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Medical students can work as assistant physicians

Partner Institute: 
PRAXIS Center for Policy Studies, Tallinn
Survey no: 
Ain Aaviksoo
Health Policy Issues: 
HR Training/Capacities
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no yes no no no


The Ministry of Social Affairs will legalize working of medical students during their final years of studies in their field under supervision of a health professional. For years Estonian students have had the opportunity to work as assistant physicians in Finland, but not in Estonia. The opportunity will be available also for students in dentistry, midwifery and nursing in their area. The main reason is to give students an early opportunity to start professional practical training in Estonia.

Purpose of health policy or idea

The draft proposal for amendment of the Health Care Services Organization Act (HCSA) legalizes on-the-job training for all healthcare students (physicians, nurses, dental care, midwives) under the supervision of a respective qualified health worker and on the patient's consent. This opportunity would be available for medical and dental care students after four (4) years and midwives and nurses after two (2) years of studies. It is considered as an early opportunity for healthcare students to acquire skills and knowledge in the same profession they are studying. 

It is also expected that this new option will help students to make choices about their future specialty, allowing to expose themselves to different primary care and hospital settings already before residency training. Mostly it is expected that such additional staffing will become most popular in summer, thus helping to mitigate the temporary shortage of healthcare workers during the season of vacations. Recently the argument of preventing brain drain was added into the debate. Indeed, many Estonian medical students had their first practical experience of physician's work in Finland and not in Estonia. It has been argued that increased willingness to start residency abroad and potentially stay abroad after that is exacerbated by the lack of opportunities for early practical training in Estonia.  

Main points

Main objectives

To give students of healthcare professions an early opportunity to start professional practical training in Estonia.

Type of incentives

Only legislative: formalize the opportunity for students of healthcare professions  to work under the supervision of a licensed healthcare worker.

Groups affected

Providers (hospitals, primary care practices) and professionals, medical schools & universities, patients

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Characteristics of this policy

Degree of Innovation traditional rather innovative innovative
Degree of Controversy consensual rather consensual highly controversial
Structural or Systemic Impact marginal marginal fundamental
Public Visibility very low low very high
Transferability strongly system-dependent rather system-neutral system-neutral

While medical and other healthcare students have always been around in healthcare settings (ie. as volunteers (interns without formal contract) or working as nurses), it is still seen as a novelty to formally legalize their presence in providing licensed care. For medical students this is allowed only in Finland among all EU member states. Once decided, the policy implementation is rather consensual - only health insurance has raised concerns regarding quality of care when non-accredited staff is incorporated into the formal care process. There has also been raised the issue of cost-efficiency due to potential need for extra effort to control the quality of students' work. However, the impact on the systemic level is probably low, as active students have already been participating in the care provision under the responsibility of health professionals. The policy is targeting the fact that students who work in their field of specialisation (but not as a nurse if being a medical student) have usually not been paid for their work and therefore their participation has been either informal or mildly illegal. After implementation of the policy, medical students who work as assistant physicians will be paid, but they will not be covered with the health professionals' wage agreement between trade unions and the Hospital Association. It is not expected to raise wide public attention, for the change does not change anything for patients - they still have the right to refuse a student providing care to them. Also it expected that there will be no public debate over quality of care for this is of nobody's interest within the current policy framework. The policy is easily transferable once the general framework of governance and quality management is in place - practical training for healthcare students is everywhere a standard practice, even if it is not implemented through dedicated medical training positions.

Political and economic background

The Estonian healthcare system is facing a shortage of healthcare workers. The potential shortage of healthcare workers is also mentioned in the National Health Strategy 2009-2020. Even more - adequacy of healthcare workers has been defined as one of the key performance indicators. By 2020 it is planned that the number of physicians will remain 320 for 100 000 population (this ratio assumes a constant or slightly increasing number of physician training) and the number of nurses will increase to 900 per 100 000 population (currently 656).

However, the only specific "measure" to achieve these targets at the government level is defined in the strategy as "the government must safeguard the optimal number of healthcare workers".

At the provider level the strategy mandates providers to "monitor job satisfaction and increase it through motivation mechanisms" as well as "improve cooperation with educational institutions to improve planning, training and recruitment of healthcare workers".

Thus, there are effectively relatively little proactive measures implemented to deal with the looming crisis of healthcare workers, except for salary. Normally the Ministry of Social Affairs is planning annual intake into vocational medical high schools and medical faculty in the university. These numbers are negotiated with the respective professional organisations and training institutions, but also with the Ministry of Education, which has to finance the training programs.

When Estonia joined the EU in 2004, there was a fear that many doctors would leave the country due to 4 times lower salaries as compared to developed EU member states including neighbouring Finland. After 2002 the salary of both doctors and nurses has increased 2,5-2,8 times in nominal value, while national average increased twofold. Thus the income reached 2 national averages for doctors and the national average for nurses. It is important to note that this increase was possible due to additional revenues available in the health insurance system during the economic growth (Estonian Health Insurance Fund, 2009).

Characteristics of physicians' workforce trends in Estonia 2004-2009
Medical doctors by year 2004 2005 2006 2007 2008 2009
Total registered MD's 5012   5202 5334  5418 5524  5636 

Practicing registered MD's

 4335 4306  4415  4504  4444   

Not practicing MD's  (%)

 677 (15.6)  896 (20.8)  919 (20.8)  914 (20.3)  1080 (24.3)  
Certificates issued to work in another EU country 
(% among practicing MDs)
 283 (6.5) 79 (1.8)  87 (2.0)  75 (1.7)  79 (1.8)  106 

 Source: Health Care Board; National Institute for Health Development

Characteristics of nurses' workforce trends in Estonia 2004-2009
Nurses by year 2004 2005 2006 2007 2008 2009
Total registered nurses 9365 9772 10264 10541 10776 11027

Practicing registered nurses

8420 8530 8556 8603 8297  

Not practicing nurses (%)

945 (11.2) 1242 (14.6) 1708 (20.0) 1938 (22.5) 2497 (30.2)  
Certificates issued to work in another EU country 
(% among practicing nurses)
118 (1.4) 89 
67 *(0.8) 100 (1.2) 97 

Source: Estonian Health Care Board; National Institute for Health Development

This rise in income may have prevented massive brain drain in the health sector. Currently 8.3% of physicians and 4.4% of nurses are probably working abroad for they had no taxable income and were not retired in Estonia. However, as the recent economic crisis reduced salaries of health professionals by more than 10% and coming years do not foresee a growth in healthcare financing, retention of health care workforce is climbing up again in the agenda of health policy making.

Estonian 5th and 6th year medical students have already been practicing for years as assistant physicians during their summer break in Finland with extremely positive feedback by students. This has been their main argument for demanding the same principle to be implemented in Estonia, too. Recently there is increasing willingness by medical graduates to start their postgraduate specialisation outside of Estonia. It is also important to mention that medical students have been very active and successful in taking the issue to serious consideration of both coalition and opposition parties in the parliament.

Given the above described circumstances, the policymakers, including the ruling party, are ready to take non-costly actions to send positive signals to the healthcare labour market. The Minister of Social Affairs expects the law to be passed before general elections in March 2011. The move is also welcomed by providers, especially in rural areas, where the shortage of physicians and difficulties in attracting postgraduate trainees is already limiting their ability to provide services. While this policy cannot compensate for the shortage of medical professionals during study period, it is expected to relieve the temporary tensions during the vacation session in summer, but also to market different post-graduate training opportunities to the students. 

Last but not least the new policy is described as helping Estonia to comply better with the European Parliament and Council Directive 2005/36/EC on the principles of recognition of professional qualifications, which includes also healthcare professions. The explanatory note of the draft amendment act states that "the directive stresses that learning must provide an assurance that /.../ upon completion [the graduates] have adequate knowledge of clinical disciplines and practices, together with clinical experience in hospitals under appropriate supervision".

Complies with

EU regulations

Government position is that the EU directive 2005/36/EC stresses that upon completion the graduates of clinical training must have adequate clinical experience in hospitals under appropriate supervision.

Change based on an overall national health policy statement

National Health Strategy 2009-2020 has defined the adequacy of healthcare workers as one of the key performance indicators.

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no yes no no no

Origins of health policy idea

Medical students have been fighting for the opportunity to practice legally in their profession for already several years. So far in Estonia medical students have had the opportunity to work as an assistant nurse after three years of medical studies. However, 5th and 6th year medical students from Estonia are already welcomed to work as assistant physicians in Finland for several years.

Initiators of idea/main actors

  • Government: During the last two years the Ministry of Social Affairs and two consecutive ministers have been moderately responsive to the medical students' request.
  • Providers: Providers are concerned about the looming shortage of healthcare workers, especially among rural hospitals. It is expected that the new policy might slightly ease their problems but also help to market rural providers to prospective employees.
  • Payers: Estonian Health Insurance Fund showed some initial scepticism due to worries about quality and potential extra costs it has to pay. Eventually it was decided not to introduce additional payment to providers for accepting students to work.
  • Patients, Consumers: The policy is not expected to have any public repercussions as the informed consent as well as the right to refuse care to be provided by a student or medical trainee is stipulated in the law and practiced by some of the patients.

Approach of idea

The approach of the idea is described as:
renewed: Following the example of Finland and legalizing current voluntary work that students often perfom in hospitals or primary care settings. Legalization involves also a clear relationship of responsibility for the care quality.

Stakeholder positions

Initially hospital managers were sceptical and also the Estonian Health Insurance Fund had some reservation towards the idea. The former were worried about the additional cost of the supervision and extra arrangements for students needed. The latter was concerned about the legal responsibility for the services that students will be providing. However, during the last two years there have been no explicit opponents to the policy and the discussion has been about technical details, even though there will be no additional payment to the providers accepting healthcare students to work for them under supervision.

Actors and positions

Description of actors and their positions
Governmentvery supportivesupportive strongly opposed
Ministry of Social Affairsvery supportivevery supportive strongly opposed
Estonian Hospital Associationvery supportivesupportive strongly opposed
Family Practitionersvery supportivesupportive strongly opposed
Professional Organisationsvery supportivesupportive strongly opposed
Estonian Health Insurance Fundvery supportiveneutral strongly opposed
Patients, Consumers
Patient (organisations)very supportiveneutral strongly opposed

Influences in policy making and legislation

On November 2, 2011, the Minister of Social Affairs sent the draft amendment of the Health Care Services Organisation Act to the Government for further submission to the parliament. The current Minister of Social Affairs expects the amendment to be passed yet before the next general elections in March 2011.

Actors and influence

Description of actors and their influence

Governmentvery strongneutral none
Ministry of Social Affairsvery strongvery strong none
Estonian Hospital Associationvery strongstrong none
Family Practitionersvery strongweak none
Professional Organisationsvery strongstrong none
Estonian Health Insurance Fundvery strongstrong none
Patients, Consumers
Patient (organisations)very strongnone none
Ministry of Social AffairsFamily PractitionersGovernmentEstonian Hospital Association, Professional OrganisationsPatient (organisations)Estonian Health Insurance Fund

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

The new amended act will introduce only minimal changes to the current service provision processes, as new formal positions will not be created. The change only stipulates that after a certain level of professional training medical, dental, nursing and midwifery students can work under the supervision of certified medical staff. The tasks that students are allowed to perform are defined by the supervisor. So does the responsibility for the consequences and quality lie fully on the supervisor.

However, in the explanatory note to the draft the Ministry of Social Affairs refers to an agreement with the medical students during the negotiations that best practice rules or even bylaws will be develop. These would define formal requirements for supervision as well as payment principles to the students working under supervision. The current assumption is that the providers will sort this out by themselves within internal working practice of each provider.

Monitoring and evaluation

There has not been set any target how many healthcare students might be employed by the providers nor is there any formal evaluation planned for the policy.

Expected outcome

Generally it is a positive move in response to the looming shortage of the healthcare workforce in Estonia. It is also a move towards greater integration of healthcare training and practical work. Estonian 5th and 6th year medical students have been practicing in Finnish hospitals and primary care practices for several years and both sides seem to be satisfied with this option.

This allows to predict that giving now formal opportunity to practice the same way in Estonia does not necessarily pose quality threats to patients, but can lead to increased retention of healthcare workers in Estonia and integrate medical training better with providers' needs.

Yet, probably not much is to change just from this amendment in the law. There is no additional funding foreseen nor is there adequate supervision practice in place. Yet, the quality of care that students will be providing and the outcome is pending on the supervision and delegation skills of licensed medical workers. Though no formal assessment has been conducted in Estonia, there is a lot of anecdotal evidence on the poor quality of supervision in residency training.

Medical students have also described that choosing doctor's assistant summer position in Finland instead of a year-along volunteer position in Estonia is related to financial reasons partially, but in part also because of the attitude of medical staff, most notably the physicians, towards students. In Estonia young doctors-to-be have described they feel themselves as cheap labour to do the dirty work rather than potential young colleagues.

Thus, in order for the policy to be successful, the formal change in the law should be followed with a dedicated implementation strategy governed by the ministry and its agencies, but also hospitals and professional organisations in cooperation with the medical schools.

It is notable that medical students have been able to get formal recognition by the ministry of the need for formal requirements for supervision as well as payment principles to the students working under supervision. This has been stated in the explanatory note to the draft law that was sent to parliament. It is also expected that the governing politicians (notably the Minister of Social Affairs) will make this move a small part of their campaign for the general elections in March 2011. 

There is also a slight chance that the current step in allowing final year healthcare students to work in their future profession under supervision will be a beginning to a series of steps leading to new professions within the healthcare provision. In order for this to happen, the change should open the discussion to what extent current jobs in health care, which are only allowed to be performed either by a physician, dentist, nurse or a midwife can be delegated to other less-skilled but motivated healthcare workers. However, this is by far not the intended consequence of the policy under discussion in the eyes of any participating interest group.

Impact of this policy

Quality of Health Care Services marginal neutral fundamental
Level of Equity system less equitable system more equitable system more equitable
Cost Efficiency very low neutral very high

Probably not much is to change just from this amendment in the law, including the quality. Most probably the quality will not be hampered from the fact that students have more chance to be incorporated into service provision. Yet, the quality of care that students will be providing and the outcome is pending on the supervision and delegation skills of licensed staff. If at all, then there may be a positive impact on the equity of the system. Hospital managers have expressed their hope and asked for support by the ministry that practical training takes place more often in smaller and rural hospitals thus alleviating the increasing shortage of staff. Most probably the net effect will be cost-neutral in short-term due to the lack of any changes in payment for the service provision.


Sources of Information

  1. National Health Plan 2009-2020 (, accessed on on 01.10.2020)
  2. Draft of the Amendment Act of the Health Care Services Provision Act, Ministry of Social Affairs of Estonia (2010)
  3. Proposal for a Directive of the European Parliament and of the Council on the application of patients' rights in cross-border healthcare. COD 2008/0142, The European Commission (2008)
  4. P Saar, Ministry of Social Affairs; personal communication, Nov 2010
  5. Estonian Health Insurance Fund Annual Report 2009, (
    , accessed on 01.10.2010) Estonian Health Insurance Fund (2010)
  6. State Audit Office. Haiglavõrgu jätkusuutlikkus ([Sustainability of Hospital Network] in Estonian) (2010)

Author/s and/or contributors to this survey

Ain Aaviksoo

Suggested citation for this online article

Ain Aaviksoo. "Medical students can work as assistant physicians". Health Policy Monitor, October 2010. Available at