Background
Policy makers often promote strategic planning for human resources for health (HRH) as a part of strategies aimed at improving healthcare system performance [
1]. Strategic HRH planning for attaining improved health goals and objectives depends on understanding the interplay among many factors within and beyond the healthcare system. Those factors include: economic policies, legislation, rules and procedures that guide health workforce production, education, deployment, performance, payment and management, as well as structures, programs, and action plans designed to be operated and delivered by a range of providers in settings with different socio-economic and demographic characteristics; all of these factors responding to environmental threats and targeting a changing demographic structure [
2‐
15]. Along with that, HRH planning can include projections that identify cross-cutting problems regarding HRH production, employment and management, such as the relative attractiveness of employment or practice in the health professions, the role of the private sector and migration of health professionals and the population [
1‐
13].
During the last sixty years, various tools have been developed and used for HRH planning [
2‐
12,
14‐
16]. Developed countries often used workforce supply and demand methods based on population needs-based requirements, others have used benchmarking or a combination [
2‐
12,
14,
15] There are qualitative approaches (for example, the Delphi method [
11]), and some studies use quantitative dynamic modeling of HRH stock and flow [
14] that may include sensitivity analyses [
15]. This paper describes a trend analysis, using existing data to anticipate supply and demand issues in Serbia.
A country may lack a coherent plan for HRH development, as well as valid data describing HRH shortages or excesses because of inaccurate data, conflicts with general policy planning, the presence of a significant private sector, or lack of a responsible body and support system to promote planning [
11].
In all former Yugoslav republics including Serbia, HRH planning was driven by simple, normatively-determined physician/dentist/nurse/pharmacists-to-population ratio. This was done in a diffuse manner with the Ministry of Education and the Ministry of Health sharing responsibility, but the former had no legal obligation to consult with the Ministry of Health on the number of medical students enrolled in medical school and could act independently in setting targets [
16‐
19]. In the South East European countries, including Serbia, systematic and strategic workforce planning has been underdeveloped, and, important for this region in recent decades, an understanding of migratory flows is lacking [
16]. For example, Romania has a binding
numerus clausus but there remains a relatively stable number of vacancies in the public sector mainly due to limitations in teaching capacity that have not been adjusted upward. Overproduction and overspecialization in Bulgaria have been the result of the lack of clear criteria for HRH planning [
16].
Specific studies of HRH planning are limited in Serbia [
20‐
25]. Since the Second World War, the public sector has been the major employer and producer of health workforce in the Republic of Serbia. Before 1961, the country had successive five-year economic plans, which included HRH. Due to scarce teaching capacity, a
numerus clausus was in place and regulated the number of graduates for that reason instead of population needs. The application of HRH decision-making was decentralized to ‘self managed interest communes’ that aimed to increase population access and equity, but these were not connected to the overall number of graduates [
20,
23].
From 1961 to 2010 there have been three formal HRH strategies: the first two were long-term strategies created within health care development plans, for 1990 [
20] and 2000 [
21] respectively; the third was part of planned activities for the reconstruction of the health care provider network during 2005 to 2010 [
22].
The first HRH development plan for 1990 followed the new Constitution (in 1974), the Labor Law, and the Law on Education of 1976 that brought broader decentralization to all former Yugoslav republics and provinces [
25]. However, after the global oil crises in 1976 the economy stagnated, national debt rose and separatist tensions emerged [
25]. By 1978 the number of employed physicians and enrolled medical students slowly increased, but in 1979 the number of enrolled medical students doubled and stayed at that level for several consecutive years [
24]. Financial restrictions on the healthcare system and the elimination of private practice forced many health workers to emigrate. At the beginning of the 1980s, Constitutional amendments limited the autonomy of republics and Serbian provinces and this led to a new approach using centralized HRH planning.
A new development plan for Serbia was enacted and was applied between 1982 and 2000 [
21]. It included a reduction of enrollment in medical studies, increased vocational education and specification of the number of posts based on health worker to population ratio and it also sanctioned private practice for dentists in 1987 and for pharmacists and physicians in 1989. However, military conflicts and Yugoslavia’s break-up during the 1990s curtailed the inter-sectoral activity over HRH development. Private practitioners were not able to support themselves with fees and many health professionals emigrated.
At the end of the 20th century, Serbia was an economically degraded and isolated country, overburdened with hyperinflation and experiencing an influx of refugees and internally displaced persons (both healthcare workers and patients). Many health development plans were subsequently proposed by various experts, but none were formally accepted.
In 2000, the new Ministry of Health collaborated with the World Bank on a master plan for the reconstruction of the healthcare provider network and a new HRH strategy for 2006 to 2010 [
22,
26]. In order to fit with a reconstructed network of public healthcare providers, and attain equity in access, and to increase efficiency, a recommended reduction in public sector staff was aligned with estimates of an increase in the private sector; the private sector was expected to absorb these workers or attract recently retired workers. Despite the fact that unemployment of medical workers was high, and the training of the health workforce at state faculties was publicly funded, as were health care costs, the enrollment and graduation rate for medical studies were not priority issues in the HRH strategy 2006 to 2010. The planning process in place did make use of several demand-based scenarios for primary, secondary and tertiary healthcare institutions and included population and economic growth, healthcare services utilization, and performance benchmarking for the public sector.
Subsequently, regulations on physician and nurse staffing and operational staffing norms were adopted [
27,
28]. The Law of Private Entrepreneurs (2005) and the Law of Private Companies (2004) allowed the establishment and operation of private medical and dental practices or companies with limited liability. The Health Care Law of 2005 described the scope of health care services private health care providers could provide.
Although staffing ratios had been set, there were no explicit boundaries regulating deviations from standards such as in Slovenia where a 10% variance was allowed [
19]. In Serbia, there were variances of up to 2.74 times for physician density and over three-fold for specialists; up to 1.98-fold for nurse density and over six-fold for midwives (Table
1). This was primarily due to population and health workforce rural-to-urban migration, differences in natural population increase, and noncompliance with staffing rules with little flexibility for health workforce movement. Nevertheless, 95% of physicians and nurses had permanent full or part-time employment. Meanwhile, annual unemployment for physicians had been growing by 5.6% and by 1.5% for nurses from 2000. Two-thirds of approximately 2,000 unemployed physicians were aged less than 30 years, and half of almost 10,000 unemployed nurses were under 25 years of age [
24].
Table 1
Districts with the highest and the lowest number of health workers in the public healthcare sector per 100,000 population in the Republic of Serbia
2005 | 428 | 631 | 353 | 693 | 143 | 332 | 186 | 430 |
2006 | 437 | 634 | 355 | 712 | 145 | 324 | 189 | 430 |
2007 | 437 | 673 | 358 | 725 | 151 | 331 | 195 | 442 |
2008 | 443 | 700 | 368 | 745 | 162 | 343 | 205 | 461 |
2009 | 421 | 676 | 368 | 742 | 175 | 364 | 206 | 455 |
2010 | 444 | 700 | 371 | 748 | 178 | 373 | 206 | 465 |
The new Health Development Plan for the 2010 to 2015 period [
29] anticipated the development of a parallel HRH strategy but it has not yet been created. The existing Health Care Law was extended with new articles by which the Ministry of Health annually sets the highest number of posts for each public healthcare institution under their control. Current annual staffing targets and the minimum required number and skill-mix of workers were unchanged and remain based on population number per square kilometer, and the population age and sex structure. Performance measures for public healthcare institutions were also unaffected [
27,
28].
This study explores these past planning approaches (between 1961 and 2008), and uses trend data from those years to model physician and nurse supply to determine if a longer term projection model can be applied in Serbia. The study purpose is to meet the requirement for the inter-sectoral activity over HRH development set out in the new Health Development Plan between 2010 and 2015 period.
Discussion
This study analyzed the relationships found in six models that described physician and nurse supply in the public healthcare system of Serbia. The models made use of over 50 years of data and estimated trends in the number of physicians and nurses required in the public health care sector of Serbia. The trends were extended to estimate the supply by 2015. This study has identified that the most significant predictors of physician and nurse staff for the last twenty-five years were GDP and population size. The relationship between changes in the economy and demand for physicians’ services was well documented in the literature [
4‐
7]. This study revealed that the GDP is a significant predictor for the number of inpatient care discharges in Serbia, and that the supply of physicians was an incentive for healthcare service utilization in general.
Besides natural population increase, social instability and migration, other factors such as health policy (that is, changes in the health institutions’ ownership and structure, voluntary specializations, HRH rationalization and piloting new health technology), and economic changes and policy (that is, GDP, hyperinflation, currency reform and flexible retirement schemes) have affected the upward and downward slopes for physician and nurse workforce density. While changes in population have small impact on healthcare workforce, the economy had relatively greater effects (for instance, the decrease of GDP by 18% influenced downsize of the hospital bed number by 3%). Emigration also affected the public workforce density, in particular before and after the country’s break-up and during the application of international sanctions (the remaining international sanctions were lifted in September 2001). Policy changes had a major impact; for example, the HRH strategy in 1982 has reduced the intake by 51% and the staff lay-offs decreased the number of physicians by 4%. The introduction of flexible retirement as a macroeconomic intervention for staff reduction is estimated to have produced a 3.5% difference between the forecasted and registered number of health workers [
9]. In our study, about 3.9% of nurses left the public sector of Serbia due to more favorable terms for retirement introduced in 1995.
Earlier studies described significant rises in the number of physicians (specialists in particular) and nurses (but not midwives) in the public sector of Serbia [
23‐
25]. This study provided evidence that enrollment and graduation rates at state medical faculties were self-directed and caused these increases; an explicit link to the number of vacancies in public healthcare sector was not observed. The constant increase of physician and nurse density suggests that access to healthcare and to education have been traditional social values in Serbia that could resist political and economic upheavals. The prediction models showed that if current physician supply policy (enrollment and graduation at state medical faculties, and their deployment) is seen as adequate by policy makers and maintained at the same level, it will result each year in almost eight times the number of graduated physicians than the number of vacancies in the public healthcare sector. Even if almost 80% of all future graduates emigrate, or the state faculties stop the intake in the next three years, there will still be enough physicians to match the public healthcare sector requirements by 2015 and beyond. The number of unemployed physicians will likely increase. Responsive partnership between government-funded medical schools, the healthcare sector and other health stakeholders is needed [
35,
36]. Health experts agree that addressing population health needs should be solved by doing more than creating more health workers [
35,
36].
The country has spent USA$ 9 to12 billion on the education of emigrated physician specialists [
37] (the lower sum corresponds to the total Serbian public debt in 2009 [
38]). The real financial losses would have been much higher if the calculation covered the total estimated 10,000 Serbian health professionals working abroad [
37], lost profits, replacement costs and other indirect losses. Given the actual tendency of Serbian health workers to emigrate [
38], the return of investments in their education and fiscal income should be assessed.
Shifts in the macroeconomic contexts were a dominant source of forecasting failures in many studies [
4,
6,
9,
11]. To overcome this problem, in this study we included a ‘pessimistic’ scenario of GDP contraction instead of the GDP central projections since the GDP growth rate in Serbia fell from 5.5% in 2008 to −3.0% in 2009 and to 1.8% - 2.0% growth in 2010 [
39]. The models in this study generated results that were fairly similar to the current situation. There was no difference between the forecasted and registered number of physicians and nurses (only 0.1% in 2011) in the public healthcare sector. This suggests that the approach can be used for projecting future workforce trends in Serbia.
Study limitations
Models are simplifications of reality and provide a glimpse into the future based on the limitations of the models [
12]. With unanticipated changes in migration of population and health workforce, the actual physician and nurse supply may also alternate. Prolonging regulations for age-related retirement in Serbia (due to an ageing workforce) may alternate the overall outflow rate from the public healthcare sector (the Ministry of Health of Serbia has estimated it at 2 to 2.5% per year [
22]). Therefore, future forecasts should include the age and gender analyses of the workforce.
Having complete and valid data on the number of private practitioners is difficult in almost all countries [
11,
12]. In Serbia this is also a complex issue since publicly employed health workers are allowed to provide specialist, consultative and/or training services in the private sector and to act as volunteers outside the public healthcare sector. Also, according to the official methodology, only the number of full-time employees was available, while the number of consultants was unknown and likely very variable. The health professionals’ authorities regularly reported increases among licensed private health workers. The greatest proportion of private sector staff was recorded in specialty clinics, then in hospitals, women’s health care facilities and physical medicine. The climate for private business is still unstable in Serbia. Each year, a large number of new private healthcare entities enter the economy while some disappear, transform or merge (for example, in one year there were 3,000 private practices including 98 clinics and 8 primary care centers, while a year later there were 1,200 entities out of which 74 were polyclinics and 9 primary care centers) [
40]. According to the assessment of the Institute of Economic and Social Research, the private sector was still poorly represented in the delivery of health care services to the Serbian population in 2009: outpatient services served 1.2% of population, and inpatient services 0.6% of population [
31].
Study implications for policy and practice
Future inter-sectoral HRH strategy and action plans should develop careful health development plans, goals and objectives. To deliver an inter-sectoral HRH strategy, the government should commission a high-level and independent body to analyze and forecast the dynamics of cross-cutting problems regarding HRH production, employment and performance. The essence of its activity should be the harmonization of HRH-related policies in all sectors with the health development plan [
3,
6,
10].
Future research should estimate how many physicians would be employed in the private sector or abroad, and its effect in preventing future mismatches between the demand and supply of physicians in the emerging economic scenario.
Although the increasing number of unemployed health professionals suggests that there will be an available supply in the future, it also makes Serbia another source country for well- qualified health workers. The WHO Global Code of Practice on the International Recruitment of Health Personnel should be enforced in order to strategically govern the mobilization and development of a national HRH.
The number of other health professions (such as dentists, pharmacists, laboratory technicians, radiographers, physiotherapists, and so on) grew in line with the expansion of the public health sector, particularly during the extension of a guaranteed healthcare benefit basket in the mid 1970s and in the beginning of the 1980s [
24,
25]. Since these other professionals represent 21% of the total health workforce in the public sector, and due to their roles in teams needed to provide specialized services, their relationship with the physician and nurse staffing ratio should be explored in future research.
Competing interest
The authors declare that they have no competing interests.
Authors’ contributions
MSM, VV and JM conceived and designed the study and have made substantial contributions to analysis and interpretation of data. MSM and VV collected data and drafted the manuscript. All authors have given the manuscript their final approval.