitation institutions In 2011 the rehabilitation took 7.8 % of all treatments done within hospitalization and it was in line after surgery (10.8 %), infusion (23.8%), medicament (35 %) and other treatments (17.7 %). 17 Data for medical rehabilitation are available only together with physiotherapy and balneology and they are available only from 2009 because of changing methodology of collecting data. In 2011 there were 28 units within in-patient health care in specialized units of physiotherapy, balneology and medical rehabilitation. Number of physicians in these institution is slightly decreasing, from 97.9 in 2009 to 90.3 in During this period we can also see a decreasing trend in number of beds, from 916 in 2009 to 835 in 2011, which means decrease about 9 %. Daily places for children patients are the highest from all specialized units, while the total daily places for patients were the fourth highest after places for surgery (287), gynaecology and obstetrics (337), psychiatry (437) and dialysis, with the highest number of daily places for patients in specialized units of health care (546). In 2011 there were 366 units of physiotherapy, balneology and medical rehabilitation within outpatient health care with around working posts (FTE), which means decrease of about 9 %. Decreasing trend in number of positions can be seen for physicians and dentists as well as for nurses and midwives (table 11). 18 Table 11 Employment in institutions of physiotherapy, balneology and medical rehabilitation In-patient health care in specialized units of institutional health care Number of units Number of hospitalizations : 224, ,144 Number of physicians posts Number of beds Bed occupancy in % Daily places 1 for patients in specialized units of health care For children Outpatient health care Number of units Working posts total in FTE Physicians and dentists Nurses and midwives Source: National Health Information Centre 2.3. Current shortage of health professions Ageing population of physicists and nurses is connected also with the changes in the education system, when we are witnessing trend of increasing age of the graduates. This phenomenon has several consequences. One of them is missing middle 17 Without transfusion (1.9 %), resuscitation (0.4 %), radioterapeutic (0.2 %) and none hospitalization, only examination (2.4 %). 18 Rehabilitations based on the medical prescription are provided without co-payments.

20 18 RADVANSKÝ M., DOVÁĽOVÁ G. age generation because of migration, when many physicists and nurses have chosen better wage conditions and work abroad, especially in Czech Republic, but also in German speaking countries, Great Britain and Ireland. It is estimated, than in the period about 2,800 Slovak doctors went abroad (approximately 15 % of the total medical workforce). Migration from abroad to Slovakia is minimal, at present it is limited to individual arrivals mainly from Ukraine and foreign graduates of Slovak universities. Number of doctors of foreign origin in Slovakia does not exceed 0.4 % of the total. Data on backward migration, i.e. doctors returning from abroad are completely absent, estimates range up to 15% of those who departed from Slovakia (Dušan Zachar, 2012). Driving force behind the mobility of health care professionals is certainly higher salaries in Western Europe, but health care professionals earn more also in neighbouring Czech Republic. Slovak Republic cannot currently compete in this field and from the provision of health care point of view it is important to draw attention on the urgent need to increase the wage assessment of health care workers in Slovak Republic, subject to an increase in payments for services of health care facilities by health care companies. Ageing and migration creates higher pressure on education system and the numbers of graduates, because contrary to the past experiences relatively higher numbers of health care personnel are going to retire at the same time. This trend is combining with developments in the field of decreasing numbers of medical graduates per 100,000 population. Table 12 Medical graduates per 100,000 population Medical Dentists Pharmacists Midwives Nurses Source: OECD Health Data, The only exception from selected categories of graduates are pharmacists, but other important occupations are indicating that the decreasing numbers of graduates could be insufficient to compensate for the downward trend in employment possibly associated with the ageing workforce, rising numbers of retired persons and migration in health care sector. Training of health care workers in SR is traditionally well advanced, as evidenced by the relatively high numbers of students from other European countries, but number of graduates (health professionals entering practice) is not sufficient to cover the lack of health care workers. It is quite difficult to quantify the shortage of health care workforce in the country. One method of how to obtain data for shortness of workforce is questionnaire completed by national policy experts, other health system stakeholders and randomly selected GPs. According the study conducted in Slovakia by WHO (2012) during the years approximately 25% of physician answered that there may be a shortage in their regional area.