For seven months, psychiatrist Ildiko Szabo got up every day before 5 a.m. and caught the first train from Szeged to Budapest. Three hours later she would be sitting in a Swedish language class. In the afternoon she took the train home to southern Hungary and prepared dinner for her three children. After they went to bed, she would go online to practice her Swedish.
One week after finishing the exhausting course and passing a language exam, and after 23 years of practicing psychiatry in her homeland, Szabo left Hungary with her husband and kids for a job in Orebro County, Sweden.
That was two years ago. Today Szabo is one of 12 Hungarian psychiatrists in the county in central Sweden. She makes several times more money than she did in Hungary, has much more free time to spend with her family and does not have to accept tips from her patients to make ends meet.
Since Hungary joined the European Union in 2004, 500 to 600 doctors have left the country each year, and a recent survey by the Health Services Management Training Center at Budapest's Semmelweis University indicates that 60 to 70 percent of first-year medical students plan to seek a job abroad after graduation. In a country already facing a doctor shortage, the migration has health-care professionals talking about a human resources crisis in the system.
Low pay is the main factor, but poor prospects for professional development and promotion and substandard working conditions also play a part, studies show. Experts say deep structural changes in Hungary's health-care system are needed to stop the exodus.
Since Hungary's EU accession, 2,218 doctors have applied for an official certificate enabling them to work elsewhere in the union. "This step does not mean that they definitely will leave the country, but it suggests a strong will to do that, considering that the certificate costs 40,000 forints [150 euros] and the monthly salary of a resident is less than 100,000 forints," says Dr. Edit Eke of the Semmelweis University team, which has been researching health professionals' migration patterns for four years.
The university researchers found that as of the end of last year, 2,065 Hungarian doctors were registered in EU countries including Belgium, Denmark, Finland, France, Germany, Portugal, Sweden, and the United Kingdom. Last year 590 doctors applied for an EU working certificate; the annual number of medical-school graduates is 750 to 800.
Not all those doctors move outright. Many just hop on a low-cost flight Friday afternoon, work all weekend at a British hospital and return with what might amount to triple their monthly pay at home. And many medical students say they only want to spend a couple of years abroad, which Eke says is not a bad thing in itself.
"We are not against foreign experience and learning. But it is a question of how that experience can be integrated into the Hungarian system of training," she says. Even if a doctor leaves with every intention of coming back before too long, she adds, a good offer or better working conditions abroad could easily change his or her mind.
Hungary currently has about 35,000 doctors. Eke said there were 2,200 vacancies for doctors in 2005, the most recent year for which statistics are available. Those data do not reflect big cuts made in the health-care system last year, she noted.
Money remains the chief motivation for doctors to leave. A new medical graduate earns less than 380 euros a month. A security guard or shop assistant can usually expect to take home 300 euros; a 22-year-old with a bachelor's degree working as an assistant auditor for a multinational corporation makes more than 600 euros.
Ildiko Szabo says she saw the situation steadily deteriorate for practitioners during her career in Hungary. She typically had night duty 10 times a month, and hardly had any time with her family. "If you see the light at the end of the tunnel and know how much more you have to take, you will bear the difficulties," she says. "I waited for more than 20 years but only saw things worsening."
For her the informal system of tipping, or hálapénz—typically handed to health-care professionals in white envelopes before treatment—is no help. "The basic strategy of all governments was to save money on health care and to force doctors to accept the tips by keeping their salaries low. & You can't work like that. And this was bad even for us, the doctors," says Szabo, who acknowledges taking tips but says she never favored those who gave her envelopes.
Some doctors leave primarily to pursue professional opportunities unavailable in Hungary. Peter Sipos chose a less typical path, going to Namibia for three years.
"I was already doing my practical training and wanted to go into obstetrics and gynecology. But I soon realized that though I could get my certificate easily in Hungary, I would not learn all the most recent techniques in this field," he says. He spent three years in the obstetrics department at a Namibian clinic and says he learned all he needed there. Today he is doing research on stem cells in Britain, although he does not rule out returning to Hungary one day.
According to Eke, poor working conditions and doctors' low standing in public esteem also contribute to the departure of physicians and physicians-to-be. "This is a complex process comprising the workload doctors have to take, their social status and their conditions, as well as many other factors," she says.
Countries like Sweden that also face a shortage of doctors are eager to import medical professionals from Central and Eastern Europe. Intermediary agencies advertise on the internet and in the journal of the Hungarian Medical Chamber. Sometimes they even contact doctors directly.
It was in a professional journal that Szabo saw an offer for psychiatrists willing to work in Sweden. After e-mailing in her CV, she was invited to attend an information session and soon afterward had an interview. Prospects and their spouses were taken on a five-day trip to Sweden to look around; on the final day she signed a preliminary contract and agreed to take an intensive seven-month language course.
Szabo did not have to pay for any of this; moreover, she and the other doctors got a monthly 300,000 forint stipend—far more than she earned practicing in Szeged—plus rent and travel allowances so they could support their families while learning Swedish, and help finding a home and settling in after the move.
In addition to the 590 physicians, 324 nurses, dentists, and other health professionals applied for the EU working certificate in 2007. Opinions vary on how serious an impact labor migration is having on the Hungarian health-care system, although Eke sees a definite effect.
"Officials have always considered this problem to be smaller than the professionals. But every day hospital directors have to face not having enough doctors," she says. "Many of the doctors leaving the country are experienced specialists. They are vital in the practical training of young doctors, and their leaving the country endangers training as well." Almost half of the doctors applying for the EU working certificate in 2007 were aged 40 and above.
Higher salaries alone will not eliminate the problem, but Eke says research indicates it could significantly reduce migrants' numbers. Such an increase could actually be cost-effective, she maintains, given the costs of training doctors who leave (about 40,000 euros for six years of medical school) and filling the health-care vacuum they leave behind, particularly in small towns.
"We asked the medical students how much money they would like to get after graduation and as a young specialist. They are not expecting a million forints, which they might make abroad, but 200,000 forints on average for a resident and 400,000 for a specialist," she said. "These are not unreal numbers and show that even a small increase would help the situation."
Eke says there is talk in the medical community of the Health Ministry working on a new strategy, "but nothing has been made public yet. If there was a strategy people could trust, that salaries will rise in the future, it would have an effect on migration plans."