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Original article

How available are specialist medical doctors in Montenegro?

Lidija Šćepanović, Goran Kecojević, Milan Mirković
  • Institute of Public Health of Montenegro, Podgorica, Montenegro

ABSTRACT

Introduction: Health workers, especially highly skilled and trained staff, with their knowledge, experience, and skills, should enable the implementation of health policy, with the aim of preserving and improving the health of the population. The aim of this study was to determine the availability of medical doctors and specialist medical doctors in Montenegro, by type of specialization, i.e., to determine their age and gender structure, as compared to other countries in the European Region (ER).

Materials and methods: Medical doctors (specialists, residents, and medical doctors without specialist training) represented the unit of observation in this study. In addition to the application of descriptive methods (absolute and relative numbers), indices of change in the number of doctors for the period between 2009 and 2021, indices of change in the age structure of doctors for the period between 2008 and 2021, indices of change in the prevalence of specialist doctors aged above 55 years (55+), by specialty, were calculated, as well as the density of different specialists per 100,000 population. Data related to the public sector, collected and published by the Institute of Public Health of Montenegro, were used.

Results: The total number of doctors (specialists, residents, and medical doctors without specialist training) in Montenegro, in 2021, in the public sector, was by a third higher than in 2009, while the number of specialists increased by a quarter. The increase in the number of specialist medical personnel was significantly higher in hospitals, as compared to outpatient facilities (increase in the number of specialist doctors by 46% and residents by 41%, compared to 23% and 5% in outpatient facilities). In 2021, the highest percentage of specialist staff was in the age group of 55 years and above (about 34%).

Conclusion: The aforementioned statistical series of data, related to specialist doctors, residents, and medical doctors without specialist training, in outpatient and inpatient health care, indicate a significant shortage of these doctors in Montenegro, as compared to most countries in the European Region, as well as an inadequate age structure, especially for certain specialties where careful human resources planning should be applied. Better and more efficient management of human resources should provide for young doctors to begin with specialist training sooner.


INTRODUCTION

The performance of the healthcare system largely depends on its most important resource – human resources, their knowledge, skills and motivation [1],[2]. Health workers, especially highly skilled and trained staff, should enable the implementation of health policy with their knowledge, experience and skills, all with the aim of preserving and improving the health of the population. On the road to universal health accessibility, human resources must be not only available in numbers, but also adequately distributed and competent, and they must also have adequate support [3].

This road is paved with numerous challenges, due to the ageing of the population, the poor geographical availability of health staff (medical deserts), and the increased demand for healthcare services. All European countries are facing a crisis regarding human resources. After the crisis caused by the COVID-19 pandemic, existing problems have become even more visible and complex. The lack of employed workforce is still present, and healthcare workers are leaving the healthcare system due to the burden of inadequate working conditions: burnout, overwork, poor interpersonal relations, and other [4].

Small countries, including Montenegro, face numerous challenges in securing the competence and necessary skills of human resources [5]. In the past decades, human resources have developed unevenly in Montenegro. The great differences occurring between regions are the result of inadequate planning of the number and structure of personnel in the past, when more was invested in the direction of faster development of specialist activities at the secondary and tertiary levels [6]. In the new millennium, reform activities emphasized the importance and role of specialist staff at the primary level of health care, which resulted in a greater number of specialist doctors at this level of health care.

The aim of this study was to determine the availability of doctors and medical specialists in Montenegro by type of specialization, i.e., to determine their age and gender structure, as compared to other countries in the European Region (ER), which offer their population a high standard in meeting the needs for specialist health care.

MATERIALS AND METHODS

Medical specialists, residents, and medical doctors without specialist training represented the unit of observation in this descriptive study, for which categories, using descriptive methods (absolute and relative numbers), indices of change in the number of doctors for the period between 2009 and 2021, indices of change in the age structure of doctors for the period between 2008 and 2021, indices of change in the prevalence of specialist doctors aged above 55 years (55+), by specialty, were calculated, as well as the density of different specialists per 100,000 population.

Based on the available series of data regarding the trends in the number of doctors, trend lines were obtained showing the average trend for the period between 2009 and 2021. The availability of medical doctors – specialists/residents (excluding specialists/residents specializing in surgery, gynecology and obstetrics, pediatrics, psychiatry, and general medicine) per 100,000 population, is an indicator that includes the following groups of specialties/subspecialties: internal medicine (including subspecialties of internal medicine), oncology, pneumo-phthisiology, neurology, otorhinolaryngology, radiology, infectology, dermatology, microbiology, biochemistry, clinical immunology, pathology, and occupational medicine. The availability of medical doctors, specialists/residents specializing in surgical branches of medicine per 100,000 population consists of the following groups of specialties: general surgery (with subspecialities of general surgery), neurosurgery, plastic surgery, orthopedic surgery, ophthalmology, urology, maxillofacial surgery, emergency medicine, and anesthesia. The density of medical doctors – specialists/residents specializing in pediatrics and the density of medical doctors – specialists/residents specializing in gynecology and obstetrics per 100,000 population are presented in this study.

Data from international databases such as: OECD Health Statistics 2020, Eurostat Database, World Health Organization (WHO) database, were used for obtaining comparative indicators for the countries of the European Region and beyond. The demographic determinants used were gender (male/female) and age (age groups: 34 years and younger, 35 – 44 years, 45 – 54 years, 55 years and above). Data on human resources, collected and published by the Institute of Public Health of Montenegro, were used in the preparation of this study, namely the total number of doctors in the public sector, which included doctors in outpatient facilities and hospitals. Population data published by the Statistical Office of Montenegro MONSTAT were used to calculate the rates.

RESULTS

In 2021, there was a total of 1,736 doctors in the public sector, which, compared to 2009, is an increase by 429 doctors, or 32.77%. Compared to 2009, the number of specialist doctors increased from 939 to 1,118, i.e., by 246 or 26.20%, while the number of residents increased from 263 to 363, or by 26.20%. The number of medical doctors without specialist training increased from 107 to 184, or by 71.96%.

In outpatient facilities, there is an increase in the number of all three categories of doctors in the period between 2009 and 2021, and the largest increase was in the number of doctors without specialist training (71%), followed by residents (23%), while the number of specialists increased by about 5%.

Table 1. Prevalence (number and %) of medical doctors, by category, in Montenegro, in the period between 2009 and 2021*

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In hospitals, the number of specialists, in the period between 2009 and 2021, increased by 243, i.e., by 46%, while the number of residents increased by 68, i.e., 41%, in this period. The number of doctors without specialist training in hospitals was negligible during the entire period.

Table 2 provides comparative data on the number and ratio of doctors (without specialist training/specialists/residents) in outpatient facilities and hospitals in Montenegro, in the period between 2009 and 2021.

Table 2. Prevalence (number and %) of medical doctors without specialist training, residents, and specialists, in outpatient facilities and hospitals, in Montenegro, in the period between 2009 and 2021*

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The prevalence of the defined categories of doctors (doctors without specialist training/residents /specialists), by observed years, is presented in Graphs 1. a, 1. b, and 1. c.

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Figure 1a. Prevalence (%) of specialist medical doctors in outpatient facilities and hospitals, in Montenegro, in the period between 2009 and 2021*

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Figure 1b. Prevalence (%) of residents in outpatient facilities and hospitals, in Montenegro, in the period between 2009 and 2021*

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Figure 1c. Prevalence (%) of medical doctors without specialist training in outpatient facilities and hospitals, in Montenegro, in the period between 2009 and 2021*

Observing the prevalence (expressed in percentages, Table 3) of doctors (specialists/residents/doctors without specialist training), by age groups, in 2008 and 2021, it can be concluded that, in 2008, specialist medical doctors were predominantly concentrated in the 45 – 54 years age group (47%), while in 2021, specialist medical doctors were, in the highest percentage, placed in the 55 years and above age group (about 34%), followed immediately by the 35 – 44 years age group (32%). In 2008, the majority of residents were in the 34 and younger age group (73%), while in 2021, this percentage was 57%. In 2008, the majority of medical doctors without specialist training were in the 34 years and younger age group (58%), while in 2021, there were more doctors without specialist training in the 35 – 44 years age group (41%). In 2008, almost 20% of doctors were still without specialist training, while in 2021, this percentage was 23%.

Table 3. Prevalence (%) of medical doctors without specialist training, residents, and specialists, in Montenegro, in years 2008 and 2021

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Out of the total number of doctors, the number of doctors in the 35 – 54 years age group in 2021 was by 6.63% lower than in 2008, while the number of doctors above the age of 55 years increased by 12.13%, as compared to 2008. The prevalence of doctors in Montenegro, in 2008 and 2021, by age group, is shown in Graph 2.

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Figure 2. Prevalence (%) of doctors, by age groups, in Montenegro, in years 2008 and 2021

Of 1,185 specialists, who were involved in the health care of the population of Montenegro, in outpatient facilities and hospitals (public sector), in 2021, 407 of them, or 34.35%, were 55 years old or above (Table 4). More than 50% of the employed medical staff above the age of 55 were medical doctors specializing in following medical fields: pneumo-phthisiology (71%), neuropsychiatry (82%), physical medicine (50%), transfusiology (56%), sports medicine (75%), occupational medicine (75%), general medicine (60%), as well as plastic and reconstructive surgery (60%). In 2021, the highest number of specialist doctors were pediatricians (148 doctors).

Table 4. Prevalence (number and %) of specialist medical doctors, aged 55 years and above, in Montenegro, in 2021

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The density of specialist doctors per 100,000 population was estimated based on the distribution of the number of specialist medical doctors in the period between 2009 and 2021 and the estimated population of Montenegro (Graph 3). Compared to 2009, when the density was 152 doctors per 100,000 population, in 2021, this indicator reached the value of 191 doctors per 100,000 population.

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Figure 3. Distribution (number) of specialist medical doctors per 100,000 population, in Montenegro, in the period between 2009 and 2021

In Montenegro, the availability of medical doctors – specialists/residents (excluding specialists/residents specializing in surgery, gynecology and obstetrics, pediatrics, psychiatry, and general medicine), in 2020, per 100,000 population, was 109, while in Greece it was 138 (2019), in Slovenia 111, and in Serbia 78 (Graph 4). The average availability per 100,000 population in the European Region, according to the latest available data (WHO, 2014), is 90.

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Figure 4. Availability of medical doctors – specialists/residents (excluding specialists/residents specializing in surgery, gynecology and obstetrics, pediatrics, psychiatry, and general medicine), per 100,000 population, in Montenegro and in other European countries, in 2020 (or latest available data)

The density of medical doctors – specialists/residents specializing in surgical branches per 100,000 population, in Montenegro, in 2020, was 57, in Greece it was 49 (2019), it was 73 in Slovenia, in the same period, while in Serbia it was 54 (Graph 5). In the European Region, the average, according to the latest available data (WHO, 2014), was 70.

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Figure 5. Availability of medical doctors – specialists/residents specializing in surgical branches per 100,000 population, in Montenegro and in other European countries, in 2020 (or latest available data)

DISCUSSION

This study analyzed specialist medical staff between two major crises, namely the economic crisis, which affected the European region in 2008, and the crisis caused by the COVID-19 pandemic in 2020 and continuing into 2021. In the period of the crisis caused by the COVID-19 pandemic in 2020, a large number of countries recorded a temporary increase in human resources numbers, which occurred as the result of response to the crisis [3],[4]. Taking into account the objective circumstances and the complex influence of socio-political and economic factors, which affected the country’s ability to strengthen and develop the health system in the aforementioned circumstances, the fact that human resources potential in Montenegro has been strengthened is quite a success. The total number of doctors (specialists/residents/medical doctors without specialist training) increased by about a third, while the number of specialists increased by a quarter, in the observed period. Nevertheless, in 2021, a significantly larger number of doctors found themselves lacking specialist training, which should be interpreted, not only in the context of the aforementioned impact of external factors, but also from the aspect of human resources management. This particularly affected younger health professionals in outpatient facilities, who waited longer to be enrolled in specialist training than was the case in 2009.

In contrast, in hospitals, there was a significant increase in the number of doctors who were enrolled in specialist training (by two thirds), which was reflected in the greater number of specialist medical doctors in hospitals. This indicates that the management of human resources, although in circumstances of lesser availability of specialists, as compared to other European countries, was more focused on strengthening inpatient potential as opposed to the potential of outpatient health facilities. Although Montenegro does not currently have a strategic framework directing the development of the healthcare system or the development of human resources (since earlier documents referred to the period until 2020 or 2022), it should be noted that earlier frameworks directed the system towards the primary health care level [6],[7] as the backbone of the health system. The draft of the Health Development Strategy, which is available on the website of the Ministry of Health, and which covers the period between 2023 and 2027 [8], states that decision-makers will stay on the course of reform commitments from 2005, which recognize primary health care as a “priority area in the development of the health system, and within it also the promotion of healthy lifestyles and preventive health care”. This strategic document (draft) recognized, in the part of the strategic goals related to human resources, the need to increase the number of specialists in the field of occupational medicine.

In Montenegro, specialist medical personnel are relatively old, since in 2021, the majority of specialists (one third) are above the age of 55 years. A large number of European Union (EU) countries are facing the problem of very old medical staff. In Italy, as many as 60% of all doctors are older than 55 years [9]. Nevertheless, it is evident that the orientation towards strengthening hospital personnel resources in Montenegro in the previous period has yielded positive results in terms of staff recruitment, whereby the number of doctors aged 35 – 44 years has increased, making up almost a third of the specialist staff. Among the youngest doctors, the ratio of those enrolled in specialist training decreased, so the number of residents was higher in the older age group. The number of doctors without specialist training in the 55 years and above age group slightly increased. Better and more efficient management of human resources should enable earlier enrolment of young doctors in specialist training. Management is crucial, not only for strengthening the workforce, but also for maintaining the competencies necessary to provide health services [10].

In the total number of doctors, it can be seen that the number of doctors in the 55 years and above age group is growing faster than the number of the youngest doctors entering the system. This kind of human resources management, particularly doctors, will not improve the availability of doctors in the long term, rather it can drive the system into an even more unfavorable situation. This will certainly depend on the effect of a large number of other external factors (migration, strengthening of the private sector, etc.).

This study has identified areas where the future functioning and provision of services are particularly threatened, due to the high ratio of older staff. These areas included the following specialties: pneumophthisiology, neuropsychiatry, physical medicine, transfusiology, sports medicine, occupational medicine, general medicine, as well as plastic and reconstructive surgery.

As compared to other countries in the region and in Europe, the availability of medical doctors – specialists/residents (excluding specialists/residents specializing in surgery, gynecology and obstetrics, pediatrics, psychiatry, and general medicine) per 100,000 population, in Montenegro, was close to the availability of this personnel in Slovenia, and was better than in other small countries, such as Malta or Iceland [11]. However, the density of medical doctors – specialists/residents specializing in surgical branches per 100,000 population, in Montenegro, in 2020, was among the lowest in Europe, and was significantly below the standard applied in European Union countries [11]. The situation is better if the availability of medical doctors – specialists/ residents specializing in pediatrics and the availability of medical doctors - specialists/residents specializing in gynecology and obstetrics per 100,000 population, is compared between Montenegro and other European countries.

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Figure 6. Availability of medical doctors – specialists/residents specializing in pediatrics per 100,000 population, in Montenegro and in other European countries, in 2020 (or latest available data)

Since, according to WHO data, the ratio of women in the total labor force has increased in the European Region, it is important to analyze the data related to the gender structure of the staff separately, so that the health system may recognize the contribution of women, as well as the inequalities that exist in the world [12], where “men lead and women provide global health services” [13]. The trend of feminization of medicine in Montenegro has long been recognized. As is the case in many countries of the European Region and in the surrounding area, there is a tendency to increase the proportion of women among the specialist medical staff, and this is especially characteristic of former Yugoslav countries.

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Figure 7. Availability of medical doctors – specialists/residents specializing in gynecology and obstetrics per 100,000 population, in Montenegro and in other European countries, in 2020 (or latest available data)

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Figure 8. Ratio of doctors in relation to gender, in 2020 (%), in the European Union and in the region (estimate/latest available data)

The main limitation of our study is that only data related to the public sector has been included in the analysis, since the human resources register has not yet been developed in Montenegro, and the laws and regulations have not as yet recognized the rapid development of the private sector, where a significant number of the specialist staff is employed. Furthermore, although the impact of migration on the availability of medical staff has been recognized, due to the unavailability of data, it was not possible to analyze the migration of doctors from this aspect. The issue of emigration has been unresolved for a long period of time, and by losing staff, especially highly trained specialist staff, the country loses considerable funds and time invested in educating this staff [14]. This study did not examine the availability and accessibility of specialist medical doctors, by individual regions, in Montenegro, but only at the national level, since Montenegro is one of the countries with a small population. Such future research would provide a more detailed account of the availability of medical specialists. Comparability of data is one limitation, as some countries report licensed health workers regardless of where they are employed or if they are unemployed, and other countries only report health workers who are actively working in the health sector.

CONCLUSION

The presented statistical time series of data regarding human resources, both for Montenegro as a whole, and especially for outpatient and inpatient health care, allow us to see the state, structure and dynamics of their changes in the specified period. In the coming years, new data will enable comparability of human resources of various profiles in Montenegro with other European countries, according to workload rates. The aforementioned statistical series of data related to specialists, doctors without specialist training, and residents, in outpatient and hospital health care, indicate a significant shortage of human resources – doctors in Montenegro, as compared to most countries of the European Union or the European Region, as well as the inadequate age structure, especially for certain specialties, where personnel should be carefully planned, in order to improve their availability in the future.

  • Conflict of interest:
    None declared.

Informations

Volume 4 No 4

December 2023

Pages 375-388
  • Keywords:
    human resources, health care, specialist medical doctors
  • Received:
    31 October 2023
  • Revised:
    07 December 2023
  • Accepted:
    14 December 2023
  • Online first:
    25 December 2023
  • DOI:
  • Cite this article:
    Šćepanović L, Kecojević G, Mirković M. How available are specialist medical doctors in Montenegro?. Serbian Journal of the Medical Chamber. 2023;4(4):373-86. doi: 10.5937/smclk4-47454
Corresponding author

Lidija Šćepanović
Institute of Public Health of Montenegro
bb Džona Džeksona Street, 81000 Podgorica, Montenegro
E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.



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1. World Health Organization. Health Systems: Improving Performance: The World Health Report 2000. Geneva: World Health Organization; 2000. [Internet]. Dostupno na: http://apps.who.int/iris/bitstream/10665/42281/1/WHR_2000.pdf. [HTTP]

2. World Health Organization. Global Strategy on Human Resources for Health: Workforce 2030. Geneva: World Health Organization; 2016. [Internet]. Dostupno na: https://www.who.int/hrh/news/2016/resolution%E2%80%90en.pdf

3. World Health Organization. Regional Office for Europe. (“2022)”. Health and care workforce in Europe: time to act. World Health Organization. Regional Office for Europe. [Internet]. Dostupno na: https://iris.who.int/handle/10665/362379.

4. European Observatory on Health System and Policies, Enhancing the labour market for health and care workers, Public Debate on the Future Health Priorities of the European Union, Press briefing transcript, 25 September 2023. [Internet]. Dostupno na: https://eurohealthobservatory.who.int/publications/m/enhancing-the-labour-market-for-health-and-care-workers [HTTP]

5. Small countries initiative: micro case studies on human resources for health. Copenhagen: WHO Regional Office for Europe; 2020. [Internet]. Dostupno na: https://apps.who.int/iris/handle/10665/336233 [HTTP]

6. Ministarstvo zdravlja Crne Gore, Master plan razvoja zdravstva Crne Gore u periodu 2015-2020. [Internet]. Dostupno na: https://www.gov.me/dokumenta/fde2ae2d-2a46-44e2-bf7c-06fdf35f4998 [HTTP]

7. Ministarstvo zdravlja Crne Gore, Strategija razvija zdravstva, 2003. [Internet]. Dostupno na: https://wapi.gov.me/download/e0fc8942-725f-41be8d13-e850a8611176?version=1.0

8. Ministarstvo zdravlja Crne Gore, STRATEGIJA RAZVOJA ZDRAVSTVA ZA PERIOD OD 2023-2027. GODINE SA AKCIONIM PLANOM ZA PERIOD 2023-2024. GODINU (nacrt). [Internet]. Dostupno na: Strategija razvoja zdravstva (www.gov.me) [HTTP]

9. Journal of the European Observatory on Health Systems and Policies, Eurohealth: Health systems in crisis: Countering shockwaves and fatigue. [Internet]. Dostupno na: https://iris.who.int/bitstream/handle/10665/372883/Eurohealth-29-1-2023-eng.pdf?sequence=1 [HTTP]

10. Barbazza E, Langins M, Kluge H, Tello J. Health workforce governance: Processes, tools and actors towards a competent workforce for integrated health services delivery. Health Policy. 2015 Dec;119(12):1645-54. doi: 10.1016/j. healthpol.2015.09.009. [CROSSREF]

11. Eurostat, Health in the European Union – facts and figures, Healthcare personnel statistics – physicians, Table 1: Physicians, by speciality, 2021. [Internet]. Dostupno na: https://ec.europa.eu/eurostat [HTTP]

12. World Health Organization, International Labour Organization. The gender pay gap in the health and care sector: a global analysis in the time of COVID-19. Geneva: World Health Organization; 2022. [Internet]. Dostupno na: (https://apps.who.int/iris/handle/10665/358057). [HTTP]

13. World Health Organization. (“2019)”. Delivered by women, led by men: a gender and equity analysis of the global health and social workforce. World Health Organization. [Internet]. Dostupno na: https://iris.who.int/handle/10665/311322 [HTTP]

14. Wismar M, Williams G, Zapata T, Azzopardi-Muscat N. The European health workforce: Building a true labour market for health workers. 2022. [Internet]. Dostupno na: https://www.researchgate.net/publication/366272230_The_European_health_workforce_Building_a_true_labour_market_ for_health_workers [HTTP]


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