Important Legislation

From The Constitution of the Republic of Croatia:

Protection of Human Rights and Fundamental Freedoms
1. Common Provisions

Article 14
All persons in the Republic of Croatia shall enjoy rights and freedoms, regardless of race, colour, gender, language, religion, political or other conviction, national or social origin, property, birth, education, social status or other characteristics.
All persons shall be equal before the law. (1)

Introduction

Being a third national doctor in Croatia, an EU country, it is nearly impossible to be accepted for any position. Since Croatia’s accession in to the EU, there have been amendments to the ordinances governing third nationals in the country. I attended the full program at the University of Zagreb, Faculty of Medicine, did the one year internship, the state licensing exam in Croatian, and am now having difficulty obtaining a permanent license, as I do not have the same rights as Croatian or EU nationals despite my commitment to Croatia.

Background

In 2003, I moved to Croatia to attend the University of Zagreb, Faculty of Medicine. It was in English and originally a Harvard Medical International program that had the promise of being, “USMLE Included”. This is a very important fact that attracted a lot of students, because most medical graduates will have to spend around USD 10,000 to complete all three steps of the USMLE. Within the third year, the school dropped the program and adjusted to become compliant with the Bologna system.

I graduated on time in 2009 and decided to go back home to Malaysia only to find that the degree is not recognized. (2) After four months of being unemployed, I moved back to Croatia and applied for the internship, only to find out that I needed a Croatian Citizenship to:
1. Attend the internship,
2. Do the state licensing examination,
3. To be regularly licensed, and
4. To be able to specialize.

Dr. Jean Loup Gassend and I managed to amend the first in 2011 and the second in 2013, allowing the foreign graduates of the University of Zagreb to attend the internship and to do the state licensing examination. Dr. Gassend is a French national, which is a point that I will bring up later in this paper. Before Croatia joined the EU and all EU amendments to the laws took hold, I was allowed a license and easily obtained a job during the summer when doctors were lacking during peak tourist season. (3)

However after July 2013 when Croatia joined the EU, the laws changed and since I am a third national and would like to stay and work in a country missing 4500 doctors (4) and Croatian doctors are leaving for better opportunities (5,6) and, the only thing hindering me now are only the ordinances from the Ministry of Interior (7), which states that I need to have an minimal one year employment contract! Most employers, even within the Ministry of Health, will not give a contract longer than 6 months unless you are in a specialization. According to the Croatian Chamber of Medicine (HLK), a person from a third nation has no right to specialize in Croatia, (8) thus limiting the possibilities of advancing my career.

In the newly published proclamation from the HLK, in the “Pravilnik o izdavanju, obnavljanju i oduzimanju odobrenja za samostalan rad (licence)” (članak/article 21-29) (9), a person like me has no right to a full license due to my nationality despite:
1. Attending the University of Zagreb, Faculty of Medicine. (10)
2. Completing my internship at KBC “Sestre Milosrdnice” (11) in Zagreb, and
3. Passing the Croatian State Licensing Examination in on April 24, 2013.

This would not be a problem, but the health institutions have not caught up to European Union standards and still require many documents that a Croatian-graduated, third-national like me cannot obtain. The usual requirements to obtain a position:

“Uz pisanu zamolbu priložiti: životopis i presliku: diplome, licence, osobne iskaznice, potvrde o poznavanju stranog jezika i elektronski zapis ili potvrdu Hrvatskog zavoda za mirovinsko osiguranje o radnom stažu.”

“In addition to a written request, submit: resume and a copy of: diplomas, license, identity cards, certificates of proficiency in a foreign language and an electronic record or certificate from the Croatian Pension Insurance Institute of proof of employment.”
– Zavod za hitnu medicinu Grada Zagreba.

Another aspect to consider is the lack of the ability to specialize in Croatia for third nationals. According to the EU Directive 2013/25/EC (12), the equivalent to a General Practitioner in the EU is to have a specialty in Obiteljska Medicina or Family Medicine. Since I cannot specialize in Croatia due to my nationality, my career is blocked only by administration. I understand the need of compliance of qualifications between nations and schools before a specialization is given. However, my qualifications and license were obtained in Croatia, and in most EU countries, there would be no hindrance in obtaining further training only based on nationality if this was the case.

Looking after my future third national colleagues graduating from the University of Zagreb, Faculty of Medicine, I am also worried that since Croatia is lowering the length of internship to five months (13), this will not comply with the time of training needed for compliance with the EU Directive 2005/36/EC (14). Therefore, for third nationals, they are not qualified to practice after attending and completing their medical education in Croatia. In comparison, EU citizens have the right to a regular license once they finish their five month internship and will be compliant in the EU.

Conclusion

With the restrictions from the government and the global shortage of doctors, I cannot help but wonder why there are bureaucratic roadblocks in this profession. When I attended medical school, my thirst for knowledge and need to be a person who can eventually contribute to society peaked. However after graduation, with the lack of guidance, I was lost as a medical doctor and have been fighting the system to let me work with patients. I have the motivation to extend my knowledge and train in Internal Medicine, allowing me to work with a wide range of patients, diseases and make my impact on society. Simply because of my nationality, I and many others in my position cannot formally apply for any position or find our direction in medicine. From all the articles and regulations, the future of medical care in the EU can be easily fixed by alleviating the differentiation between nations and its borders.

What Can You Do to Help?

Help me by emailing or sending a letter of concern, and by signing and sharing this petition.  I would appreciate any help in changing the policies that discriminate people from third nations who studied, interned and passed Croatia’s state licensing examination.  Read below at the responses from other Medical Chambers and if you want to help, I have put up the email list so that you can cut and paste.

Hopefully they will listen!

hlk@hlk.hr, hrvoje.minigo@hlk.hr, vjekoslav.mahovlic@hlk.hr, info@baek.de, registration@mcirl.ie, gmc@gmc-uk.org, conseil-national@cn.medecin.fr, info@bag.admin.ch, post@aerztekammer.at, info@collegemedical.lu, dadl@dadl.dk, yl@dadl.dk, fas@dadl.dk, plo@dadl.dk, ufl@dadl.dk, info@slf.se, medlem@slf.se, legeforeningen@legeforeningen.no, hege.gjessing@legeforeningen.no, marijan.cesarik@miz.hr, info@ombudsman.hr, malzgreb@kln.gov.my, info@indianembassy.hr, zagrb@international.gc.ca, gassend@gmail.com, mahsihye@gmail.com, aiffel.azman@gmail.com, smeetz@gmail.com, davorjezek@yahoo.com, pitajtenas@miz.hr

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  1. Dear Dr. Azmann

    In order to work as a doctor in Denmark you must have an authorisation from the Danish Health and Medicines Authority.

    You will find useful information on their webpage: http://www.sst.dk/English.aspx

    Best regards

    Susanne Holsaae
    Danish Medical Association
    International Team
    Department of Health Policy
    Kristianiagade 12
    DK – 2100 Copenhagen
    Tel.: 35 44 85 00
    Tel.: 35 44 82 23 (Direct)
    Telefax.: 35 44 8505
    E-mail: sho@dadl.dk
    Web: http://www.laeger.dk

  2. Dear Sir,

    with reference to your E-mail.

    To practise as a physician in Norway you will need to apply for a license (permanent or temporary). The application should be sent to:

    Norwegian Registration Authority for Health Personnel (SAK)
    P.O. Box 8053 Dep
    NO-0031 OSLO
    Norway
    Visiting address is Calmeyersgt. 1

    Tel: +47 21 52 97 00
    E-mail: post@sak.no
    See http://www.sak.no for information about application etc.

    Medical practitioners who have received their education and training outside of Norway must satisfy a number of specific requirements before they can be officially authorized to practise in Norway.

    These requirements vary, for example according to the country in which the education and training took place.

    For specialist approval, please contact:

    The Norwegian Directorate of Health (Helsedirektoratet)
    P.O. Box 7000 St. Olavs plass
    NO-0130 OSLO
    Norway
    Visiting address is Universitetsgt. 2

    Tel: +47 810 200 50
    E-mail: spesialistgodkjenning@helsedir.no
    See http://www.helsedirektoratet.no for further information.

    Most vacancies are published in the Journal of The Norwegian Medical Association (Tidsskrift for Den norske legeforening).

    The journal is published three times monthly and the printed edition is in Norwegian language only.

    A subscription to The Journal costs approximately NOK 2,500 a year. You will find more information on http://tidsskriftet.no/english.

    The vacancies are also available on http://www.legejobber.no/.

    You may also take direct contact with hospital departments to find out if they have short term vacancies.

    The Norwegian Medical Association cannot provide specific information regarding vacancies.

    Usually there are many applicants to each hospital job and it is impossible to obtain a job for a non-Norwegian speaking doctor. A fair command of the Norwegian language is necessary before you can be employed as a physician in Norway.

    The Norwegian Registration Authority for Health Personnel (mentioned above) will have information about language requirements.

    You might also visit the following web-sites to get further information about language courses:
    http://www.uio.no/english/studies/summerschool/
    http://www.studyinnorway.no/

    You may also find useful information at NOKUT, which recognizes foreign higher education qualifications in response to applications by individuals and provides information to holders of foreign qualifications
    about Norway’s various mechanisms for the recognition and authorization of foreign qualifications:

    NOKUT (Nasjonalt organ for kvalitet i utdanningen)
    P.O. Box 1708 Vika
    NO-0121 OSLO
    Norway
    Visiting address: Kronprinsens gate 9, 4th floor

    Tel: +47 21 02 18 00
    See http://www.nokut.no/en/ for more information.

    Yours sincerely
    The Norwegian Medical Association

    Brit Torill Gutbier
    Department of Professional Affairs
    Section of education

    • Dear Brit Torill Gutbier,

      Thank you for your prompt reply. Therefore the only thing hindering an application to Norway is my command of the language. The question was based, because in Croatia, I am nearly fluent, but based on my nationality, I cannot specialize. Is this the same as in Norway?

      Thank you,

      Dr. Azman

      • Dear Dr. Azman,

        Doctors within Norway, no matter what nationality they have, can become specialists. There is no restriction based on nationality.

        But, yes, of course language fluency is required. Since you come from outside the EU, you would need to apply work permits, residency permits and such. Please contact:

        Norwegian Directorate of Immigration
        P.O.Box 8108 Dep
        N-0032 Oslo
        NORWAY
        Tel: +47 23 35 15 00

        Yours sincerely
        The Norwegian Medical Association

        Brit Torill Gutbier
        Department of Professional Affairs
        Section of education

  3. Dear Dr Azman

    Thank you for your email about obtaining registration with a licence to practise.

    As you are an International Medical Graduate (IMG) you will need to satisfy us that:

    your English language skills meet the requirements set out in our guidance
    you hold an acceptable primary medical qualification
    your fitness to practise is not impaired
    you have the necessary medical knowledge and skills.
    You would demonstrate your medical knowledge and skills in one of the following ways:

    a pass in the PLAB test
    sponsorship by a GMC approved sponsor
    possession of an acceptable postgraduate qualification
    eligibility for entry onto the Specialist or GP Registers.
    You can find more information about applying on our IMG web page. We strongly recommend you also read our guidance for doctors thinking about applying for registration.

    If your application is successful, you will be restricted to working in an approved practice setting (APS) until your first revalidation. Please see our APS web page for more information.

    If you would like to discuss this further, please reply to this email or call me.

    Yours sincerely

    Ian Quinn
    Contact Centre Adviser
    Registration and Revalidation Directorate
    Telephone: 0161 923 6602 (+44 161 923 6602 from outside the UK)
    Website: http://www.gmc-uk.org

    • Dear Mr. Quinn,

      Thank you for your prompt reply. The question was based, because in Croatia, based on my NATIONALITY, I cannot specialize. Is this the same as in the UK? Do I have rights for a full license or just temporary (only valid during employment periods).

      Thank you,

      Dr. Azman

  4. Dear Dr bin Azman,

    Thank you for your email.

    The German Medical Association (Bundesärztekammer) is the federation of the 17 state chambers of physicians in Germany. As the central organisation in the system of medical self-governance, it represents the professional interests of the 459, 021 physicians of Germany (data 31/12/2012).

    In order to practise medicine in Germany, you will need to obtain a licence to practise medicine (Approbation = full licence, Berufserlaubnis = temporary licence). Since the act on improving the appraisal and recognition of professional qualifications gained abroad (Gesetz zur Verbesserung der Feststellung und Anerkennung im Ausland erworbener Berufsqualifikationen – “Anerkennungsgesetz”) came into force on 1 April 2012, it has been possible for all applicants to apply for a full licence to practise medicine regardless of their nationality. The competent authorities responsible for issuing the licence to practice medicine are the state health authorities of the individual federal states (Oberste Landesgesundheitsbehörden). You can find a list of addresses of the state health authorities on our website: http://www.baek.de/downloads/Approbationsbehoerden20110713.pdf

    The relevant legal documents relating to admission to the medical profession may be found under the following link (Licensing Regulations for Physicians – Approbationsordnung, Federal Medical Regulation – Bundesärzteordnung): http://www.baek.de/page.asp?his=1.101

    The state health authorities compare basic medical qualifications and medical licences gained abroad with the provisions contained within the Licensing Regulations for Physicians in order to assess their equivalency. If foreign qualifications are not deemed to be equivalent then it is decided whether disparities in medical training can be compensated for by relevant professional experience. If this is not the case then applicants must carry out a proficiency test (those with medical qualifications from outside the EU) or an aptitude test (those with medical qualifications from an EU Member State). Proof of sufficient German language skills to at least level B2 (intermediate) of the common European framework of reference is generally required.
    Please contact the relevant state health authority for further information on the specific details of equivalency assessment, the documents required to make an application, proficiency and aptitude tests, and the changes to the legal situation as a result of the Anerkennungsgesetz.

    All physicians are mandatory members of the state chambers of physicians (Landesärztekammer) of the federal state where they work. As corporations under public law, the state chambers of physicians are in charge of the administration of all matters related to specialty training in Germany. The content and periods of specialty training for each field are set out in the specialty training regulations of the state chambers of physicians. You may find the addresses of hospitals and physicians entitled to conduct speciality medical training under the heading “Weiterbildung” on the websites of the state chambers of physicians. For a list of websites and contact details see:
    http://www.baek.de/page.asp?his=0.8.5585
    You may also find useful information on specialty training on our website (in German): http://www.baek.de/page.asp?his=1.128

    As the bodies responsible for specialty training, the state chambers of physicians are also responsible for the recognition of periods of specialty training carried out abroad, as well as specialty medical qualifications from abroad. Membership of a state chamber of physicians is a prerequisite for the assessment and possible recognition of specialty training qualifications gained abroad.

    Detailed information regarding visa regulations may be found on the website of the Federal Foreign Office:
    http://www.auswaertiges-amt.de/sid_2DD8DD29A31B250F715C9217F19121A6/EN/Startseite_node.html

    We hope this information has been useful to you.

    Best regards,

    Rosie Ellis
    Sachbearbeiterin / Programme Assistant

    • Dear Ms. Rosie Ellis,

      Thank you for your prompt reply. The question was based, because in Croatia, based on my NATIONALITY, I cannot specialize. Is this the same as in Germany? Do I have rights for a full license or just temporary (only valid during employment periods).

      Thank you,

      Dr. Azman

      • Dear Dr Azman,

        Thank you for your email. As mentioned in my previous email, since the act on improving the appraisal and recognition of professional qualifications gained abroad (Gesetz zur Verbesserung der Feststellung und Anerkennung im Ausland erworbener Berufsqualifikationen – “Anerkennungsgesetz”) came into force in Germany on 1 April 2012, it has been possible for all applicants to apply for a full licence to practise medicine regardless of their nationality.

        A license to practise is a prerequisite for becoming a member of a state chamber of physicians and carrying out specialty training (all physicians are mandatory members of the state chambers of physicians (Landesärztekammer) of the federal state where they work). These are the bodies responsible for all matters pertaining to specialisation. For a list of websites and contact details see: http://www.baek.de/page.asp?his=0.8.5585

        As the German Medical Association is not the competent authority for granting the license to practice, we cannot assess individual cases. Please contact the relevant state health authority for further information on the specific details of changes to the legal situation as a result of the Anerkennungsgesetz. You can find a list of addresses of the state health authorities on our website: http://www.baek.de/downloads/Approbationsbehoerden20110713.pdf

        I hope this answers your question.

        Kind regards,
        Rosie Ellis

  5. Dear Mr Muhammad Zeitsev bin Azman, MD BSc,

    I regret to inform you that one of the prerequisites to engage in a medical activity for training purposes in Austria is either EEA citizenship, or a specific valid residence permit or residence title in Austria according to the Austrian settlement residence act (NAG) or recognized right of asylum or subsidiary protection status.

    EEA and non – EEA Member Country nationals being granted equal treatment having graduated from a Medical University outside of the EEA have to have their medical degree recognised as equivalent with Austrian standards by an Austrian University. Nostrification means the recognition of a third-country medical degree in Austria and it usually means that further exams have to be passed at university in Austria in order to obtain the recognition. However, this process of nostrification is purely within the competence of Austrian medical universities (Vienna, Graz or Innsbruck). Further information regarding medical activity in Austria can be found in our information leaflet for EEA-citizens and non – EEA Member Country nationals being granted equal treatment.

    Foreign medical doctors who do not fulfill the above mentioned prerequisites only have the possibility to apply for an authorization according to § 8 par 5 or §35 of the Austria Medical Act (see attached leaflets).

    § 8 par. 5 medical act – Postgraduate training undergone by foreign doctors without EU-nationality
    If you apply for an authorization according to § 8,5 postgraduate training may be undergone in any specialty (that means 4 years of the main course of specialization) or in any subspecialty (if applicant has a qualification of a specialist doctor).

    An authorization according to § 8, 5 can only be granted if the costs are born by the home country or a supranational organization. Any funding by private persons or institutes is impossible. The certificate the medical doctor will obtain upon completion of training, however does not constitute a basis for claiming the right to medical practice in Austria.

    § 35 medical act – Medical activites for educational purposes, undertaken by foreign doctors
    An authorization according to § 35 is for educational purposes only and may only be extended for a period of up to one year, respectively until the completion of a scientific paper. The maximum extension of this period is three years. A new authorisation may be granted not earlier than five years after the date of expiration of the prior authorisation.

    Kind regards,

    Irene Podest

    Mag. Irene Podest
    Österreichische Ärztekammer
    Internationales
    A-1010 Wien, Weihburggasse 10-12
    Tel: +43 1 51406 – 3932 (fax – 63932)

  6. Muhammad Zeitsev bin Azman, MD BSc
    Trpimirova 27
    10000 Zagreb
    Croatia
    TEL: +385 97 623 9367
    EML: yeopazman@gmail.com
    WEB: https://sites.google.com/site/yeopazman

    October 23, 2013

    To the respected EU Ombudsman,

    My name is Muhammad Zeitsev bin Azman and I would like to lodge a complaint against the Croatian Medical Chamber, to see what I can do about my situation as a Medical Doctor in the EU, and to see the ways that I can advance in my career. Currently I am unemployed and am having difficulty grasping the regulations and bureaucratic procedures needed to work as a Medical Doctor. There will be a few doctors, who are citizens of “third” nations, who will graduate from the University of Zagreb and will be in the same position.

    Since my father was stationed in Croatia, I decided to move to Croatia in 2003 and attended an ex-Harvard Medical International program at the University of Zagreb and graduated the 6 year program in 2009. I then went back to Malaysia to start my internship. However the degree was not recognized in Malaysia and after 4 months of fighting unemployment, I decided to come back to Croatia to finish my internship, only to find that the Croatian law stated that I needed to be a Citizen of Croatia to attend my internship, get licensed and to specialize. Dr. Jean Loup Gassend, from France, was also in the same situation.

    With the help from the EU Ombudsman, we manage to amend the regulations from the Ministry of Health. I started the one year internship, studied for the Croatian state licensing examination, passed and was only allowed a temporary license in Croatia. Since Dr. Gassend was an EU citizen, he obtained a full license and moved to Switzerland to work when Croatia joined the EU in July 2013. Croatia is lacking 4500 doctors, so I decided to stay and work despite the compensation compared to other EU countries. I found a job as a General Practitioner in Emergency Medicine in Zadar County and began work. In July, I moved to Primary Health Care for Rijeka because of the direction I wanted my career to move into. I could not extend my contract after tourist season and am now looking for new employment as a General Practitioner in Croatia, or to specialize in Family Medicine or in Internal Medicine to advance my career as a Medical Doctor. You can see that although I graduated from the University of Zagreb, did my medical internship in Zagreb and passed the Croatian Licensing Examination, I am only allowed a temporary license solely based on my nationality.

    Since I also cannot specialize in Croatia due to the regulations set forth by the Croatian Medical Chamber, am a third national in the EU, have a degree that is not recognized in my home country, I am looking for better opportunities where my degree, education, “temporary” EU license and citizenship is accepted so that I can advance my career as a Medical Doctor. I would appreciate your effort to quickly answer this question:

    Would it be considered some form of discrimination because I cannot apply for employment without a license and I cannot obtain a license without employment?

    An article can be found on my blog at: https://yeopazman.wordpress.com/2013/10/02/a-fight-for-equality/ explaining all these points in this email and responses from several European Medical Chambers/Councils implying that the Croatian Medical Chamber is creating a way to discrimate third nationals. Especially one who was educated and trained in Croatia. Please read through the article carefully and I look forward to your reply.

    Thank you for your patience and Sincerely,

    Dr. Azman

    • Strasbourg, 28/10/2013
      Acknowledgement of receipt

      Dear Sir/Dear Madam,

      I am writing to let you know that your complaint dated 23/10/2013 was registered on 23/10/2013 and assigned registration number 2019/2013/HK. It will be dealt with by Ms Hanna Kubiak (tel: +33 (0)3.88.17.25.63).

      Enclosed, please find an information note concerning the treatment of your complaint and the rules governing the protection of personal data which the Ombudsman applies when dealing with complaints.

      Your complaint will first be examined to determine if it falls within the Institutionʹs mandate. If it does not, I shall inform you accordingly. If it does, the Ombudsman will write to you.

      I would also like to draw your attention to the fact that complaints submitted to the Ombudsman do not affect time limits for appeals in any administrative or judicial proceedings (Article 2(6) of the Statute of the European Ombudsman).

      Yours sincerely,

      Peter Bonnor
      Head of the Registry

  1. 1 The Background | The Hitchhiking Doctor

    […] So there you have it.  In 2009, I graduated and since my degree was not recognized in Malaysia, I realized that I just wasted my time.  I borrowed money and returned to Croatia to license myself only to find out that I had to be a citizen of Croatia to accomplish anything.  A colleague from France and I then started fighting to change the Croatian laws and ordinances hindering (discriminating) CROATIAN-qualified individuals from being in Croatia and working as medical doctors! […]

  2. 2 This One is for The Azman Family | Medical Advice and Life Blog

    […] when you’re confronted with problems, what do you do?  Click HERE to read my fight and responses to the situation with the Ministry of Health, Ministry of Interior […]




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