»Pune čekaonice, prazne ordinacije«: motivi iseljavanja liječnica i liječnika iz Hrvatske
Authors: Pintarić Ljiljana ,   Odsjek za sociologiju, Filozofski fakultet Sveučilišta J. J. Strossmayera u Osijeku, Osijek, Župarić-Iljić Drago ,   Odsjek za sociologiju, Filozofski fakultet Sveučilišta u Zagrebu, Zagreb
Published: July 2024

The problem of a healthcare workforce shortage is present on a global scale, as evidenced by the World Health Organization's estimate that by 2035, there will be a global deficit of 12.9 million healthcare workers (Campbell et al., 2013). Previous research indicates that the emigration of highly qualified professionals is relatively under-researched within the Croatian scientific community. Some studies have focused on surveys among student populations and their inclinations towards emigration as a form of potential emigration (Golub, 2003; Šverko, 2005; Mlikota and Prelas Kovačević, 2013; Bojanić, Bojanić and Likić, 2015; Mrkonjić et al., 2019; Troskot, Prsaklo and Šimić Banović, 2019; Šlibar, Oreški and Klačmer Čalopa, 2023). According to existing research, the most common reasons contributing to the inclination to-wards migration among healthcare workers in Croatia include issues in the organisation of the healthcare system and working conditions, low financial compensation, issues in the education and specialisation process, nepotism and political favouritism in the healthcare system, as well as the general political climate in society. This study is part of the first author's research for her doctoral dissertation on the topic “Key Factors in the Emigration of Healthcare Workers from the Republic of Croatia.” The general aim of this research was to map the relevant reasons for the emigration of healthcare workers from Croatia from their perspective and based on their statements, and to identify the key reasons for emigration, i.e., those that prevail in the decision-making process regarding emigration. The research questions were defined as follows: What are all the factors that influenced the decision of emigrated physicians to leave Croatia? Which of these factors are more important than others, i.e., prevail in decision-making? How can we explain the differences in the importance of these factors? The research was conducted using qualitative methodology as the optimal framework considering the research topic. The study included 45 healthcare workers, both emigrated and non-emigrated. We interviewed members of the two largest groups of healthcare workers, nurses/medical technicians and physicians, but in this paper, we present preliminary results obtained from one of the researched subsamples: emigrated physicians. Some of the results presented here were obtained from research on a sample from the population of physicians who emigrated from Croatia, constituting a subsample of the total sample of emigrated healthcare workers, with a total of 18 interviews conducted (13 women, and 5 men). The research was initiated in September 2021 and completed in February 2023, with all interviews conducted online due to the pandemic context. Regarding the method of data analysis and processing, we opted for a thematic analysis approach, specifically a variant of thematic analysis developed by King (2004), called pattern analysis. We argue that this approach is particularly suitable for studies aimed at comparing different perspectives of actors in a phenomenon within a specific context. Through the process of inductive and deductive thematic analysis and in accordance with the initial theoretical-conceptual framework of this research, we established three main themes that describe and encompass important groups of reasons for the emigration of physicians from Croatia: 1. Professional aspirations of physicians. This type of motivation represents a key or significant reason for the decision to emigrate, or it is indirectly related to that decision. It may involve a desire for training that is not offered in Croatia at all, or if it is, the quality of education is perceived as inadequate, i.e., some physicians strive for higher-quality education. Physicians who want to educate themselves and/or specialise in narrowly specialised areas can only acquire their knowledge in countries with larger healthcare systems. Furthermore, reasons related to the possibility of obtaining the desired specialisation are mentioned, as well as the perception of fairness in the competition process, i.e., the perception of corruption and nepotism in these processes. 2. Organisational context of the Croatian healthcare system. This theme is crucial when discussing the reasons for the emigration of physicians from Croatia. Emigrated physicians uniformly express a high degree of dissatisfaction with various aspects of working in the Croatian public healthcare system, and in the vast majority of cases, they cite this as the key reason for deciding to emigrate. These aspects include interpersonal relationships (along with the theme of mobbing), overtime work and excessive workloads, high levels of politicisation of the profession (including the themes of corruption and nepotism in the healthcare system), and management of the healthcare system (at both higher and lower levels) along with the related theme of the system’s structure and organisation. 3. General/broader social context. The theme of quality of life did not emerge as one of the decisive reasons for emigration, but the theme of the broader social context, i.e., the perception of the general socio-political atmosphere in Croatia, appeared important for some physicians, and for a smaller number, as one of the decisive reasons for emigration. We believe this broader context is associated by interlocutors with the context of working in the healthcare system. The politicisation of the profession/ system and the phenomenon of corruption and nepotism in the system are recognised as part of the broader socio-political context in which corruption and nepotism are important features of the general socio-political climate. We contend that, for a small portion of interviewed physicians, the inability to realise their professional aspirations in Croatia is an important push factor for emigration. However, we believe that our research provides grounds to conclude that this concerns a very small number of physicians, and that the phenomenon of emigration would not represent any burden to the healthcare system if other important push factors were not present. The organisational context of the public healthcare system, i.e., various aspects of the experience of working in that system, takes precedence in our analysis in terms of key push factors for emigration. In this group of reasons, there is no simple answer, as the aspects of this issue are multiple and intertwined. A large portion of emigrated physicians speak of poor interpersonal relationships as one of the most important reasons for emigration. This theme is often associated in their statements with the theme of excessive politicisation of the profession, forming opposing groups (“us/our” and “them/theirs”), which directly harms cooperation. In the context of the theme of interpersonal relationships, we notice that there are two types of mobbing, individual cases of abuse of power, and systemic mobbing, where the system accepts and legitimises it to some extent since there are no sanctions for instances of abuse. We recognise the second type mostly in relation to younger physicians, especially specialists, in the undermining of work standards and norms manifested in the frequency of overtime work, overloading with work tasks, and problems in interpersonal relationships and in managing work organisation. We also observed a specific type of systemic mobbing characterised by gender-discriminatory abusive behaviour and the use of positions of power within the system for inappropriate and disturbing practices by superiors towards staff. The overall picture we describe points to an organisational climate that tolerates, or even encourages, but most importantly conceals problems in its functioning. These issues are addressed inadequately or not at all, and there are no adequate mechanisms for sanctioning (or they exist but are not applied, and when they are, they often have little real effect for the victim). Other possible factors contributing to emigration were mentioned, such as individual and family reasons that facilitate decision-making about migration and most often increase the likelihood of emigration. In addition, factors include active recruitment by foreign agencies, changes in regulatory frameworks that facilitate mobility, recognition and evaluation of qualifications, perception of favourable conditions for immigration and integration at the destination, better opportunities for the education of children, desire for change and openness to new experiences, among others. The limitations of this research relate to the predominant focus on the physicians’ reminiscences of reasons for emigration, which may sometimes be post-hoc rationalisations of their decisions. Another limitation concerns the method of conducting interviews, which, although initially planned to be face-to-face, were ultimately conducted remotely and virtually due to the circumstances of the global COVID-19 pandemic. From the presented results, we can conclude that the emigration of physicians from Croatia is shaped by numerous interconnected factors. Without investment in education and training, and the retention of the medical workforce, there is a risk of potential degradation in treatment standards due to a shortage of necessary professionals. Therefore, research on the emigration of physicians is relevant for various national stakeholders involved in the creation and implementation of public policies, especially healthcare, migration, and educational policies related to healthcare worker education and specialisation, among others.