In civil engineering, the load-bearing capacity of a structure is judged by its weakest element. A bridge does not collapse because the whole was miscalculated, but because one span, one node, one weld stopped carrying the load. In a healthcare system, that load-bearing node is not a building, a contract or a server. It is the person on shift.

The first week of June 2026 brought three events which, read together, say more about the state of that node than many a government strategy. On 4 and 5 June in Riga, the health ministers of the WHO Small Countries Initiative adopted the Riga Outcome Statement, recognising expressly that a strong health workforce is the foundation of health security, and that Europe will be short of close to a million health workers by 2030. On 8 June the Polish Ministry of Health published a draft amendment to the Act on the professions of physician and dentist, intended to keep young doctors in the regions worst affected by shortages — a draft the resident doctors’ community called a five-year bond of indenture. On 11 June the public learned of the recommendation of the Agency for Health Technology Assessment and Tariff System (AOTMiT) on the annual July pay rises for medical staff: some 9 billion złoty a year, against a gap in the National Health Fund budget estimated at around 16 billion złoty.

Three events, three languages: the language of values and long-range planning in Riga, the language of administrative compulsion in the ministry’s draft, the language of accounting despair in the pay recommendation. All three bear on the same question, which Poland still does not ask systematically: what, in fact, is the workforce capacity of our healthcare system, who measures it, who decides on the basis of that measurement — and who answers for its loss.

The measurement we do not take

Let us begin with the numbers, because the series “Capacity of the healthcare system” holds consistently to the sequence measurement → decision → implementation → accountability. The World Health Organization estimates that the European Region will be short of close to a million health workers by 2030 — a shortage driven by an ageing population, rising demand for care, the ageing of the workforce itself, and difficulty in attracting and retaining doctors, nurses and the other medical professions. The paradox is that Europe is today training more doctors than ever. According to Eurostat data cited by Euronews, more than 66,000 people obtained a medical degree in the European Union in 2023 — roughly fifteen graduates per 100,000 inhabitants — and the number of medical graduates has risen over the past decade in almost every Member State. Yet the shortages deepen. The inflow is rising while the water level in the reservoir falls, which means the problem is not intake but outflow. In the language of capacity: not design capacity, but loss of operational capacity.

The age-structure data confirm the diagnosis. In 2023, close to one third of doctors in EU countries were over 55 — a generation that will leave the profession within a decade, and in many countries it is only their willingness to work past retirement age that shields the systems from a far deeper crisis. The specialty mix is shifting at the same time: across the EU only around one doctor in five is a family physician, and graduates — as Tiago Villanueva, president of the European Union of General Practitioners, reports — choose specialties that offer a predictable way of life, steering clear of family medicine and of the on-call disciplines. The system produces doctors, but not where the structure is cracking.

Poland fits this picture with complete clarity. The government’s Occupational Barometer for 2026 again lists doctors, nurses and midwives among the shortage occupations. In a draft regulation of February 2026, the Ministry of Family, Labour and Social Policy identified 329 shortage occupations in which foreign nationals are to receive priority processing of visa and work-permit applications — the list includes doctors of many specialties, nurses, midwives and care staff, and the ministry stated plainly in its explanatory memorandum that demand for medical and care workers will grow at least until 2050. This is a document of considerable symbolic weight: the Polish state has formally acknowledged that it will not reproduce its medical workforce from its own demographic resources, and is opening a channel for importing competence. It is all the more astonishing that there exists, in parallel, no publicly reported, unified indicator of workforce stability that would let a citizen, a hospital director and a minister look at the same figure and draw conclusions from it.

And there is much to measure — beyond the arithmetic of full-time posts. The latest WHO/Europe study of the mental health of nurses and doctors (MeND), the largest of its kind in Europe, shows that levels of depression and anxiety among doctors and nurses are five times higher than in the general population, and that on average one third of them have experienced violence or threats in the workplace. These are not “wellbeing” data — they are capacity data. An exhausted, intimidated or burnt-out team carries less load, makes more errors and leaves the structure sooner. The WHO Regional Director for Europe, Dr Hans Henri P. Kluge, put it in Riga in a sentence that ought to hang above every decision-maker’s desk: no recruitment campaign will on its own resolve the health workforce retention crisis. The countries that grasp this earliest, he added, will have the strongest health systems in the years ahead.

Staff stability as an indicator, not a slogan

What, then, would a workforce stability indicator amount to in the logic of capacity? The series proposes four levers of system capacity: revenue, efficiency, resilience and capacity proper. Staff stability is the capacity lever in its purest form — because the capacity of a health system is not the number of beds but the number of safely staffed clinical hours the system can field in a given week, in a given voivodeship, in a given field.

A bed without a team is furniture. A CT scanner without a radiologist is sculpture. A contract with the National Health Fund without staff is a promise without cover.

Measurable workforce stability consists of several layers, every one of which is available for rigorous measurement today. The first is retention: what share of staff remains in a given facility and in the public system year on year, how long it takes to fill a vacancy, what the median age is in each field, and how the age pyramid compares with the curve of retirements. The second is territorial distribution: differences in access to specialists between Polish voivodeships can exceed a factor of two even in family medicine — which means the national average is a statistical illusion, and that system capacity is set by the weakest region, not the strongest. The third is the condition of teams: rates of absence, turnover on on-call wards, reports of adverse events linked to overload, and the results of periodic anonymous safety-climate surveys — precisely those that have been routine in aviation for decades and remain the exception in Polish hospitals. The fourth, finally, is intent: declared readiness to leave the profession or the country, measured before it becomes fact, because an exodus shows up in survey data two to three years before the HR department sees it.

An indicator so understood should be published on a regular cycle — by facility, by district, by field — and it should have an owner. In the logic of measurement → decision → implementation → accountability, each phase needs an addressee: measurement is carried out by an institution independent of day-to-day politics (in Poland the natural candidates are the health needs maps and AOTMiT, whose May 2026 pay data showed that the state can gather precise information on remuneration — the median salary of a specialist physician on an employment contract being 23,660 złoty gross, and 25,595 złoty on a civil-law contract); allocation decisions are taken by the payer and the voivode on the basis of those same, published figures; implementation belongs to facility boards; and accountability — and here is the crux — must extend to answering for the loss of staff. A hospital director who has lost a third of the anaesthetic nurses within two years should be held to account for it as seriously as for the financial result. Today, the departure of thirty nurses is not a reportable event in Poland. A fractured span is.

Money is necessary, but not sufficient

For years Poland has answered the workforce crisis above all with money — and it must be said honestly that this answer has produced measurable results. The Act on the manner of determining the lowest basic pay of employees of medical entities raises minimum salaries every year on 1 July, indexing them to average pay in the economy. From 1 July 2026 the minimum salary of a specialist physician on an employment contract will be 12,910.16 złoty gross, a nurse with a master’s degree and a specialisation will receive at least 11,485.59 złoty, and pay across the sector will rise by 8.82 per cent. AOTMiT recommends a variant costing the public payer some 9 billion złoty a year — 4.5 billion in the second half of 2026. Medical professions in Poland are no longer poorly paid relative to the economy; the median pay of specialist physicians is several times the national average wage.

And yet the same week that brought the pay recommendation brought data on a 16-billion-złoty gap in the National Health Fund, and a question without an answer: where is the money to come from for rises the Act guarantees regardless of the state of the payer’s accounts. This is the classic mechanism of lost financial capacity described in the first article in this series: fixed obligations grow faster than revenue, so the system finances pay at the expense of access to services — that is, at the expense of the very thing pay exists to deliver. But there is a second conclusion, more important for this text: if pay has been rising sharply for years while the workforce deficit, burnout and internal emigration (from the public system to the private, from on-call disciplines to outpatient ones) do not abate, then money has ceased to be the binding constraint on retention. European experience says the same. Romania, which in 2012 was losing fifteen hundred doctors a year to emigration, reduced that outflow to 461 people in 2021 — and yes, pay rises were central, but as part of a package with better training and working conditions. Latvia, host of the Riga meeting, presented a workforce development strategy for 2025–2029 in which funding sits alongside residency planning, financial support for professionals working outside the large cities, and a statutory strengthening of the role of advanced practice nurses. Latvia’s health minister, Hossam Abu Meri, summed it up soberly: training more doctors and nurses is necessary, but it is only part of the solution — conditions must also be created in which health workers can build lasting careers and stay motivated across a working lifetime.

Compulsion as a false lever

Against that background it is worth reading the Polish Ministry of Health’s June draft carefully, without cheap polemic. The problem the ministry is trying to solve is real and serious: differences of more than twofold between voivodeships in access to specialists mean that constitutional equality of access to services is, in part of the country, a fiction, and that the health needs map has drifted apart from the map of residency posts. The intention of correcting that imbalance deserves support. It is the choice of instrument that raises doubts. The draft provides that the list of training institutions will be set by the voivode according to the region’s workforce needs, and that a resident will lose the ability to transfer a residency between institutions — the training post will stay where it was granted. A doctor who does not take up an allocated post may be excluded from the two following qualification rounds.

The Residents’ Agreement of the national physicians’ trade union OZZL called this solution a five-year bond of indenture, and the metaphor is hard to shrug off when set against the data the same organisation publishes on training quality: according to its report, as many as 90 per cent of psychiatry residents have on-call duties organised in breach of the specialisation programme, more than 80 per cent of respondents do not feel safe during 24-hour shifts, and one in three has no contact — not even by telephone — with an experienced specialist while on call. Maria Kłosińska, president of the Mother Physician Foundation, adds a dimension the workforce debate tends to pass over in embarrassment: more than 63 per cent of doctors aged 26–40 are women, so any rule that makes it harder to combine specialty training with parenthood strikes first at them — that is, at the largest group now entering the profession.

In terms of Just Culture — the fair organisational culture that forms the value axis of this series — the draft commits a fundamental error: it shifts the cost of repairing the system onto its weakest link, without repairing the mechanisms of oversight. If a facility trains badly, tolerates bullying or breaches the specialisation programme, the fair systemic response is to enforce accountability against the facility — withdrawing its training accreditation, making funding conditional on the results of a working-conditions audit — not to close off the resident’s route of escape. Binding a young doctor to an institution over which oversight is ineffective does not increase system capacity in that region; it merely raises the pressure at the structure’s weakest point. An engineer who “reinforces” a bridge that way loses their licence. What is more, the behavioural arithmetic is easy to predict, and the profession states it openly: once accepting a training post becomes irreversible, candidates will choose more cautiously — that is, give a wide berth to the regions and hospitals with poor reputations, precisely those the reform was meant to help. In systems built on qualified and mobile people, administrative compulsion does not stop the outflow; it merely changes its direction, often towards emigration abroad, against which a voivode is powerless.

Retention is built through conditions, not bonds of indenture.

This is not an ideological claim but an empirical one — borne out by Romanian and Latvian experience and stated expressly in the Riga Outcome Statement, in which states undertake to address health worker mobility through cooperation and balanced approaches, rather than by restricting freedom to practise.

A shield for citizens: why patients should care

The workforce debate is often presented as a sectoral quarrel about money and privilege. That optic is false and harmful. Staff stability is a shield for citizens in the most literal sense: a team that has worked together for a long time knows its procedures, its equipment and its weaknesses, and makes fewer errors; a ward whose shift is covered by an agency doctor seeing the hospital for the first time is a statistically more dangerous place for a patient, with identical equipment and an identical contract. When the MeND study reports fivefold elevated levels of depression and anxiety among staff, that is not a bulletin about how doctors feel — it is a bulletin about clinical risk, to which every one of us is exposed. The EU Commissioner for Health, Olivér Várhelyi, said in Riga that a safe and resilient health system begins with the people who care for patients day in, day out. A citizen has the right to know the workforce stability of the hospital where his wife will give birth and his father will be operated on — just as he has the right to know the results of a restaurant’s sanitary inspection. A published workforce stability indicator is not a bureaucratic gadget but part of the right to information about safety.

There is a second face to that shield: national security. The Riga Outcome Statement links the health workforce directly to preparedness for pandemics, climate change, geopolitical instability, cyber risks and supply chain disruption. In a NATO front-line state such as Poland, the health system’s workforce reserve is as real a component of defensive resilience as stocks of blood and ammunition. A system running on fumes in peacetime — patching shifts with overtime and contracts for pensioners — has no reserve whatsoever for a mass casualty event. That dimension of capacity will be taken up in later articles in this series on dual-use capabilities; here it is enough to note that staff stability is a dual-use indicator.

What the world offers Poland — and what Poland can offer the world

The perspective of this series is always two-way. What, then, do the world’s best practices offer Poland? First, a method: the Riga Outcome Statement commits its signatories to strengthening workforce governance and long-term planning, making better use of data to anticipate needs, adapting education to changing health needs, improving working conditions and career development, protecting the mental health of professionals, and managing mobility responsibly. That is a ready-made frame for a Polish workforce strategy — it need only be adopted and, harder still, equipped with indicators and a calendar of accountability. Second, a laboratory: the small countries of the SCI, from Iceland to Malta, are testing solutions — advanced nursing practice, incentives for work outside the metropolitan centres, residency planning against the needs map — at a scale where effects show quickly. Poland, with more than twenty million patients in the public system, can scale those tested solutions rather than experiment on the living organism with its own untested instruments of compulsion. Third, a warning: for two decades eastern and southern Europe have supplied the workforce of the continent’s north and west. Poland has been, and still is, a donor; as it grows wealthier it is also becoming a recipient — including of doctors and nurses from beyond its eastern border. The February regulation on shortage occupations formally enrols us in the global competition for medical personnel and imposes an obligation to conduct that recruitment ethically, in line with the WHO code, so that we do not drain systems weaker than our own — as we ourselves were drained for years.

And what can Poland offer the world? More than the national reflex of self-criticism suggests. We have one of the youngest cohorts of medical graduates in the region and a growing teaching base. We have — as the AOTMiT data show — a system of minimum pay in healthcare indexed by statute to economic growth: a solution which, for all its fiscal strains, is studied as one of the furthest-reaching anti-dumping mechanisms in Europe. And we have the federated infrastructure of the hospital community, in which management practice is forged: the Polish Federation of Hospitals, bringing together hospital employers of every form of ownership, conducts systematic regulatory dialogue through its Government & Public Affairs function — from commenting on draft workforce legislation to transferring the standards of the European Hospital and Healthcare Federation (HOPE) and the International Hospital Federation (IHF) into Polish management practice. The Healthcare Poland Foundation, working with the Polish Federation of Hospitals within its ecosystem, treats staff stability as one of the foundations of the system capacity indicators it is designing: without credible measurement of retention, age structure and the condition of teams, no debate about financing, digitalisation or resilience has a factual basis. This is precisely the kind of work — laborious, measurement-driven, unphotogenic — that the Polish system needs more than another legislative revolution: building a dashboard that a minister, a voivode, a director and a citizen look at together, seeing the same figures and the same trends.

Accountability: who answers for the hands we have lost

At the end of the sequence measurement → decision → implementation → accountability, the question of responsibility must be put — asked in the spirit of Just Culture, and so without a hunt for culprits, but with a firm expectation that roles are accountable. Measurement of workforce stability should be the responsibility of the state — and today that responsibility is scattered across the registers of the professional chambers, National Health Fund reporting, the health needs maps and the surveys of professional organisations, which nobody assembles into a single picture. Allocation decisions belong to the minister and the voivodes, who should take them on the basis of published indicators rather than intuition. Implementation of the working conditions that keep people belongs to facility boards, held to account for retention as they are for the balance sheet. Accountability for the whole belongs to parliament and to the public, who are owed an annual public report on the stability of the health workforce, just as they are owed a report on the state of public finances. The Riga Outcome Statement shows that this can be organised at intergovernmental level; the Polish AOTMiT data show that we can measure precisely when we choose to; and the residents’ protest shows that the young generation of doctors will not walk away from a table at which they are treated as partners — but cannot be chained to a table at which they are disregarded.

The capacity of a healthcare system is measured by its weakest shift.

Everything else — contracts, statutes, strategies, billions — is merely the load that shift must carry. Policy that means to be serious begins by counting people before it counts money; by asking them why they are leaving before forbidding them to leave; and by taking responsibility for conditions before demanding loyalty. That is how structures are built that do not crack. And that is how a shield is built that genuinely protects citizens.