More than a thousand doctors, nurses and carers are leaving Bosnia and Herzegovina for Germany each year, with frightening implications for the country’s own health service.
Hard-working Selma Dzafic breezed through her studies at the Faculty of Medicine in Tuzla, northern Bosnia.
While she won top marks, securing her first job as a doctor in Bosnia and Herzegovina proved tougher than passing exams.
‘’It was impossible to find a job without connections or paying someone,’’ Dzafic told BIRN.
Exasperated, she looked to Germany for her first post and, two years on, is a well-established doctor in Saarbrucken’s main hospital.
Dzafic’s tale is far from unusual. She is part of an exodus of skilled workers from Bosnia, including doctors, nurses and healthcare assistants, all leaving for the better pay and better working conditions in Germany.
She estimates that half of her cohort from medical school are now working abroad, an assessment which is given added weight by statistics obtained by BIRN under Freedom of Information rules.
More than 10,000 nurses, doctors and carers from Bosnia have followed her path, according to figures obtained from Germany’s Federal Employment Agency.
And, although Germany has sought to tighten migration from the Balkans in recent years, new measures introduced in 2013 have actually made it easier for skilled healthcare workers to head for Germany, increasing the pace of departures.
As a result, the last three years all saw more than a thousand Bosnian medical staff taking advantage of two government-backed programmes aimed at helping Germany fill the skills gap.
Experts say that while this is good news for Germany, it is a looming disaster for Bosnia.
Healthcare coverage is falling to worrying levels, according to doctor and nurses’ associations.
The Bosnian state coffers are being drained at the same time, because it pays millions of euros each year to train doctors and nurses on courses who intend to emigrate when they finish their studies.
Deal in 2013 accelerated exodus
|Hasan Zolic, former director of the Statistics Agency of Bosnia and Herzegovina, said salaries and working conditions must improve at home if Bosnia is to have any hope of stemming the outflow. Photo: BIRN|
Germany has long been a popular destination for Bosnians looking to escape unemployment in their homeland, which currently stands at 27 per cent and rises to more than 60 per cent among the young, according to the World Bank.
The Ministry of Security of Bosnia said the majority of Bosnian emigrants in 2014 resided in Germany, 153,470 in all.
Most left during the 1992-5 war in Bosnia. But another wave started in April 2013 when Bosnia and Germany agreed to two new programmes, making it much easier for healthcare workers to emigrate.
One scheme, called the Arrangement on Mediation in Fixed-term Employment of Workers, allowed Bosnians who had completed medical high school to apply for jobs as care assistants or nurses in hospitals, clinics or in homes for the elderly in Germany via job centres in Germany.
Since April 2013, Bosnian nurses can also find employment in Germany through the “Triple Win” system, so called because it is supposed to alleviate unemployment in Bosnia, ease the shortage of nurses in Germany and encourage the flow of remittances back to Bosnia.
The programme involves candidates responding directly to a public call for healthcare workers, rather than looking for individual jobs.
While nurses had been able to secure work permits in Germany prior to this, the new rules made it far easier and more attractive, sparking an unprecedented exodus of healthcare workers.
Between June 2013 and March 2016, some 4,213 Bosnians took up jobs in the German healthcare sector, bringing the total figure to 10,726.
The number of nurses and carers, who were targeted with the two programmes, doubled in that period to 7,478.
Data from the German Employment Agency also show that in March 2016, 1,102 Bosnian doctors were employed in the country, a rise of 20 per cent rise from June 2013 to March 2016, even though physicians did not form part of the programme.
As only about 6,000 doctors work in Bosnia, this means for every six doctors working in Bosnia, one is now working in Germany.
Boris Pupic, from Bosnia’s Labour and Employment Agency, which is responsible for administrating the work permit programme, said: “All work agreements are signed for the duration of one year, after which workers must pass a caregiver’s vocational exam in Germany.”
The salaries for nurses in first year are 1,900 euros a month, three times the earnings in Bosnia, increasing after the carer passes the first-year exams.
“The possibility of staying in the country [Germany] depends on the employer and specific staffing demands, but it is important to say that after a year, each worker has the right to independently change their employers,” Pupic said.
„In parallel to these arrangements, doctors are constantly leaving for abroad on their own, since there are demands in most foreign labour markets,” he added.
Charlotte Hermelink, director of Goethe Institute in Bosnia, which is the sole provider of German-language certificates for the schemes, told BIRN that demand had been growing since 2013, leading to courses being rolled out across the country.
The lure of work in Germany has even sparked a glut of forged certificates, which German Embassy staff have now been trained to spot.
Paul Ebsen, from the German Employment Agency, said he expects the flow of workers from Bosnia to continue in coming years, especially since Germany improved the rules from January 2016.
Under these changes, Bosnian workers must receive identical salaries to Germans for carrying out the same tasks.
Only the unambitious stay in Bosnia
|Merima Rahmanovic, a ninth-grade student in Tuzla Secondary School of Medicine, said she and a large number of her friends are aware of the opportunities on offer in Germany and Austria. Photo: BIRN|
Dr Harun Drljevic, president of the Federation Medical Chamber, a group which champions the interest of doctors in the Federation entity, one of the two entities in Bosnia, said the future of healthcare in Bosnia looks bleak.
The current provision of doctors’ services in Bosnia is already well below EU standards, he says, and is likely to fall further as more healthcare workers leave the country.
The EU average is 350 doctors per 100,000 residents, while Bosnia has just 190, according to World Bank figures. In Germany the figure is 380.
“Only doctors who lack ambition stay in Bosnia and Herzegovina,” he told BIRN
He fears the exodus is leading to a serious shortage of qualified professionals that can only worsen.
“We will not have young physicians who now need to specialise and mature into this profession for ten years, to take over the medical system [later],” he warned.
“We will only have senior physicians who will have no one to impart their knowledge to,” he added.
Hasan Zolic, former director of the Statistics Agency of Bosnia and Herzegovina, said that while Bosnia has experienced a net outflow of people for years, it was worrying that it now includes skilled healthcare workers.
He said salaries and working conditions must improve at home if Bosnia is to have any hope of stemming the outflow.
“Our physicians are in demand not only in Germany but also in Austria, Norway and Qatar,” Zolic said. “The new country gets a finished product that only needs some final touches.
“If this trend continues, the consequences will be poor medical services, which will affect citizens the hardest.”
The Association of Nurses, Technicians and Midwives of Republika Srpska, Bosnia’s other entity, says that the departures are already having an impact on levels of care.
“Nurses are leaving for Germany because of low wages and bad working conditions and because their work is not sufficiently appreciated in their own country,” it told BIRN.
“All this already has an effect on the quality of medical treatment in our hospitals.”
Dr Drljevic estimates that the cost of educating a single doctor is 50,000 BAM, roughly equivalent to 25,000 euros.
On that basis, the departure of 185 doctors between June 2013 and March 2016 represented a loss of 4.6 million euros.
As the number of students opting to study at medical school in the hope of finding a job abroad grows, the financial burden on the Bosnian state also increases.
In recent years, local governments have been forced to expand the student intake to cope with rising demand for medical training.
For the school year now underway, Tuzla Canton Government added a further 273 places to its classes, an increase of almost 50 per cent, it told BIRN.
Merima Rahmanovic, a ninth-grade student in Tuzla Secondary School of Medicine, said: “I and a large number of my friends are aware of the opportunities on offer in Germany and Austria, which is one reason why the interest in Medical High School is so great.”
The recent departures are also putting another strain on the budget as Bosnia is forced to send more and more patients abroad for treatment.
In the last two years, Bosnia spent more than 64 million BAM – around 32.7 million euros – sending patients to other countries.
The figure increased from 29 million BAM in 2014 to 31 million in 2015.
The final bill will be significantly higher, however, as six out of the ten cantons in the Federation entity have not declared their spending on this sector.
Dr Selma Dzafic said she could not see herself returning to Bosnia, given the opportunities she is being offered to develop her skills in Germany.
“I attended a seminar in Munich recently and everything was covered by the hospital,” she noted.
“We could only dream of that in BiH, where even if you are willing to pay for it yourself, you cannot get further education and develop yourself in what you do.
“I do not see myself back in BiH [Bosnia and Herzegovia] – not in the near future and not in distant future,” she concluded.