Brain drain: Will the last doctor leaving Kosovo turn off the lights?

BIRN reveals the alarming consequences of migration to the Kosovo health system, which has become even worse by the private industry that is receiving medical export staff to Germany.

Ahmetjekaj Gorance, Pristina, Nuremberg, Munich, Ivankovo and Zagreb BIRN

He once gave up. His long, long work trips convinced him to make the unwanted decision.

Blerim Berisha was a cardiologist at the University Clinical Centre in Kosovo, the capital, Pristina, where he worked day after day examining electrocardiograms and ultrasound.

After an eight-hour shift, he boarded a barren car and traveled 60 miles [60 km] along M9 to the town of Kline, west of Pristina, where he lived with his wife, daughter, and son.

In fact, it is not as if he could see them often. This was because the only way to cover the expenses of life and specialism was to work in night shifts at the Dubrava prison 20 miles [30 km] away. Then he would go home just to eat and rest a bit and again to Pristina to start over again.

Sometimes I felt like I could never get enough sleep,” he remembers. “E A lot less time spent with my family. ”

These days, Berisha, 42, goes to work by car along the semi - wooded road in the picturesque town of Pegnitz, near the German town of Nuremberg, where he works as a cardiologist at the main hospital in the area.

He earns ten times as much as in Kosovo and spends weekends visiting historic settlements with his wife and children.

Five years after taking the stethoscope and moving to Germany, Berisha has not regretted it.

The decision to come here was very difficult, but I had no choice,” he said, as he waited for me for an interview at his home in Nuremberg.

While long hours of work and daily travel have worked hard, the diagnosis he made to Kosovo's health system is what eventually changed his mind.

“Corruption, lack of perspective and nepotism in public institutions are killing the country's future,”, he said.

Berisha is one of hundreds of Kosovo doctors who have exchanged low wages and high stress for better living abroad. Most go to Germany, a country that recognises Kosovo medical diplomas.

As migration routes become easier for Kosovo doctors, nurses and other health workers, BIRN discovered vast proportions of brain drain in Europe's newest state.

In a country that has one of the lowest doctors' densities on the continent per capita, one doctor migrates every two days as two nurses leave every day, based on the medical Oda's data and the Infermiencies.

Emigration comes at a cost: medical centres are gradually being emptied by staff, patients are facing lack of primary care while public schooling is going bankrupt. And then there's the cost for taxpayers since it's estimated that another doctor's education costs about 100,000 euros.

“The storm is coming,” says Africa Blyta, a neuropsytry professor at the Faculty of Medicine at Pristina University.

I can say that 95 percent of students are learning German and aiming to go to Germany. Soon Kosovo will face an acute lack of medical staff. ”

Health experts blame the system in general as the main cause, given low wages and lack of employment prospects in Kosovo, add to the extraordinary demand for medical staff in Germany, the country that is Europe's largest economy but is facing population aging.

But a less-known phenomenon is also fuelling evacuation -- a thriving private industry whose sole purpose is to attract willing health workers to be sent to Germany.

From private colleges to numerous companies recruiting to receiving fake German-language certificates, B. The IERN sheds light on this generally unregulated export market of health workers.

Critics say the consequences of this will be to empty the country, as well as promote the amount against quality, which will have serious consequences for the public health sector.

Blerim Syla, head of the Health Workers Union, is concerned about the consequences of the escape of the medical brain. Photo: Ahmetjekaj Shkumbin

Doctors Without Borders

Brian Syla, head of the Health Workers Union, is worried about the effects of medical branding. Photo: Ahmetjekaj Shkumbin

In Gorance, a village nestled in the hills of southern Kosovo, the natives have been accustomed to doctors fleeing to Germany. The last one left many months ago, and residents say they have little hope of a quick replacement.

In the medical center, nurse Sevime Shkretta does what she can to care for the sick. She is an assistant to a thermometer and to tie bandages around minor wounds. But she often needs to send patients to the Hani Elez health center.

This is not an option for the family of 65-year-old Arife Berisha. She suffers from hypertension as her husband has problems with her mother - in - law.

“We are not able to travel to Han Elez because we don't have a car and my children are unemployed,” she said, while nurse Shkretta measured the tension.

Throughout the country of 1.8 million people, some once noisy health centers have become ghost offices. Regional hospitals in the western cities of Peja and Gjakova were also forced to close units.

Throughout the country, 4,100 doctors exercise this profession, according to the Council of Doctors, this means that the country has 2.3 doctors per thousand inhabitants, one of the lowest rates among the 47 countries making up the Council of Europe (Kosovo is still not a member of this organisation).

The only countries that have the worst ratio are Albania (1.2), Turkey (1.8) and Bosnia and Herzegovina (2.0), according to World Health Organisation data. In contrast, Germany has 4.2 doctors per thousand, while Sweden has 5.4.

Pleasat Sejdiu, head of the Kosovo Medical Association, says the country needs at least 5 thousand doctors to meet the standards recommended by the World Health Organisation. This means that there is a need for 900 doctors other than the existing ones.

But statistics show alarming levels. As the country educates 150 doctors annually, at least 180 doctors leave, Sejdiu explained.

Their “Most of them plan to leave Kosovo, despite the fact that they will have to pass through additional training and practices in the host country,” said Sejdiu.

Over the past year, he received 176 requests from doctors for certificates on ethical and professional pasts, which are legally required to take jobs abroad.

Susan Manjuka Krliu, dean of the Faculty of Medicine at Pristina University, is also bombarded by demands for certificates by senior and current students seeking to emigrate.

The negative side is that our mental power is leaving,” she said. “on the positive side, what we're offering in the market is being positively assessed, but for us this is bad because we're going to face shortages. ”

She added that almost all medical students at Pristina University are attending private courses to learn German in preparation for migration.

You can't ask someone to stay alone for patriotism,” she said. “Not unless we offer good work and study conditions. ”

You can't ask someone to stay alone for patriotism. Not unless we offer good work and study conditions.

• Susan Manjuka Kerliu, dean of Pristina University Medical Faculty

The irony is that despite the deficit in doctors, many medical graduates are failing to employ in Kosovo.

Oda Chamber of Doctors says Kosovo has produced 440 qualified doctors who have not found jobs at least not at home.

Experts blame a nepotism culture in a country that spends only 220m euros a year in health care, according to the Health Ministry. This amounts to 122 euros per person, compared to the 5,000 euros spent in Germany.

“If you don't have recognition, it's hard to find a job or a place in specialisation programmes,” says Blerim Syla, chairman of the Federation of Health Unions in Kosovo.

But even those who have business contracts are two-minded.

A recent research by Oda's doctors found that the main reason why medical staff target migration are poor working conditions, followed by lack of professional development opportunities. Only after that is the lower wage factor.

Flamur Labyan, 34, is a typical dissatisfied person. Graduated for five years, he is close to completing specialisation in gastroenterology at the University Clinical Centre in Kosovo, in Pristina, where he works every day, traveling from the city of Ferizaj, 40km south.

Dr. Flager Labjan, besides Germany, has other job opportunities in Europe. But within a few weeks, he will be subject to the national test in Germany. Photo: Ahmetjekaj Shkumbin

Unfortunately, the most experienced doctors who are supposed to teach us and give us the knowledge they have, are not doing so, with any exception to” he said.

Lobjan fears that it will complete specialisation without learning how to conduct basic diagnostic procedures, such as gastroscope and coloscopine. He expects to have additional commitments in Germany under specialisation.

“I was classed against leaving,” he said. I can see now that even my closest friends who begged me not to do it are thinking of leaving. ”

Nurse students at the University for Business and Technology in Pristina, attending a speech. Many of them want to leave for Germany. Photo: Ahmetjekaj Shkumbin

Business prospers

Germany needs about 7,000 doctors and nurses more than 500 grand currently in place, Germany's health ministry says.

About a tenth of the labour force comes from abroad, attracted to a country that spends more on public health than any other country in Europe - 351.7 billion euros in 2016, according to the European statistical agency Eurostat.

Only a very small portion of foreign doctors in Germany are from Kosovo. German Medical Oda measures 292 to December 31st 2018, though the Kosovo Medical Oda says there are more than 450.

As small as these figures appear compared to Germany's population of 84 million, they are still a significant part of the health workforce in Kosovo.

And experts say Kosovo's dismissal gates are opening especially with regard to nurses.

It is impossible to educate more than 40,000 students properly. I see them walking around in hospital halls every day, but they don't get the necessary practice.

• Plerata Sejdiu, head of the Kosovo Medical Chamber.

Kosovo has about 27,000 certified nurses, according to the Nurses' Chamber, though only 21,000 are employed in the country. The chances are that many of them may be working in Germany. And many others are on their way.

In 2016, Kosovo allowed private colleges to start educating nurses and mothers in large measure. Six currently function along with two public universities offering medical studies.

While private colleges can accept students without limits, public universities have a 50-year limit for each of the institutions, the ceiling set by the Kosovo Agency for Accreditation (AKA), which oversees higher education standards.

The entrance of private colleges to the stage has brought an explosion of nursing. Almost immediately, these directions crossed the economy and law as the youngest's most popular study elections.

More than 5,700 students were active in nursing and Mom in the 2017/18 academic year, according to data from the education ministry.

The first generation of students from private colleges will graduate this year, which means thousands of nurses will be looking for jobs.

Critics say this massive wave of students in nursing raises questions about quality control (see box: A matter of standards.

“It is impossible to properly educate more than 4,000 students,” said Sejdiu from Oda of Doctors. I see them wandering day by day through clinic corridors, but they don't get the necessary practice. ”

Ecosystem Migration

It's not coincidence that an entire ecosystem was created to send health workers to the German market.

Hundreds of language course centres across Kosovo promise assistance to those aspiring to emigrate that they will pass German-language tests required for visa applications.

Many private colleges have contracts with employment agencies designed to find hospital staff in Germany.

Michael Weiss-Gehring, nurse manager at the Hassberg public hospital in the Bahvarese town of Hasfur, told BIRN in July, that German hospitals usually pay 6 thousand euros for every doctor or nurse agencies they bring.

One of the largest language centres in Kosovo is Interpersonnel in Pristina, which offers 18 months of free German-language courses and nursing practice for about 550 students a year, all with a destination Germany.

This centre only extracts money from the recruiting fees from the German institutions themselves. Savings must sign a contract in which they agree they will find work through InterPersonnel, which works with German human resource company Dekra.

Every 3 months we open competitions for 140 free countries, we accept about 3 thousand applications,” says InterPersonnel Executive Director Musa Ahmeti. “We are not contributing to emptying Kosovo but to reduce unemployment and offer nurses an opportunity for a better life. ”

For every 140 countries available, we get about 3 thousand applications. We are not contributing to empty Kosovo but to reduce unemployment and offer nurses an opportunity for a better life.

InterPersonnel Executive Director Musa Ahmeti

Smelling an opportunity, human resources agencies concentrated in Kosovo and other Balkan countries are emerging throughout Germany.

The request from hospitals is high and is growing greatly,” said Sadik Shkreli, who left Kosovo in 1991 and currently heads a recruiting company in the town of Landshut, near Munich. He estimates he brings 50-60 nurses and doctors to Germany annually from Kosovo, Albania, Northern Macedonia and Serbia.

But human resource recruits can soon find less demand for their services.

In January, Germany will ease restrictions on foreign professionals seeking employment, allowing doctors and nurses to enter with six-month visas so that they can look for work themselves.

Employees will again be required to know the language ʹa significant obstacle for those who do not have a flair for tongues. Some, though, have found a shorter, though not ethical, route.

BIRN chats with four Kosovars who say they have paid others to pass the German-language exam instead.

One was a 39-year-old nurse from the eastern part of the country who decided to go to Germany after his mother died of breast cancer. A problem with medical supplies at the hospital caused him to pay for her own medicine - a process that was almost financially bankrupt.

“Imagine what it is when you paid only 400 euros a month but you have to buy drugs that cost 5 grand,” he said. I felt abandoned. I was in the medical field myself, but I couldn't help my mother much either. ”

To apply for work visas at the embassy, the nurse needed a testimony to her ability to level B2 in German. He said he found himself agreeing with British playwright Oscar Wild, who says that “life is too short to learn German”. And for 2 thousand euros, he did not need to learn the language at that level, receiving a certificate from one of the language centres in Serbia.

Executioners on tests such as Austro-German Language Diploma (OSD) and the Goethe Institute say they are doing what they can to prevent such frauds.

Test experts like the OSD are being severely damaged by such fraud described in connection with taking a language test,” said Brigitte Mittteregger, director of the Vienna Office for OSD in an email.

Reports of fraud have also prompted the German Embassy in Pristina to limit the list of centres that accept their certificates. The embassy accepts certificates from OSD and Goethe-Zentrum in Kosovo; OSD in Northern Macedonia and Austria; and Goethe Institute and T ELC in Germany.

Michael Weiss-Gehring, nurse department manager at Hassberg Clinic in the German town of Hassfurt, I know very well how difficult it is to meet staff shortages. Photo: Ahmetjekaj Shkumbin

New Horizons

In February, Kosovo's parliament passed new law on salaries, which would almost double doctors' salaries, but this law has not yet begun to be implemented. Doctors in public hospitals currently receive between 600 and 750 euros a month.

Nurses will also receive an increase of about 50% to around 600 euros a month, up from 400 currently present.

“Baska with an improvement in working conditions, young doctors and nurses will have to think better before deciding to leave,” said Basri Sejdiu, director of the University Hospital Centre of Kosovo.

He added that the centre, which manages regional hospitals, is working to revamp specialisation programmes across the country so that jobs can be divided fairly.

The health ministry aims to increase the number of medical students at Pristina University to 250 out of 150 currently.

At the same time, Gazmend Luboten, head of the accreditation agency, said plans to restore quotas in admissions to private colleges could begin to be implemented as early as this year.

Such efforts to keep talent in the country, however, could be jeopardised by an agreement between Kosovo and Germany in July to open a regional centre to prepare and discredit nurses from Kosovo, especially for the German market.

The centre, which will be built in a still undefined country in Kosovo, will offer schooling funded by the German state, practical work experience and German language courses for those who want to work as nurses in Germany.

In return, Germany will help Kosovo empower its healthcare system, including the development of public health insurance.

Critics believe that this initiative will become a means of transportation for those seeking a single-way ticket to Germany.

Asked at a news conference whether the government was trying to promote medical migration, Health Minister Uran Ismaili said: “it is up to them to decide whether they want to return.”

Meanwhile, for Kosovo health workers, options are only increasing because other countries are opening their doors as well.

Ahmeti, the executive director of InterPersonelli, said his company is in talks with the Swiss Red Cross, which certificate nurses, “to open a new market in Switzerland”.

“Pages are extremely good and start at 8 thousand Swiss francs (7,200 euros) [in months],” he said. “But they will have to have at least three years of work experience and German level B2.”

For doctors like Blerim Berisha in Pegnitz near Nuremberg, it's not just about money.

Asked whether there is anything that could push him back to Kosovo, he thought a moment before answering.

“Respect and honesty,” he said.

Shkumbin Ahmetjekaj is an editor at Kosovo Public Television and reports on currentity and news from the world. This article was developed as part of the Balkan Stock Exchange for Economist Journalism, based on the Erste Foundation in co-operation with the Balkan Network for Investigative Journalism. The publication was done by Timothy Far away.

Box: A Standard Issue

As thousands of students target nursing as a way to move towards Germany, health experts worry about lowering standards.

Suzana Manjuka Kerliu, dean at the Faculty of Medicine at the University of Pristina, condemned a decision three years ago by the Kosovar Agency of Discension (KAA) to allow private universities to accept strict students in the infirmary every year.

“ “It's good to have competition, but we should also pay attention to the quality and strict monitoring. ”

AK head Gazmend Luboten said the decision was based on an assessment that the market's <x0 needs were higher than the offer by the Faculty of Medicine” despite the fact that hundreds of medical and nursing graduates have failed to find jobs in Kosovo.

Lul Raka, professor of microbiology at Pristina University and former AKA board member, said Kosovo has violated both the European Commission directives and the laws on higher education.

“Based on EU directives, titles such as medicine, dentist, pharmacist, nurse or physical therapist can only be given by a university or universities that are linked to scientific institutions,” he said. None of the private universities meet this condition. ”

What adds anxiety about standards are reports of short routes found by private colleges.

They don't respect the rules... There's a lot of staff with the title professor who don't have Phd,” said Manjuka-Kerliu.

Private colleagues who usually bill students for 1,000-2,000 euros a year respond by saying that Pristina University has no monopoly on quality.

Fitim Alidemaj, head of the nursing department at Business and Technology University, said his institution invests more in staff and infrastructure.

We have 102 staff only at the infirmary,” he said.

A BIRN analysis of CV staff published online finds that all public and private universities offer nursing studies with academic staff that do not have PhD in accordance with the requirements of the law. In many cases, teachers are teachers.

In their defense, the institutions of higher education cite an administrative order issued by the education ministry in 2017 that gives them a “gress period”, during which time they must provide needed postgraduate diplomas.

The AKA is supposed to monitor universities and colleges to ensure that the staff is adequate, but some experts question the ability or willingness of the AKA to do so.

In September, the European Association for Quality Guarantee at Higher Education (ENQA), a Brussels-based group representing security organisations, cancelled the AKA membership with the argument that it was not doing enough to guarantee the standards.

“There was no monitoring or tracking of recommendations made by previous reviews,” wrote EQUE in a letter to AKA, e Available Online. “Monitore is limited to formal requirements, limited to control rather than quality reinforcement. ”

Experts say the ECQA decision could make it more difficult for Kosovo students to observe diplomas.

Box: International Integrity

Experts give many reasons to explain shortages in health workers in Germany, including low natural rates, as well as the migration of local doctors and nurses, mainly towards Switzerland, Britain, the United States and Austria, where wages are higher.

Administrators trying to fill the shortages of 70 thousand health workers say employment from abroad is not easy because applicants should know German as well as have recognised and certified diplomas. At best, the process can take between 9 and 12 months.

Hospital managers say integration of foreign staff could also be a problem.

Even after employing them, it may take two years to have full integration of a new employee here,” says Michael Weiss-Gehring, a nurse manager at the Hassberg Clinic in the German town of Hasfurt, where half of all doctors are non-German.

Weiss-Gehring organises weekly, tour type meetings to help staff improve language and integrate.

“juha is the biggest problem we have, but the other thing is culture,” he said. The “people come from completely different health systems especially for nurses, because their work here is quite different. ”

He added: “Many patients believe doctors do not understand their problems. ”

Alfred Schmittt, an 82-year-old patient at the Hassberg Clinic, said he was not concerned that many of the staff are not Germans. “They understand my needs,” he said.

But an Albanian nurse working in the southern town of Munich said others were not so tolerant.

In one of the night shifts, out of 10 staff, only two were Germans,” said the nurse who refused to be identified. “You could listen to patients complaining and slandering the fact that they were being treated by foreigners. ”

A nurse cares for Alfred Schmittt at the Hassberg Clinic. It's just the second time in his life that he's been admitted to the hospital. Photo: Ahmetjekaj Shkumbin

Box: Croatia's mined medical campaign

Kosovo is not the only country in Southeast Europe facing the removal of the medical brain. Fenomen affects all countries in the region, including the newest EU member, Croatia.

Croatia's Oda of Doctors says more than 10% of the country's doctors -- about 1,700 in total -- have requested certificates needed to work abroad.

“Zaconally I say that the Croatian health system is a mined field for doctors and patients, and that the situation is deteriorating daily,” says Ljiljana Cenan, a Family Medicine doctor in the village of Ivankovo in the east of the country.

After 20 years in the village, Cenan has provided a job in Sweden. She says it will be difficult to find a substitute doctor when she leaves.

Like their colleagues in Kosovo, many Croatian doctors complain they have limited access to specialisation.

In an effort to stop the program, Croatia has decided to ask doctors in specialisation programmes to continue working at the hospital where they perform specialisation after they finish the course or pay a fine, ranging from 135,000 euros.

Ivan Bekavac, head of the International Affairs Medical Chamber Office, said that while he opposed the relationship with the new doctors' épranga in this way, the country was still facing a major problem.

He cited an example of a hospital in Slavonski Brod that declared jobs free for 32 doctors but received only seven applications.

Our new “System shows how many doctors will retire within the next few years in each region, and how many doctors according to all specialisations have the letters ready to leave the country,” he said.

Croatia has about 470 retired doctors continuing to work part-time because there are no new doctors.