Mitigating health workforce migration in Romania: policy lessons for Europe

Abstract

Health workforce migration is an important challenge for healthcare systems across Europe, with Romania facing one of the most significant impacts following its accession into the European Union. This article examines the trends, drivers, and consequences of health workforce migration in Romania, particularly physicians and nurses, explores policy interventions aimed at mitigating its effects and assesses their effectiveness. The analysis highlights the strategies employed to retain and attract healthcare workers, including financial incentives, regulatory reforms, and expanded educational opportunities. The study shows a two-thirds reduction in the annual migration of Romanian doctors to mainly countries of the WHO European Region, decreasing from 1532 in 2012 to just 461 in 2021, demonstrating the significant impact of policy interventions on workforce retention. While these interventions have successfully increased the overall number of health professionals in Romania and reduced overseas migration, challenges remain in ensuring equitable distribution and addressing workforce shortages in key specialties and occupations. Romania's experience offers valuable lessons for other European countries facing similar challenges and offers policy lessons for addressing one of Europe’s most pressing healthcare priorities.

Background

Health workforce migration is a pressing concern for many European countries, with the availability and mobility of healthcare professionals influencing the accessibility and quality of healthcare delivery [1]. For countries in the southern and eastern part of the European region, these challenges are particularly acute, as they contend with significant outflows of healthcare workers to higher income countries, including many in the west and north of the European Region.

Romania's health care system, like many others globally, has faced significant challenges in recent years, such as insufficient funding, regional disparities in healthcare access, high burden of chronic diseases and inefficiencies in service provision [2]. These challenges have been shaped by complex factors, including the COVID-19 pandemic, economic conditions, policy decisions, and the broader global and regional context [3]. In addition, with Romania’s accession to the EU in 2007, health care professionals have been exposed to new opportunities abroad offering better working conditions, leading to notable shifts in the health workforce and labor market dynamics.

Since Romania's accession to the EU in 2007, health care professionals have increasingly migrated to other European countries, attracted by better working conditions, higher salaries and more opportunities for professional or personal development [4]. This migration, influenced by both external pull factors and internal push factors, such as dissatisfaction with local working conditions, has disrupted the health labor market, particularly through shortages in family medicine, emergency medicine and certain surgical fields. Against this background, the newly created conditions themselves have become a push for even more workforce migration.

The government, in collaboration with international bodies like World Health Organization (WHO) and the World Bank (WB), has been proactively reforming human resources for health (HRH) policies to address these challenges. Efforts have focused on decreasing workforce migration, improving the availability and geographical distribution of the health workforce and increasing the number of family practitioners, especially in geographic areas where staffing shortages are most acute. Although the total number of healthcare professionals has increased, there has been little progress in improving their distribution across different regions.

Health workforce overview

As illustrated in Fig. 1, the healthcare workforce, totaling 370,293 professionals, makes up nearly 2% of Romania's population and 6.5% of the total salaried workforce, highlighting its significance and role in the national economy [5]. Nurses represent the largest group in the healthcare workforce, but only one-tenth of nurses have a university degree. The second largest group is made up of auxiliary personnel, most of whom are assistant nurses. Physicians account for 19% of the healthcare workforce, of which almost one-third are undergoing a residency program. Pharmacists and dentists both represent 6%, while physiotherapists amount to only 1% of total.

Fig. 1.

Romanian Healthcare Workers by categories in 2022. National Institute of Statistics—Activity of The Health Facilities yearly report 2022 [6]. The outer ring is the decomposition of the inner ring

A notable fact in relation to the composition of the health workforce is the high proportion of women, i.e., more than 80% overall, above EU average [7] (Fig. 2). With regard to the ownership of health units that employ the workforce, two-thirds of personnel are hired in publicly owned hospitals, while the rest are active in a vast array of privately owned providers, from family medicine practice to hospitals [8].

Fig. 2.

Medical Professionals Demographics. Compiled from The National Institute of Statistics—Activity of The Health Facilities yearly report (2015–2022) [9]

The demographic profile of Romania's medical workforce is young, with 63% of physicians other than family medicine being under 45 years old (Fig. 2). However, family medicine does not mirror this composition: less than one-third of family physicians are younger than 45 years old, while 40% are aged 55 years and older. As of 2022, the headcount of family physicians reached 12,445, marking a slight increase from 12,323 in 2015.

Family medicine is compounded by problems related to geographic maldistribution. Data from the National Federation of Family Physicians' Employers indicate a critical shortage in rural areas, with 328 of local governments out of 3181 local governments lacking a family physician and an overall deficit of approximately 2187 family doctors [10]. The shortage of family doctors reflects multiple contributing factors, including the lower prestige and limited career prospects associated with primary care, as well as a narrower scope of practice; these challenges have been compounded by emigration, although specific data on the specialty profiles of emigrating physicians are not available.

Health workforce migration in Romania (describing the problem/challenge)

Out-migration has been a factor impacting the healthcare workforce [11]. Between 2007 and 2013, the Romanian College of Physicians has reported that 14 000 medical doctors sought work in other EU member states, leading to a significant reduction of the active workforce [12]. As of 2021, there was substantial migration of Romanian medical professionals, with almost 22 000 Romanian physicians choosing to practice mainly in other countries of the WHO European Region (Table 1). Among these, the top destination nation was France, followed in decreasing order by Germany, the United States of America, Israel, Hungary, Belgium, the United Kingdom, Sweden and Ireland. These nine countries collectively benefited from 90% of the total Romanian migrant physician population.

Table 1.

Romanian physicians reported working in the WHO/Europe countries, Canada and United States 2011/2021

Destination country	2011	2021	Difference between 2011 and 2021
Canada	341	331	-10
Czechia	1	12	11
Netherlands (Kingdom of the)	47	60	13
Poland	4*	29	25
Austria	22	68	46
Norway	65	185	120
Italy	320*	441	121
United States	2324	2455	131
Finland	38*	192	154
Hungary	1652	1848	196
Switzerland	156	441	285
Ireland	226	686	460
Sweden	485	1087**	602
Belgium	744	1501	757
United Kingdom	582	1388	806
Israel	1245	2100	855
Germany	1840	3914	2074
France	2697	5064	2367
Total	12,789	21,802	9013

Compiled from WHO/Europe-Eurostat-OECD Joint Questionnaire on non-monetary health care statistics 2022 [13]. Numbers represent total stock reported by each “destination” country in respective year

^*Data from 2010 instead of 2011

^**Data from 2020 instead of 2021. Missing data from Spain and Denmark

Because most of the trends in migration of Romanian health care professionals are mainly to countries of the WHO European Region, this overview utilizes data from the WHO/Europe-Eurostat-OECD Joint Questionnaire on non-monetary health care statistics (JQ) [13], providing insights into the international outflow of Romanian doctors and nurses mainly to countries of the WHO European Region. The JQ data used in this study refer to foreign-born Romanian health professionals, rather than foreign-trained individuals, thus providing a more accurate reflection of emigration patterns among Romanian nationals rather than international graduates of Romanian medical institutions. Estimates show that more than 97% of Romanian emigrants worldwide reside mainly in other WHO European Region countries [14], and considering the lack of comprehensive migration data from non-OECD countries, we believe that conducting the analysis using WHO/Europe-Eurostat-OECD Joint Questionnaire on non-monetary health care statistics database is sufficiently relevant and representative. It is important to note that the figures presented in Table 1 represent gross numbers, which provide a snapshot of the total number of Romanian health care professionals working in the respective countries in the reference years, and do not account for individual emigrations or repatriations.

Romania is the 5th largest producer of medical doctors in the WHO European region, highlighting its high output of trained professionals. However, despite this significant production, the availability of medical doctors in Romania remains below the regional average, ranking 31st out of 53 countries in the European Region in 2022 [13]. This disparity is primarily due to high levels of out-migration, with many Romanian doctors seeking opportunities abroad, contributing to ongoing workforce shortages in Romania.

The changes to the annual stock numbers of migrant physicians by recipient country between 2011 and 2021 are also highlighted in Table 1. Notably, from 2011 to 2021, there was a substantial decrease in the number of Romanian physicians reported in the United States and Canada when compared with the baseline numbers of 2011. This decline can be attributed, at least in part, to the simplification of migration to other EU member states following Romania's accession to the EU in 2007. The accession facilitated the free movement of Romanian medical professionals to other EU member states, where they encountered more familiar working conditions and regulatory frameworks, as well as ease of travel, than found in non-EU destinations.

The data from 2021 reveal that France and Germany have reported the highest annual stock numbers for Romanian physicians, with the intakes of Romanian physicians into both countries doubling to 5064 and 3914 physicians, respectively, between 2011 and 2021. This emphasizes the high regard for the expertise and contributions of Romanian medical professionals within the European medical community. Romanian doctors represent 19% of France's total foreign medical workforce and they constitute the second-largest group of foreign doctors, following closely behind Algerian doctors. A similar trend is observed in Germany, where Romanian doctors represent the second-largest group of foreign medical professionals, surpassed only by Syrian doctors. Their presence accounts for 7.5% of the total number of foreign doctors.

Between 2012 to 2021, the trend of annual net migration of Romanian doctors decreased substantially, with fluctuations in 2015 and 2019 (as shown in Fig. 3). Since 2012, when 1532 Romanian doctors left the country, the annual outflow has gradually decreased, with only 461 physicians emigrating in 2021 (representing only 30% of the baseline number in 2011). This shift in emigration patterns is reflective of multiple factors influencing the decisions of Romanian medical professionals to seek opportunities abroad.

Fig. 3.

Evolution of Yearly Net Migration of Romanian Doctors Towards WHO/Europe Countries, Canada and United States. Compiled from country information from WHO/Europe-Eurostat-OECD Joint Questionnaire on non-monetary health care statistics 2022 [13]

An acceleration of the downward trend of migration occurred in 2017 when a substantial salary increase was implemented in the public sector in Romania, which positively impacted the retention of medical professionals. The total number of Romanian doctors emigrating between 2018 and 2021 (totaling 2493 persons) was 33% lower than the number in the previous 4 years (2014–2017), when 3737 doctors left the country.

Notably, in 2020 and 2021, further deceleration of migration was recorded, with the number of doctors leaving Romania falling to fewer than 500 people each year. The global health crisis brought on by the COVID-19 pandemic likely influenced medical professionals' decisions to remain in the country, possibly due to many Romanian health professionals voluntarily choosing to remain in the country, while destination countries reducing the active recruitment due to international mobility restrictions. Additionally, Romania adopted emergency government ordinances allowing vacant positions in the health system to be filled rapidly, ensuring sufficient staffing during the crisis [15]. At the end of the emergency state, another ordinance permitted the professionals who had occupied these temporary positions to remain in their roles, further stabilizing the workforce [16].

The migration patterns of Romanian nurses exhibit unique characteristics when compared with those of Romanian doctors. The emigration of Romanian nurses between 2011 and 2021 can be divided into two different phases. Table 2 provides insights into the emigration of Romanian nurses mainly to WHO/Europe countries, indicating the total numbers for 2011, 2016 and 2021 and the associated trends. An important migration wave occurred between 2011 and 2016, with more than 8000 Romanian nurses seeking opportunities abroad. However, the outflow of nurses has almost stopped since 2017. It is worth noting that data from countries with a substantial Romanian diaspora, such as Spain and Germany, are unavailable, potentially resulting in the underestimation of the actual figures. The distinction between the 2011–2016 and 2016–2021 periods reflects a clear break in the emigration trend, with significantly higher outflows prior to 2016 and a noticeable decline thereafter, although no single policy change in 2016 can fully account for this shift.

Table 2.

Romanian nurses reported working in the WHO/Europe countries, Canada and United States 2011–2021

Destination country	2011	2016	2021	2016 versus 2011	2021 versus 2016
Belgium	421	1329	1890	908	561
Canada	448	527	513*	79	-14
France	115	199	595	84	396
Hungary	300	431	595	131	164
Israel	92	71	50	-21	-21
Italy	11,215	11,714	11,906	499	192
Netherlands (Kingdom of the)	34	88	100	54	12
Sweden	4	50	91*	46	41
United Kingdom	1909	8115	7369	6206	-746
Total	14,538	22,524	23,109	8286	585

Compiled from WHO/Europe-Eurostat-OECD Joint Questionnaire on non-monetary health care statistics 2022 [13]. Numbers represent total stock reported by each “destination” country in respective year

^*Data from 2020 instead of 2021. Missing data from Spain, Germany, Ireland, United States and Denmark

Although not shown in Table 2 due to considerations of space, the decline in nurse emigration began after 2016 and was more abrupt than the downward trend observed for physicians. Between 2016 and 2021 only 585 nurses emigrated, suggesting that the phenomenon may have temporarily halted. This has coincided with the new pay policies implemented by the Romanian government for nurses working in public hospitals, which have led to wage increases.

In 2021, 23,109 Romanian nurses were reported to be registered as working mainly in WHO/Europe countries. The countries with the highest number of Romanian nurses differ from those with the highest number of Romanian doctors, with Italy being the main preference (hosting 11,861 nurses, more than 50% of the total population of Romanian emigrant nurses mainly in WHO/Europe countries). The United Kingdom ranked second with 7369 nurses. Negative migration trends were also reported for Israel and Canada between 2016 and 2021 [13]. JQ data may underrepresent Romanian nurses working abroad in informal roles, such as live-in care, which are often unregistered and not reflected in official statistics.

Figure 4 presents a line chart showing the numbers of Romanian nurses reported to be working in Belgium, Italy and the United Kingdom each year between 2011 and 2021. The chart provides insights into the changing dynamics of nurse migration in some preferred destinations for Romanian nurses. Between 2011 and 2021, migration to Italy, the main destination country, has remained relatively constant. The number of Romanian nurses in the UK increased more than in any other WHO/Europe country between 2011 and 2016, with more than 6000 nurses choosing to work there. However, the impact of Brexit is also reflected in the migration trends, with the number of Romanian nurses working in the United Kingdom decreasing by 746 nurses between 2016 and 2021, possibly reflecting either a shift in preferences or changes to the United Kingdom’s immigration policies [17]. Migration to Belgium exhibited a different trajectory, showing a slow but steady increase throughout the decade. This steady growth suggests that Belgium has become an attractive destination for Romanian nurses, potentially due to factors such as favorable working conditions and linguistic similarities.

Fig. 4.

Yearly Evolution of Romanian Nurses Working Abroad. Compiled from O WHO/Europe-Eurostat-OECD Joint Questionnaire on non-monetary health care statistics 2022 [13]

The impact of migration on the Romanian health care workforce has been profound. A 2016 survey by the Bucharest College of Physicians, titled "Migration, Causes, and Perceptions Among Young People Studying Medicine at the University and Residency Levels", highlighted the fact that around 82.3% of respondents, mainly young professionals, were considering emigration. The primary reasons cited included low salaries, poor material conditions in medical facilities, long working hours and insufficient support for research activities [18]. These factors not only demonstrate the challenges faced within Romania's health care system, but also underscore the allure of better opportunities abroad.

Policy responses to workforce migration

The Romanian health care system has undergone notable changes in workforce composition and distribution in the past decade. These have been outlined in the “Strategy for the Development of Health Workforce 2022–2030” and related documents [19]. The Strategy also identified the main objectives for achievement by 2030, among which are decreasing out-migration and improving retention throughout the country [20].

In response to this significant outflow of healthcare professionals, Romanian authorities have focused on creating conditions conducive to retention. Key initiatives have included increasing salaries, modernizing and equipping healthcare facilities, expanding residency positions, and enhancing medical education and research conditions.

Educational interventions

The substantial shortage of doctors recorded in 2015, largely attributed to migration, prompted a compelling need for government intervention. The total number of medical residents has increased by 34% since 2018, driven by a legislative amendment stipulating that the minimum number of positions to be filled through the national residency exam, organized by the Ministry of Health, should correspond with the number of medical graduates in the respective year. This pivotal change has resulted in an increase of more than 1000 residents per year (33% increase), as illustrated in Fig. 5. While no significant changes were made to the residency programs curriculum, there was a targeted increase in residency positions in specific fields, such as family medicine, to address workforce shortages and the aging population of family doctors.

Fig. 5.

Number of national residency positions. Compiled from The MoH Website—Residency Sect.  [21]

Romania's rich tradition of medical education, dating back to pre-communist times, underpins this accomplishment. Currently, the country is home to 11 accredited public medical universities (located in Bucharest, Timișoara, Craiova, Iasi, Cluj-Napoca, Constanța, Galati, Târgu Mureș, Brasov, Oradea and Sibiu), along with two private medical universities in Bucharest and Arad. Considering the fact that Romania's population is 19 million people, the number of medical universities is substantial.

In response to the health care workforce challenges exacerbated by migration, Romanian universities have taken significant steps to increase the number of students and graduates in the medical field. These initiatives include expanding enrollment capacities and creating additional medical education program to meet the growing demand for health care professionals. As a result, there has been a noticeable rise in the number of medical students and graduates, which has contributed to alleviating the overall shortage of healthcare workers. However, it is essential to strike a balance between increasing enrollment and maintaining the quality of medical education, to ensure that the health care workforce remains highly competent and well prepared to address the diverse health care needs of the population.

The surge in student admissions to medical universities began in the early 2010s and continued to increase steadily each year until 2021. In total, there has been a 73% increase in the number of medical graduates per 100,000 population from 2011 to 2021. Consequently, Romania has consistently fared high among EU member states in the past 12 years in the number of medical graduates per capita, as highlighted in Fig. 6. When compared to WHO Europe countries, Romania is the fifth largest producer of doctors among the 53 European countries. Notably, most of the countries that rank high in this figure, apart from Romania, have populations of six million or less, making it relatively easier for them to achieve a high number of medical graduates per capita. In contrast, Romania's sustained growth in medical graduates is particularly significant given its larger population size.

Fig. 6.

EU Graduates—Medical Doctors, 2011 and 2021 (per 100 000 inhabitants). Eurostat, Healthcare personnel statistics (hlth_rs_grd) [22]. *2011: not available. **2020 instead of 2021

Additionally, Romania is an attractive destination for training international students in biomedical sciences, particularly medicine, contributing to the high number of medical graduates. Romania's medical education system attracts a significant number of students due to its multilingual programs (offered in English and French), affordable tuition fees, and relatively accessible admission processes. These factors make it an appealing destination for both domestic students and international applicants, some of whom view Romanian medical degrees as a stepping stone to medical practice in other countries [23]. In the most recent National Report on Postgraduate Education (2021–2022) [24], it is highlighted that there has been a 26% increase in the number of international students studying in Romania in the last 6 years, with 35,392 students studying in various fields in 2022. The biomedical sciences is the most popular choice for international students enrolled in Romania, with 17,320 students enrolled, representing almost half of the total number of international students. Even though the exact percentage of international students in health-related bachelor's programs out of the entire pool of health students in Romania is not clearly provided, based on the data available in the 2021–2022 report, we estimate this percentage to be around 18.2%, which is a significant proportion. The leading countries of origin are—in descending order—the Republic of Moldova, Israel, France, Morocco, Italy, Germany, Greece, Syria, Tunis, Serbia, Hungary, Jordan. However, there is limited evidence that these graduates remain in the country after completing their studies, as most return to their home countries or pursue careers within the European Union.

Regulatory and development interventions

In addition to increasing the supply of new graduates, Romania has also implemented indirect retention measures, primarily through significant salary increases and infrastructure investments aimed at improving working conditions. Regulatory interventions have been used in tackling the migration of health care workers from Romania and increasing retention. While these measures are expected to support workforce stability, their specific impact on retention is difficult to isolate or quantify.

A significant regulatory reform involved expanding job opportunities in the public healthcare sector. This effort aimed to make positions in public institutions more attractive and accessible by creating new roles and streamlining recruitment processes. While progress has been achieved, strategic plans continue to focus on enhancing the public sector’s appeal. Between 2016 and 2022, the total number of public healthcare personnel—primarily employed in hospitals and ambulance services—grew by 20%, equating to an increase of 43,000 employees. Of these, 11,500 were specialist and resident physicians, while 13,000 were nurses. 1^,2

Additionally, the growth of private healthcare providers has played an important role in diversifying the sector. By offering modern infrastructure and significant investment, private facilities have provided alternative career paths for healthcare professionals; however, access to these services may be limited for some population groups due to out-of-pocket costs. This expansion has not only helped retain talent within Romania, but has also encouraged some healthcare workers to return from abroad, further strengthening the national workforce. Unfortunately, there are no systematic data sources capturing return migration among health professionals, and re-registration processes do not differentiate between new entrants and returnees, making it difficult to quantify this phenomenon.

The overall development program of the healthcare system have also been key in addressing the migration of health care workers from Romania. Programs such as the National Program for Resilience and Recovery [25] or the Regional Hospitals Development have laid out ambitious plans to construct and upgrade medical facilities nationwide. They extend beyond infrastructure development, offering employment opportunities and improved working conditions. The establishment of new and modernized medical facilities enhances access to quality health care services, making the professional landscape in Romania more attractive for health care workers and thus supporting retention.

The opening of university branches in smaller cities has impacted personal and professional development, although being in its initial stages. This measure allows health care professionals to pursue academic and teaching careers outside major urban centers, fostering knowledge dissemination and reinforcing the academic sector.

Financial interventions

Notable measures include a substantial salary increase implemented by public health care providers in successive rounds from 2015 to 2018. 3 This adjustment sought to retain health care workers in Romania and attract those working abroad back to the country. By offering more competitive salaries, aligned with those available in other European countries, this measure served as a strong motivation for health care professionals to continue their careers in Romania. After 2018, the rate of wage growth decreased.

The pay rises were exceptional in amplitude and time frame as depicted in Table 3. In 2022, the monthly median pay of a physician in public hospitals increased by almost 200% compared to 2016. In euros the growth was even higher: by 2022, the median gross wage of a physician with the highest professional grade was 250% higher than in 2016, up to more than 3800 euros per month. The real growth of pay for nurses during the same period was lower than that of physicians but was still substantial: median gross wages increased by between 40 to 70% in lei at constant prices and between 70 to 100% in euro equivalent, depending on the education and professional grade of nurses. In relative terms, compared to the national average gross wage, the remuneration of physicians increased by 40% (for primary and specialist physicians, from a ratio of 2 and 1.66 in 2016 to a ratio of 2.95 and 2.27, respectively, in 2022). However, for nurses, after the initial increases in 2015 to 2018, wages stagnated until 2023, which has translated in a relative decrease compared to the national average gross wage (for nurses with secondary education and professional grade “principal”, which are the most numerous in public hospitals, the ratio decreased from 1.48 in 2016 to 1.15 in 2022). This raises the need for a review of the remuneration of nurses to avoid a new migratory trend.

Table 3.

Median gross wages for selected positions and grades in the public hospitals (in lei at constant prices 2022 and in euro)

Job name	Professional grade	2016	2022	2022 vs. 2016 (%)	2016	2022	2022 vs. 2016 (%)
		RON at constant prices 2022			EUR
Physician	Primary	6498	19,061	193%	1104	3866	250%
	Specialist	5422	14,681	171%	922	2978	223%
	Resident	3549	10,069	184%	603	2042	239%
Nurse—tertiary education	Principal	6038	8620	43%	1026	1748	70%
	Basic	4609	7138	55%	783	1448	85%
Nurse—secondary education	Principal	4812	7457	55%	818	1513	85%
	Basic	4054	6936	71%	689	1407	104%

Corroborated data from two reports developed by the World Bank for the Romanian Ministry of Labor and Social Solidarity: Methodology for Monitoring the Public Sector Pay Law, World Bank, Bucharest, 2019, and Romania, The implementation of Pay Law 153/2017, Bucharest, 2023. National Institute for Statistics, Tempo database, for data on inflation 2016 to 2022. In Romania, a 'specialist physician' is a doctor who has completed residency and passed the specialization exam, while a 'primary physician' holds a higher rank, requiring at least 5 years of specialist experience and a subsequent primary exam. This hierarchy is reflected in their respective compensation levels

Another notable measure was enhanced financial support for family doctors, as a gradual introduction of a motivating financial mechanism for family doctors, starting from 2021. Given the integral role of family doctors in primary health care, this initiative has focused on improving their financial stability. The aim is to enhance the quality and accessibility of primary care services, especially in underserved regions, by providing better financial support to family doctors. Among the measures promoted to increase the appeal of family medicine in general, and to underserved rural areas in particular, the following stand out: expansion of the scope of services in family medicine, such as preventive consultations, screening procedures, ultrasonography, spirometry, electrocardiogram and diabetes medication prescriptions; increase of tariffs for all consultations either reimbursed by capitation or fee for service; an additional increase of tariffs for preventive consultations; introduction of a pay-for-performance mechanism for preventive consultations; generous lump sum payments for 3 years for family physicians who settle in rural local governments with no family medicine practice [26]. Family medicine has experienced a 124% increase in budget allocation over the past 7 years, rising from 1.66 billion lei in 2017 to 3.72 billion lei in 2023 [27] (in euro, the growth was 106%).

While these financial incentives will continue to generate positive effects, it is important to recognize that they are part of a broader solution. The complex nature of health care professional migration necessitates a comprehensive approach that goes beyond monetary compensation. Continuous collaboration with local authorities is essential to create an environment that not only offers financial rewards, but also fosters professional satisfaction and growth, thereby contributing to the overall sustainability of Romania's health care system.

Trends in health workforce in Romania 2015–2021

Human resources in health care in Romania have witnessed a significant transformation in recent years, characterized by a substantial increase in the number of physicians. Between 2015 to 2022, the total number of doctors registered in the country surged from 56,110 to 71,293, representing an increase of 27.5% (Fig. 7). This surge has played a pivotal role in elevating Romania from a worrying density of 282 doctors per 100,000 inhabitants in 2015 to a much-improved density of 374 doctors per 100,000 inhabitants in 2022, inching closer to the European Union's average of 410 physicians per 100,000 inhabitants [28].

Fig. 7.

Evolution of the Number of Physicians in Romania. Compiled from The National Institute of Statistics—Activity of The Health Facilities yearly report (2015–2022) [9]

Figure 7 reveals the categories in the growing number of physicians between 2015 and 2022. The biggest contributor has been the number of residents in training, which in 2022 was 56% higher than the number in 2015. Additionally, there was consistent growth in the number of specialists employed in the public sector, which by 2022 was 21% higher than in 2015. Of note, the pandemic years saw the hiring of nearly 1000 more specialists in the public sector, bolstering health care services across public hospitals, ambulance services and public health departments.

Furthermore, the private sector has shown significant development in recent years, reflected by a 15% increase in the number of specialists employed in 2022 vs 2015. This growth underscores the expanding role of the private health care sector in Romania's medical workforce. The collective impact of these dynamics has led to substantial enhancement of Romania's healthcare workforce, contributing to the ongoing improvements in health care accessibility and services within the country.

The evolution of the total number of nursing professionals is equally remarkable, which in 2022 was 21% higher than in 2015 (Fig. 8). However, it is important to note that, due to trends in the migration of nurses, the nursing deficit in 2015 was not as severe as that of doctors, and the subsequent increase was mostly due to new supply from training. In 2015, Romania had 667 nurses per 100,000 inhabitants and in 2022, with 843 nurses per 100,000 inhabitants, was close to the EU average of 871 nurses per 100,000 inhabitants [29].

Fig. 8.

Evolution of the Number of Nursing Professionals working in Romania. Compiled from The National Institute of Statistics—Activity of The Health Facilities yearly report (2015–2022) [9]

A particular aspect of the Romanian population of nurses is that a significant majority is represented by nurses who graduated nursing colleges [referred to as “nurses” in Fig. 8], while only a minority is represented by nurses with higher education studies. Figure 8 provides a visual representation of the marginal rise in the percentage of nurses with university-level education, which increased to 11.8% by 2022 from 9.7% in 2015.

Conclusions

Romania’s experience with health workforce migration underscores the complexity of addressing healthcare imbalances in an interconnected Europe. Despite high migration levels following its accession to the EU in 2007, Romania successfully implemented a bundle of coordinated policy interventions that led to a two-thirds reduction in the annual migration of doctors from 2012 to 2021 and a 32% increase in the availability of doctors in the country between 2015 and 2022. This demonstrates that out-migration challenges can be overcome, providing a model for other European countries facing similar issues.

The migration of healthcare professionals has provided opportunities for career growth and economic advancement for individuals but has simultaneously created significant challenges for the Romanian healthcare system. One key takeaway from Romania’s experience is that financial incentives alone are insufficient to sustain improvements in workforce retention. The substantial salary increases implemented in 2018 slowed migration rates, yet they did not fully address poor working conditions and limited access to advanced equipment. Similarly, while expanding medical education and increasing the number of residency slots have bolstered the overall healthcare workforce, these measures have not resolved the unequal geographical distribution of professionals. The Multianual Strategy for the Development of Human Resources in Health 2022–2030 outlines national-level priorities to address workforce maldistribution, including newly launched guidelines to support local authorities in recruiting and retaining health professionals in underserved areas [30].

On a broader scale, Romania’s challenges and interventions offer valuable lessons for other European countries experiencing high health workforce outflows, highlighting the importance of sustained policy efforts, strategic funding, and educational measures to address workforce migration and its long-term impacts. By continuously monitoring and refining workforce policies, European nations can ensure a more stable and sustainable healthcare workforce for the future. Looking forward, Romania’s health workforce strategy must respond to emerging challenges such as fiscal sustainability, EU-level labor mobility, and persistent regional disparities. While recent salary increases are currently sustainable, maintaining investment in infrastructure and broader retention programs will be essential, though potentially challenging, in a constrained fiscal environment.

While this study focused on Romania as a case study, future comparative analyses across EU member states—particularly those that joined in the 2004 and 2007 accession rounds—could provide deeper insight into whether observed migration trends are primarily driven by national policy interventions or by broader structural dynamics within the EU labor market. Additionally, future research could explore return migration motivations through qualitative methods, leverage alternative datasets such as the EU Regulated Professions Database, and examine underreported migration pathways, including Romanian nurses employed in informal care roles across the EU.

Author contributions

RC, TCB, and NDG created the initial draft of the manuscript, conceptualized the study framework, and coordinated the research process, with support of AR and IN. TZ, CS, YA, NAM and KA conducted the further review, provided critical feedback, and contributed to refining the policy evaluation and contextual interpretation of the findings. All authors participated in multiple rounds of manuscript revision, ensuring intellectual content accuracy. They reviewed and approved the final version for submission. The authors take full responsibility for the integrity of the content and agree to be accountable for all aspects of the work. All authors had full access to all data in the study and had final responsibility for the decision to submit for publication.

Data availability

No datasets were generated or analyzed during the current study.

Declarations

Competing interests

The authors declare no competing interests.