KEY DETERMINANTS FOR RETENTION AND DEVELOPMENT OF MEDICAL SPECIALISTS IN BULGARIA

:Introduction: The shortage of medical specialists and the lack of motivation for work and professional de-velopment/carrier among healthcare workers due to different reasons, such as low level of salary, burnout, stress, deteriorated working conditions, etc., threaten the effective functioning of the healthcare system in Bulgaria. Human resources in the healthcare sector are a key prerequi-site for improving the health status of citizens. Aim: The article aims to outline guidelines and to indicate the gaps in the implemented policies and measures for retention and development of medical specialists in Bulgaria. Material and methods: The empirical analysis is based on an author’s survey conducted through online platform www.survey.bg in the period February-April 2022 among 344 Bulgarian healthcare professionals. The results of the survey were processed with Microsoft Ex-cel, v.16.55. Results : The insufficient remuneration, the difficulties for professional and career development like the lack of specialization opportunities, the overload, the burnout, and the stress as a result of the COVID-19 pandemic, com-plicates and causes to test the medical specialists who, despite the difficulties, prefer to live and work in the national health sector. Moreover, the aging of medical specialists in the country (60% of physicians are older than 50 years and 30% of practicing nurses are 61+) and physicians deficit in different specialties like neonatology, infectious diseases, and pediatrics significantly compli-cate the provision of healthcare services to the popula-tion. Conclusion : The study shows the attitudes of respondents regarding the Bulgarian healthcare system and points out the shortcomings related to the professional development of healthcare workers. In order to improve working conditions and increase the motivation and sat-isfaction of medical specialists, the government should urgently implement long-term policies for their retention, sustainability and development.


INTRODUCTION
The digitalization and information technologies advancement in the XXI century undoubtedly bring its outstanding advantages to the development of mankind. Telemedicine has proven to be an extremely useful tool, especially given the 2020 outbreak of the COVID-19 pandemic. Despite this undeniable fact, as per today, the medical specialists are an irreplaceable resource [1], which plays a key role in the effective functioning of the health system and help reducing health inequalities by providing access for health services to citizens.
At the beginning of 2022, an authors' survey was conducted among medical specialists in Bulgaria, in order to evaluate and examine their attitudes and opinions, which would give guidelines to decision-makers for the creation and implementation of effective policies for retention, sustainability and development of human resources in the healthcare sector.

MATERIALS AND METHODS
The survey was conducted in the period 27.02-08.04.2022 among 334 medical specialists, representatives from all medical universities in the country. The survey included 21 questions. Healthcare professionals, who completed the survey, represent various medical fields, including medicine, dental medicine, pharmacy, nurses, midwives, etc., with the largest share of medical specialists between 20 and 30 years (106 people or 31.09%), followed by specialist between 30 and 40 years of age (89 people or 26.1%).

RESULTS AND DISCUSSION
More than 70% (245 respondents) informed that they speak foreign languages, of whom 97 respondents speak three foreign languages, and 6 speak four foreign languages. Based on their opinion, language is not a barrier when they take the decision whether to work in Bulgaria or abroad. https://doi.org/10.5272/jimab.2022284.4593  Figure 1 indicates the distribution of medical specialists by specialty, with the largest share of nurses, midwives, rehabilitators, medical laboratory assistants and associated medical specialists (148 respondents). Out of 140 respondents who pointed "Medicine" as their specialty, only 42% indicated a specialty, that is with highest physician deficit in the country: • General and clinical pathology -8 respondents.
• Infectious diseases -1 respondent. The shortage of healthcare workers is deepened due to lack of clearly defined measures, as well as retention and irregular development policies of human resources in healthcare. According to 147 respondents (43%), there are no difficulties related to their future professional realization in Bulgaria. As for the rest 53%, there are various obstacles and problems to their successful professional development, among which the following stand out the most: • "They offer me monthly salary 600 BGN; my flat rent is 550 BGN." • "Bureaucratism and administrative arbitrariness. Uncertainty in the administrative system." • "Inadequate remuneration. One healthcare worker works for three." • "I did not find a place to specialize and qualify, despite an excellent results from state exams".
• "I have to work in several workplaces for better opportunities." On one hand there are difficulties associated with the professional realization of medical specialists and on the other hand a high percentage of respondents speak one or more foreign languages, but more than half of the respondents (214 specialists or 62%) do not wish to work in another country. For the rest, the preferred countries for professional development are mainly Germany and the United Kingdom.

Fig. 2. Lack of medical specialists in Bulgaria
Source: based on author's survey results Figure 2. The question "Do you think there is a shortage of medical specialists in the country?" gives the respondents the opportunity to answer on a scale from 1 to 5, where 1 means that there is no shortage, and 5 means there is a severe shortage. According to 206 respondents (64%) there is an acute and striking shortage of healthcare workers in the country, while on the other hand only 6 respondents marked that there is not yet such deficit.
Among the main problems are low wages in the sector, lack of opportunities for professional development, lack of good working conditions, ongoing ageing of healthcare workforce, concentration of medical specialists in larger cities and districts, leading to regional imbalances in healthcare services provision [2].
The remuneration in the healthcare sector is not sufficient according to 97% of the respondents. Although Bulgaria has a good supply of doctors at national level (4.2 per 1 000) in 2019 [3], according to the Bulgarian Medical Association over 60% of the physicians in the country are over 50 years of age, and the average age of doctors is over 60 years of age as of February 2022 [4]. The aging of physicians or medical specialists in general is one of the main problemñ hindering the effective functioning of healthcare systems worldwide, not only in Bulgaria. According to the Association of Americal Medical Colleges 2020 Physicians Specialty data Report 44.9% of active physicians are over 55 years of age [5].
For 2019, the total number of nurses in the country (4.4 per 1 000) is the lowest among the EU member states with an average value being approximately twice as high in the EU -8.4 per 1 000 [3]. The ageing of nurses in the healthcare system is also a fact and raises concerns about the future effective functioning of the sector -30% of the total number of nurses in the country are over 61 years of age and 31% are expected to leave the system and retire in the next 10 years. If urgent measures are not taken, according to Milka Vasileva, president of the Bulgarian Association of Healthcare Professionals, by 2032 there will be less than 10 000 nurses working in the country, with a need of 30 000 [6].
The migration of medical professionals is another key factor for the deficit of medical specialists in the country. The opinion of the health personnel themselves is similar -according to the results from the survey, nearly 90% believe that the migration of medical specialists reduces the chances of the Bulgarian healthcare system to effectively meet the health necessities and needs of the population.
Problems in the functioning of health systems worldwide have been brought to the top and deepened as a result of the COVID-19 pandemic. The pandemic has resulted in extreme stress, exhaustion, and burnout of medical professionals. The result from the survey indicates that 17% of respondents even indicated that they had considered leaving the medical profession because of the COVID-19 . The low levels of vaccination in the country, the lack of trust in the government [7] and media pressure also have their negative impact on the stress and burnout of medical professionals. If asked about the determining factors when planning to stay in Bulgaria or to leave the country and work abroad, the respondents had the opportunity to choose up to three main influencing factors for them. On the first place is adequate remuneration, marked 249 times, followed by good working conditions, marked 237 times. Third place was the standard of living, selected 190 times. Further, on fourth, fifth and sixth positions, are the effective functioning of the health system, opportunities for career development and social and/or cultural reasons, selected 134, 121 and 69 times, respectively. The following quotes stand out as suggestions form the respondents in order the shortage of medical specialists to be limited: • "Hourly regulated payment by law." • "More positive news about healthcare workers to be broadcast by media".
• "Children of medical specialists should have priority when applying for nurseries and kindergartens." • "Better distribution of healthcare workforce, as they are currently concentrated only in the big cities".

CONCLUSION
The government must undertake a targeted and sustainable policy to retain medical specialists in the country. This is the only possible solution and the right way the crisis with human resources in health care to be controlled to a certain extent and acceptable level. A reasonable and proper supply of medical specialists, not only at the national but also at the regional level, is a key prerequisite for improving the health status of the nation and limiting health poverty [8] in the country.