Viljandi County's Mulgi Municipality had no choice but to get involved in the medical business. Over the course of four years, all of its attempts to attract a family doctor failed, despite the local government's offers of covering travel expenses, settlement allowances and even a fully equipped doctor's office lacking for nothing but a doctor.

"The law also allows for a local government to manage a family medical center or practice list," Mulgi Municipal Mayor Imre Jugomäe said. "That's the route we went, because over these years we'd reached the point where, if we ourselves hadn't taken the initiative, then 3,500 people in Mulgi Municipality would have ended up without a family doctor as of July 1."

They aren't the only local government to set up shop this way in order to attract a family doctor. A similar business is already operating in Lääne-Viru County's Väike-Maarja Municipality, and another is set to begin in Jõgeva County's Palamuse Municipality this fall.

Mulgi Municipality managed to attract a doctor to Abja-Paluoja, the local government's administrative center, after meeting with the Young Family Doctors of Estonia (NOPE) in March. A few days later, a doctor got in touch with the municipality themselves.

"In short, the message we got at that meeting was that when one goes into medicine, then family medicine is the speciality with the most work obligations and lowest pay," Jugomäe said.

Until now, the state has paid doctors who agree to work in smaller towns and more remote areas a beginner's allowance, or starting bonus, of €15,000. According to the municipal mayor, one thing that came up during their discussions with the young doctors was the fact that, spread across the mandatory five-year period, that means an extra just €200 per month, which isn't remotely incentivizing. Going forward, however, young family doctors may be eligible to receive a bonus of up to €45,000.

"Under a new regulation, it will now be possible to apply for €15,000 three times," explained Maarika Liivamäe, chief specialist at the Estonian Health Insurance Fund's (EHIF) Partnership Communications Department. "Not that this amount will triple; it's needs-based and is highly dependent on where the family doctor is going to work."

In addition to increasing the starting bonus, Estonia intends to introduce a new recruitment method for doctors as well. EHIF, which took on the task this month, wants to start recruiting doctors during their first year of residency already.

"It's certainly good that this recruitment policy is being expanded," said NOPE board member Anu Parvelo. "In reality, the current situation is such that even if a family medicine resident or residency graduate wants to choose a rural area to work, they often don't end up finding one because they don't know where job offers are opening up or where there are family doctors thinking of retiring, and they end up missing out on that contact."

According to Parvelo, increasing young family doctors' starting bonuses will help, but that alone still won't be enough. She believes that family nurses should be eligible for starting bonuses as well, and that the process for taking over a practice list should be simplified.

This year, 33 applications were received for a total of 40 residency spots in family medicine. A followup competition will be held to fill the rest.

Rapla Hospital chief: Bigger bonus may not help

Speaking on Vikerraadio morning program "Vikerhommik" on Thursday, Pille Mukk, head of the Internal Medicine Clinic at North Estonia Medical Center (PERH) and director of Rapla Hospital, said that even tripling the starting bonus for young doctors may not attract enough new doctors to rural areas.

"We can't rely too much on that," Mukk said. "It's important, and it will change something — prompt someone to decide not to work in a city and enable them to work somewhere in the countryside too — but truly, if there's one doctor instead of two, you can't split [that one doctor] in half."

According to the hospital director, one mistake dates back to the mid- and late 1990s, when fewer than 100 students per year were admitted to medical school at the University of Tartu, which has since led to the current shortage.

"This created a deficit, due to which we've now found ourselves in a situation where one third of doctors are over 60 years old, and the median age of doctors is 55," she stressed.

Shortages contributing to burnout

The shortage of family doctors is the most severe, with 50 practice lists, i.e. a total of 60,000 patients, without a family doctor of their own last year, Mukk said.

But Estonia is also facing shortages of emergency doctors, psychiatrists, internists, and even oncologists. "So there are some specialties that are even worse off, but the issue is a general one," she said.

The healthcare field is struggling with a shortage of nurses as well, she added.

A shortage of doctors means that doctors working at hospitals have to make choices when treating patients, as one doctor is on average doing the work of one and a half. This means that more emergent cases are ending up at the hospital, and scheduled treatment can't be scheduled. Ultimately this situation contributes to doctor burnout and discourages them from working at hospitals in the first place.

"Then they have to choose — do they work in a hospital with an intensive workload, or part time in a more peaceful environment, although still in medicine?" Mukk said.

More money needed

Asked whether refugees from Ukraine with medical degrees could be of help to the Estonian healthcare system, the clinic and hospital director noted that preparing them to work in the Estonian healthcare system will take time.

"They couldn't start work tomorrow," she said. "The help we'll get from them nonetheless seems limited in light of the current issue."

Asked what else besides expanding training for medical personnel could be done to help the country's healthcare system, Mukk said that, broadly speaking, investments need to be made in people, including support staff and nurses on top of doctors, and contributions made to innovative solutions, including information systems, as well as support staff to help doctors work with these systems.

"Unfortunately, this, in my opinion, means the need to find additional resources, i.e. money, to direct into that," she acknowledged.

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