TALLINN - When surgeon Inna Lupina was finishing her residency three years ago, she was faced with a choice: keep working in Estonia under conditions of strained budgets and shaky job security, or take up a stable hospital position in the Finnish city of Kotka at ten times the pay.
Like a number of younger Estonian doctors, she chose to continue her medical career abroad.
"The Estonian [health care] future was quite depressing," she said, noting that she doesn't believe the situation has improved enough since then to encourage her to return.
Now one of three Estonian doctors working in the municipal hospital in Kotka, Lupina is satisfied with her salary and is glad she no longer has to deal with the kinds of resource problems 's i.e., lack of technical equipment and funding 's that prevented her from doing her job properly in Estonia.
Finland, which suffers from a scarcity of doctors in its public sector, is also benefiting from the increased number of Estonian medics working in the country, an option made much easier by Estonia's accession to the EU in 2004.
"In a way it's good because we have a relative shortage of doctors in Finland, and there [has been] very good experience [with] Estonian doctors. They usually learn Finnish easily, and their level of competence is good," said Dr. Hannu Halila, director of Education and Research at the Finnish Medical Association.
Halila added that around 300 Estonian doctors have applied for the necessary permits to practice medicine in Finland, and estimates that around 100 have begun to do so.
But Finland's gain is Estonia's loss. And there is a real concern among Estonia's medical establishment that the nation's health care is losing its best and brightest.
"The outflow of doctors is quite remarkable," said Dr. Vallo Volke, a member of the board of the Estonian Medical Association. "Some amount of emigration and migrating back is good for the system. It means shared ideas and shared skills," he said, but that's not the dynamic he sees currently in play.
"The trend is that younger doctors are more eager to leave. â€¦If you leave just after graduating from university, there is a chance that you will just make a new life abroad," he said.
This isn't a phenomenon that caught anyone by surprise. In a survey undertaken by the Estonian think tank Praxis in December 2003, 20.6 percent of Estonian physicians and 44.9 percent of resident doctors in training said they had a "developed" or a "definite" plan to emigrate.
According to Estonia's Health Care Board, since EU accession 437 doctors, or about 8 percent of the roughly 5,100 doctors registered in the country, applied for and received the Certificate of Acquired Rights, the document that allows them to practice in other EU member states. There are no reliable statistics on the number of Estonian doctors who have actually emigrated, but applying for the certificate is a strong indicator of intent.
The immediate fear is that, with so many young doctors choosing to leave Estonia after their training, the nation will eventually develop a shortage.
"When we don't have enough young doctors and the old [doctors] retire, we will just have empty places in hospitals," said Ullar Kaljumae, head of Estonia's Health Care Board. He predicts that the first problems, shortages in small town and rural hospitals, will be visible in two to three years.
Volke is less concerned about the number of doctors than in the overall quality of health care in Estonia, as it's the doctors with above average skill who are more likely to emigrate.
The main problem, and the key to the solution according to Volke, is narrowing the gap between doctors' salaries in Estonia and those in the more developed EU states. It's something he believes is a real option, despite the huge differences in economies.
"The salary difference is substantial, but the position of our association is that it's not so traumatic. If Estonia wanted to, salaries could be increased to the level that would virtually stop the emigration. It's a question of choices," he said.
Because of Finland's much higher income tax (in many cases more than 50 percent of salary), and its higher cost of living, Volke believes Estonia could stem the tide of doctor emigration with a rise in the minimal gross salary to about 25,500 kroons (1,630 euros). Volke said that the current minimum salary for doctors in Estonia is around 12,600 kroons. By comparison, first year residents in Finland make 2,600 euros, according to the Finnish Medical Association.
Health Care Board's Kaljumae points out that the salary gap is already narrowing and that this is starting to alleviate the problem. "Salary has increased quite remarkably, some 45 to 50 percent during two or three years," he said.
Kaljumae attributes the dramatic fall in the number of applications for Certificates of Acquired Rights, a decrease by 50 percent from 2004 to 2005, to this rise.
But in a country that, according to figures provided by the Estonian Medical Association, spent only 5.5 percent of its GDP on health care in 2003 (as compared with 7.3 percent in Finland and 9.2 percent in Sweden), resources to make further salary increases are scarce, and problems with job security caused by hospital mergers and cutting back of services are likely to continue. Only a real change of government priority is likely to change the situation.
In any case, it will take some radical improvements to encourage doctors like Inna Lupina to return to the Estonian market.
"I will think about working in Estonia if my net salary will be about 40 or 50,000 kroons, but that won't happen in the next five yearsâ€¦ so I'll stay in Finland," she said.