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Health Professionals Migration – the Case of Romania

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Published in: Journal of Health Economics and Management, Vol. 2(40), 2011, pp. 3-21

HEALTH PROFESSIONALS MIGRATION – THE CASE OF ROMANIA

МИГРАЦИЯ НА МЕДИЦИНСКИТЕ ПРОФЕСИОНАЛИСТИ В И ОТ РУМЪНИЯ

Maria Rohova
Department of Health Care Economics and Management, Medical University - Varna

Мария Рохова
Катедра по икономика и управление на здравеопазването, Медицински университет - Варна

Abstract: Migration of health professionals is an important concern not only in developing but also in developed
countries. It has different forms and types and affects health systems of sending and receiving countries both
positively and negatively. In Romania immigration is negligible in its size and importance and emigration is the
prevailing migration process. The most important health professionals’ deficit in the country is of physicians and
nurses. The major part of this deficit is due to emigration.
This paper presents the main results from a study about health professionals’ migration in and from Romania,
which is part of international project „Mobility of Health Professionals”, funded within the Seventh Framework
Programme. The general objective is to investigate and analyse current trends of migration of health
professionals in Romania. The research combines quantitative with qualitative methods but emphasise on the
qualitative studies (in-dept interviews with key stakeholders in health system).
Before Romania’s accession to European Union in 2007, nurses were more likely than physicians to practise the
same profession abroad; after January 2007, the situation changed with physician diplomas recognised in the
European area and now more Romanian physicians are willing to emigrate. The main destination countries for
Romanian health professionals are: for physicians and dentists - France, United Kingdom, Germany, Italy, and
Spain, and for nurses – Italy, Spain and United Kingdom. There are several reasons for migration: level of
professional development, level of salaries, living and working conditions, career development opportunities,
etc. The main influence of emigration on the national health system is a negative one as a whole, because
generates mainly health workforce deficit with further negative consequences on quality of health services,
specialised health care, expenses for health education, etc. Nevertheless, there isn’t specific human resource
strategy in Romania, regarding the migration of health professionals. The measures, both incentives (such as
salaries increase, access to training and professional enhancement opportunities, etc.) and restrictive ones
should be established based on evidences.

Key words: emigration, return migration, physicians, nurses, health system, push/pull factors

Резюме: През последните години все по-значим става проблемът, свързан с миграцията на
медицинските професионалисти, като засяга както развиващите се, така и развитите страни.
Миграцията има различни видове и форми и оказва едновременно положително и отрицателно
въздействие върху здравните системи на отделните държави. В Румъния имиграцията е незначителна
в сравнение с емиграцията. В страната се наблюдава съществен недостиг на лекари и медицински
сестри, като значима част от този недостиг се дължи именно на емиграционните процеси.
Настоящата разработка представя основните резултати от изследване относно миграцията на
медицинските професионалисти в и от Румъния, което е част от международен проект по Седма
рамкова програма - „Мобилност на медицинските професионалисти”. Целта на изследването е да се
проучат и анализират тенденциите в миграционните процеси в Румъния. За постигане на целта са
използвани количествени и качествени методи, като приоритетно се набляга на вторите, свързани с
провеждането на дълбочинни интервюта с представители на различни нива на здравната система.
Преди приемането на Румъния в Европейския съюз предимно медицинските сестри търсят работа в
чужбина, като след януари 2007 ситуацията се променя с признаването на дипломите за медицинско
образование и в момента повече лекари желаят да емигрират. Румънските професионалисти избират
приоритетно страни-членки на Съюза: лекарите и стоматолозите емигрират предимно във Франция,
Англия, Германия, Италия и Испания, докато сестрите предпочитат Италия, Испания и Англия.
Няколко са основните мотиви за работа в чужбина: професионално развитие, равнище на заплащане,
условия на работа и живот, условия за кариера и др.
Емиграцията на медицинските професионалисти влияе предимно негативно върху здравната система,
водейки до недостиг на работна сила и оказвайки въздействие върху качеството на здравните услуги,
специализираната медицинска помощ, разходите за обучение и т.н. Въпреки това обаче в Румъния няма
стратегия за задържането на медицинските професионалисти и въпросите за емиграцията не стоят
на дневен ред в здравната политика. В тази връзка разработването на комплекс от мерки за справяне с
проблема – както стимулиращи (като увеличаване на заплащането, възможности за обучение и
професионално развитие), така и рестриктивни – трябва да бъде основан на доказателства и включен
в здравната стратегия на страната.

Ключови думи: емиграция, лекари, медицински сестри, здравна система, мотиви за миграция.

1. Introduction
The migration of health professionals within and between countries is a growing phenomenon
worldwide. This migration affects provision of services, quality of care, and distribution of
staff across administrative units and countries (Diallo 2004). Globalisation and liberalisation
of regional labour markets accelerate the migration processes.
There are different types of migration: internal migration (describes movements of health
personnel within national borders - across national administrative units or between rural and
urban areas); international migration (describes movements of health workers who
temporarily or permanently settle abroad) and return migration (includes migrants who return
in home country and continue to work in health care and has mainly positive effects on the
health systems).
Health workers migrate from developing or less developed to developed countries to better
their economic or social situation immediately or for the purpose of career development
(Rutten 2009). These outflows (permanent emigration of health professionals) are usually
associated with so-called medical “brain drain” which causes the unique problem of severe
workforce shortages in home country’s health systems. The permanent departure of skilled
labour might deplete the human capital of sending countries, thus reducing the possibility for
economic growth and raising the level of inequalities and poverty in those countries (Forcier
et all. 2004). Because of this the international migration of health workers has become one of
the major features on the health policy agenda.
The paper presents the main results from a study about migration of health professionals in
Romania. The study is part of the project Mobility of Health Professionals, funded within the
Seventh Framework Programme. The general objective of the project is to investigate and
analyse current trends of the mobility of health professionals, i.e. first of all nurses and
physicians, to, from and within the European Union (EU). The national research is conducted
in 25 countries worldwide (in- and outside EU), which are determined as predominately
receiving or predominately sending countries. One of these 25 countries is Romania. The
research combines quantitative with qualitative methods but emphasise on the qualitative
studies (in-dept interviews). The general idea of this approach is to put the focus on key
stakeholders (individual health services entities at micro level and different health
associations, unions and institutions at national level) in order to collect existing data and
statistics, but first of all to generate new qualitative data that can qualify the statistics. The
study is implemented in two phases:
 macro level research – this phase has two major tasks: to investigate and analyse available
statistics about migration and previous studies and to conduct in-dept interviews with
representatives of institutions and organisation at national level as Ministry of Health,
national insurance funds, associations of health professionals, scientific institutes, etc.
 micro level research – this phase is concentrated on conducting qualitative in-dept
interviews with health professionals working in home country and health professionals
working abroad in order to investigate the attitudes toward migration, as well as reasons
for migration.
This paper presents the main results from the research about Romania,1 conducted between
2009 and 2011. The objectives of the paper are as follows:
 to analyse some quantitative data about supply of health professionals in Romania and
statistics about general migration in and out of country;
 to present data and information about in-and outflows of health professionals in Romania,
including available statistics and previous studies;
 to discuss some of the results from in-dept interviews with key stakeholders at macro and
micro level.
The approach is the same as described above and combines quantitative (analyses of available
statistical data) and qualitative (in-dept interviews) methods. Detailed description of
respondents and the motives for including different groups in the sample are presented in
chapters 6 and chapter 7. This paper does not discuss internal and cross-sectoral migration of
health professionals in Romania, as well as illegal migration (which are analysed in the whole
report). The discussion is limited to international migration and partly refers to return flows to
the home country.
In the paper, the terms “health workers”, “health personnel”, “health workforce” and “health
professionals” are used interchangeably.

2. Background – some basic facts about Romania

Romania has experienced a long and difficult transition during the last 22 years. After the fall
of the communist régime in 1989, there were significant changes in the political and
economic model in the country, which also affected the health system. After 1989, the
political system moved towards democracy and Romania made great progress in
institutionalising the democratic principles, civil liberties and respect for human rights.
Romania joined the EU on January, 1 2007. The prospect of becoming an EU member
constituted a solid external anchor for the transformation of the country throughout its
transition.
Romania is classified by the World Bank as an uppermiddle-income country with gross
national income per capita of US$ 7,930 in 2008 (World Bank 2009). The economic
performance of the country has been remarkable between 2000 and 2008 - inflation and
interest rates have declined steadily, foreign exchange reserves increased to historic highs and
external debt was held to comfortable levels. The export growth has become vigorous.
Progress in economic reforms has translated into robust annual Gross Domestic Product
(GDP) growth, averaging 5–6%, for eight consecutive years. Nevertheless, important
vulnerabilities remain. In 2007, the real GDP per capita reached 42% and in 2008 it was
around 45% of the EU average. Among the 27 EU countries, Romania took 26th place in
2008, followed only by Bulgaria, according to real GDP per capita (Eurostat 2009). In 2009,
after eight years of rapid economic growth and impressive gains in poverty reduction, the
shockwave of the global economic crisis has affected the Romanian economy.
After the early 1990s the demographic trends in Romania show continual population decline
that is supposed to accelerate in the future. The negative values of the natural increase, added
to the external migration, led to a considerable diminution of the country's population. The
demographic changes in Romania are result of a few basic developments:
 birth rate is low and further decreasing as a result of different social and economic factors;
 death rate is close to the rate in EU countries but there is an increasing trend;
 life expectancy at birth increases slightly but still remains at the lowest levels among the
EU countries.

1
The results are published in National Report: Romania (334 pages).
Despite the improvement of some health indicators (life expectancy, infant and maternal
mortality) in recent years, there is still a significant difference between health status in
Romania and in the other EU member states. The standardised death rate for all ages in
Romania is higher than the EU average. In 2008 it was 964.3 per 100,000 inhabitants or
around 30% higher than the EU average (WHO EURO 2009). In recent years the leading
causes of death were cardiovascular diseases, cancer, digestive diseases, injuries and
poisoning. As compared with EU averages, mortality due to diseases of circulatory system is
far more significant in Romania. Since 2003, mortality due to infectious and parasitic diseases
has been decreasing but it is more common in Romania than in other EU member states.
Romania experiences high death rates from causes that are amenable to effective health care.
Indeed, during the 1990s, amenable mortality actually increased in Romania at a time when it
was declining elsewhere in Central and Eastern Europe. Access to high-quality prevention
and care remains problematic for a large proportion of the population.
Social health insurance plays a central role in the Romanian health care system. Since 1998,
the national budget for health care has had two major sources: the state budget and the
National Health Insurance Fund (NHIF), with the latter representing more than two-thirds of
the total health care budget. The introduction of the health insurance scheme has increased
public expenditures and total expenditures on health. Between 1999 and 2007, the public
spending on health has fluctuated between 3.4% and 4% of GDP and in 2007 it was 4.2%.
Health expenditures per capita in Romania increased from US$ 75 in 1999 to US$ 329 in
2007 (WHO EURO 2009). However, Romania still spends a lower percentage of GDP on
health than in all neighbouring countries and almost all countries in Europe. The level of
health expenditures per capita in Romania is also much lower compared with countries from
Western Europe and with many countries from Central and Eastern Europe.
Compared with other European countries, Romania has high inpatient care admission rate,
reflecting the low efficiency and underutilisation of primary and ambulatory care services.
According to the analysis of the World Bank, while the average length of stay in Romania has
decreased significantly over time and bed occupancy rates are relatively high compared with
other countries in the EU, making the Romanian hospital system look efficient, in reality this
reflects the current practice of boosting utilisation rates by increasing the number of cases
admitted in a manner that more than offsets the decreased length of stay (World Bank 2007).

3. Health workforce in Romania

Romanian health care personnel can be grouped into four categories: doctors (physicians and
dentists), nursing professionals, pharmacists and auxiliary staff. Nursing professionals include
nurses, midwives, social workers, dental technicians. Other categories of personnel in the
health care sector (administrative staff) account for less than one in twenty of health sector
employees (Vlădescu et all. 2008).
In the 1990s, the number of physicians in Romania fluctuated between 176 and 181 per
100,000 inhabitants and the ratio had not changed significantly till 1999 (WHO EURO,
2009). The number of physicians has risen slightly in 1999 and 2000 in comparison with the
early 1990s; however, this cannot be attributed to any specific policies. It was still very low
compared with the EU average (304 in 1999 and 307 in 2000) (Fig. 1), or even with similar
countries such as Bulgaria.
Since 2000, there has been an increasing trend in the number of physicians in Romania. Data
from 2005 indicate that Romania had one physician for every 456 people, or 219 physicians
per 100,000 people (Fig. 1). In 2008, the number of physicians in Romania was 50,238 or one
physicians for every 428 people (234 per 100 000 people). Although the number of physicians
has been increasing in the recent years, it is still comparably low in comparison with
European countries (Fig. 1), as well as with the neighbouring countries. However, what the
number of physicians hides are the country’s main problems in this area: geographic and
medical speciality misdistributions and quality concerns (Vlădescu et all. 2008).

Fig. 1 Physicians per 100,000 inhabitants in Romania and EU, 1999 to 2008 (2007 for EU)
350
Physicians per 100 000 inhabitants

330
310
290
270
250
230
210
190
170
150
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Year

Romania EU

Source: National Institute of Statistics (NIS) 2009; WHO EURO 2009.

According to the Ministry of Health statistics, there aren’t significant changes in the number
of family physicians between 2000 and 2007. The NHIF estimated that there was a deficit of
1,930 family doctors in 2004, while 1.35% of the rural population was not registered with any
family doctor. Since 2004 there was a slightly increase, but the number of family doctors was
only with 175 higher than in 2004 (Ministry of Health 2008). Regarding the medical
specialties, where is the biggest deficit, these are: intensive care and paediatric. Other
specialties are anestheology, clinical laboratory and clinical pathology, narrow specialties
such as cardiology. The major part of this deficit is due to emigration especially for intensive
care. There are also problems with general practitioners, psychologists and neurologists.
The number of dentists also has been increasing in the last ten years, but in contrast to the
number of physicians the increase in number of dentists is significant. In 1999, there were
7,708 dentists (34 per 100,000 inhabitants); in 2008, their number was with 55% higher –
11,898 or 55 dentists per 100,000 inhabitants (NIS 2009).
The number of nurses in Romania, by European comparison, is low, almost at half of EU
average (Fig. 2), more than a half of EU-15 average (805 per 100,000 in 2006) and below the
average of EU members since 2004 and 2007 - 567 per 100,000 in 2006 (WHO EURO,
2009).
Fig. 2 Nurses per 100,000 inhabitants in Romania and EU, 1997 to 2006 (last available)
800
Nurses per 100 000 inhabitants

750
700
650
600
550
500
450
400
350
300
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Year

Romania EU

Source: WHO EURO 2009.

Between 1986 and 1994 there was a slight decline in the number of nurses in Romania. In
1996 there were 441 nurses per 100,000 inhabitants (WHO EURO 2009). After that, there
was significant decline till 2001, when the number of nurses decreased to 403 per 100,000
people. After slightly increase in 2003, there was another period of decline and in 2006 (the
last available data) the number of nurses fell to 397 per 100,000 inhabitants or one nurse per
252 inhabitants (WHO EURO 2009). The reasons for this decline are probably connected
with the outflow of professionals both from the country and from the health sector.
The midwife density in Romania also has been declining since 1999 and in 2006 it was 23
per 100,000 inhabitants or 4,393 inhabitants per one midwife (WHO EURO 2009), which was
also below EU average.
The number of registered pharmacists and pharmacies was not regulated until 1999, when
Ministerial Order introduced restrictions: the number of pharmacists cannot exceed 1 to 5,000
inhabitants; and pharmacies have to be located no less than 250 metres apart. After extensive
debates, in 2004, the Ministry of Health revised the limits as follows: 1 pharmacist/5,000
inhabitants in Bucharest, no more than 1/3,500 in district capital cities and no more than
14,000 in the remainder of the cities. There are no constraints regarding the location and no
limits in rural areas (Vlădescu et all. 2008). Despite of the limits, the number of pharmacists
has been increasing steadily since 1999. In 2008 the number was almost double in comparison
with 1999; in 2008 the pharmacist density reached 55 per 100,000 inhabitants (NIS 2009).
There was also increase in the number of pharmacies and pharmaceutical outlets, so that in
2008 their number amounted to 7,252 units, with 1,429 more than in 2005 (NIS 2009). The
main reason is that the pharmacies are predominantly private and very attractive sector for
business and work.
One of the main challenges for human resources management in Romania is the unequal
geographical distribution of medical staff. There are significant imbalances in the territorial
distribution of physicians. Most of the health workers are concentrated in the big university
cities (Bucharest, Cluj-Napoca, Iaşi, Timişoara, etc.) or in the most economically developed
districts (from Transylvania and western Romania). There are considerable differences in the
distribution of specialists between urban and rural areas. This situation is associated with a
lack of good incentives offered for general practitioners and specialists to work in rural or
deprived areas (Galan 2006).
The social status of doctors and of the other personnel categories from health care sector is
low, relating directly to their wages. In 1998, the average monthly salary in the health care
sector was below the national average salary as calculated by the NIS. In the same year, a
survey conducted by the Centre for Health Policy showed that 93% of the primary health care
physicians considered their income as insufficient. Since 1999, this situation has improved
(Vlădescu et all. 2008). However, between 1999 and 2008 the average salary in health and
social assistance has been increasing, but still remaining below the national average. In 2008,
the net monthly salaries in health and social assistance (1,267 lei, app. EUR 344) took the 6th
place among other activities of the national economy (NIS 2009).

4. General migration flows in Romania

Emigration from Romania abroad is greater than immigration and that is one of the main
reasons for the population diminution. According to the NIS (2009), the population that has
left Romania between 1990 and 2008 is estimated at 404,396 persons, with this flow
decreasing at a rate of about 10,000 people annually. Between 1991 and 2008 the immigration
is estimated at 104,835 persons. The simple mathematical difference between immigrants and
emigrants over the period 1991-2008 is a negative. The exceptions were registered in 2001,
2007 and 2008 when immigrant numbers were surpassing the emigrant numbers (Fig. 3). But
the data refer only to the permanent migration; NIS calculate only the number of foreign
citizens, who have settled their permanent residence in Romania, as well as the number of
Romanian citizens, who have settled their permanent residence abroad.
From the census data of 1992 and 2002, one can see a decline in the recorded population of
Romania of about 1.13 million persons. Only 330,000 of this decline are accounted by the
natural population increase, leaving a residual of net migration at about 800,000 persons. The
data are also misleading, because circular illegal migrations are unlikely to be captured by a
census, or indeed any other usual statistical measure (Baldwin-Edwards 2005). According to
Gheţău (2008), between 1990 and 2006 the Romanian population has been decreased with
about 1.5 million inhabitants or with 6.5%. Only 29% of the population loss is caused by the
negative natural increase rate; 21% is caused by the known and recorded emigration and the
rest 51% - by the not recorded but estimated external migration.

Fig. 3 Net migration in Romania, 1991 to 2008

5000

0
1991
1992
1993
1994
1995
1996

1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007

2008

-5000

-10000
Net migration

-15000

-20000

-25000

-30000

-35000

-40000

-45000
Year

Source: NIS 2009.

At the beginning of 1990s Romania had a relatively modest level of immigration. Toward
the end of 1990s and the beginning of 21st century, a peak seems to have been reached
(11,907 individuals in 1998 and 11,024 in 2000), after which the numbers started to drop until
2005 (NIS 2009). Between 2006 and 2008 the number of foreign citizens with a permanent
permit in Romania has been increasing.
The immigrant’s dominant profile (a refugee, an asylum seeker, an immigrant for labour,
study or business purposes) is predominantly male. In recent years, the profile of the average
immigrant is male aged 18–35, with vocational or high school studies, working as skilled
workers in big cities and Bucharest (Lăzăroiu, Alexandru 2008).
After 1990, migration movements in Romania largely concern emigration. Between 1990
and 1993 there was mass permanent emigration of ethnic minorities (German, Hungarian).
Since the second half of the 1990s temporary migration for work to developed countries has
become the main form of outward migration.
2002 is considered a turning point in the migration phenomenon. The elimination of the
Schengen visa requirement promoted a rapid growth in circular migration. Permanent
migration fluctuated between 8,000 and 14,000, significantly below the levels from the first
half of the 1990s and was almost replaced by temporary migration (Mircea, Pristavu 2008). In
2007 and 2008, migration movements in and out of Romania were marked by the country’s
accession to the EU. It is estimated that more than 1.5 million Romanians were working
abroad in 2007 (Sandu 2007).
The data for permanent migration shows that most Romanian emigrants, who settled their
permanent residence abroad, are 18–40 years of age, and have already acquired some
professional experience and skills. This age also gives a large enough span of active life
remaining, including readiness for training and continuing education programmes. There are
more female emigrants than males (NIS 2009). Regarding temporary labour migration,
migration flows are male dominated, composed of average-educated people, young persons,
skilled workers from Bucharest and other big cities. After 2007, both low- and high-skilled
workers took advantage of the open borders.

5. Inflows and outflows of health professionals in Romania

In Romania, as in most other countries there is a basic problem with the current data
availability on health professionals’ migration. Data referring to internal and external
migration are extremely poor as there is not a standard and constant procedure for data
collection. There are extremely few studies in Romania attempting to assess the level of
emigration phenomenon, and even fewer focusing on health workers. This is due to the fact
that there are very scarce sources of information and moreover, they are not publicly available
(Wiskow 2006; Buchan, Gabay 2007; Galan 2007; Vlădescu et all. 2008).
If data on emigration are difficult to retrieve, data on immigration are even scarcer. Still the
definitions used for immigration are different for different data providers. For instance, the
NIS defines the immigrant as the person having a stable official residence in Romania
(repatriates and foreign persons with Romanian citizenship), while the Ministry of
Administration and Interior defines the immigrants as foreigners living in Romania for more
than 120 days. Data do not allow detecting the structure of immigrants by profession, so
number of immigrant health workers is unknown (Galan 2006).
Nevertheless, it is well known that health care personnel migrate (especially physicians)
towards the main university centres (Bucharest, Cluj-Napoca, Iasi, Timisoara, etc.) and the
economically developed areas (in the west of Romania and in Bucharest). There are several
international studies in the field of health professionals’ migration, some of them addressing
also the issues of Romanian health workers migration and providing partial information about
this phenomenon.
Zaman and Sandu (2004) conducted a study about the emigration of highly educated
Romanian citizens between 1980 and 2000. The analysis of emigration trend among
physicians reveals the decline of emigration after 1990. During 1980-1990 the share of
physicians/pharmacists has been fluctuating between 13.4% and 16.6% of total number of
high-educated emigrants. After 1990 there was a decrease – from 14.2% in 1990 to 11.7% in
1995. In 2000 the share of physicians/pharmacists fell to 9.9%. This can be due to the fact that
before starting employment, health professionals have to fulfil the appropriate registration and
licensing requirements of the receiving country that can be very difficult for this profession.
Some emigrants preferred to attend again the courses of medical universities in the recipient
countries rather than to follow the licensing procedures. According to the study, in 2001 the
Romanian emigrant physicians represented a small share of the total emigrant stock -
approximately 1.9%. It isn’t clear and valid information is not available if they continue to
practice medicine in the receiving countries. In 2001, the most of the Romanian emigrant
physicians were of 30-39 years old, when they have already acquired professional experience
and skills. Females were preponderant in the case of physicians.
An idea of the dynamic health worker flows within the OECD member countries can be
gained from a recent OECD study on physician supply (Dumont, Zurn 2007). The data
suggest that a large part of Romanian health professionals have migrated in OECD countries
and before the Rumania’s accession to EU a significant number of doctors and nurses from
Romania were already working abroad. According to the study of Dumont and Zurn (2007),
in 2000, there were 4,592 Romanian physicians, 5,182 nurses, 1,038 dentists and 407
Romanian pharmacists, who have been working in OECD member countries.
According to Roberfroid et all. (2009), since 2004, the larger group of immigrant doctors in
Belgium has come from the eastern part of EU (Poland and Romania). The same state
Dumont and Zurn (2007). They suggest that the enlargement waves from 2004 and 2007 have
undoubtedly affected the inflows of foreign doctors and nurses from new accession states,
although these changes may be difficult to identify in migration statistics. After 2000, the
immigration from Romania has been showing increasing trends. In Italy, for instance, about
half of the recognition of foreign nursing qualification in 2005 was for Romanian nurses.
A study carried out by Garcia-Perez et all. (2007) show that in 2005 4,397 Romanian
physicians were registered in other countries or this was 10.37% of the total number of
Romanian physicians. In the same year one-third of them or 1,523 Romanian physicians have
been working in other EU country.
Totally different are the data concerning health workers that left Romania, either temporary or
permanently, which the Ministry of Health of Romania is collecting. Data from the Ministry
of Health show that in 2004, there were 2,012 Romanian health professionals working abroad.
Out of them 360 (18%) were physicians, the rest of 82% being nurses. Most of the physicians
working abroad were specialists working in hospitals (76%) and only 6% were family
doctors. The same situation could be noticed for nurses: 82% were nurses working in
hospitals. However, this is only a rough estimation of health staff working abroad, possibly
underestimating the phenomenon. The data do not provide clear information on
temporary/permanent emigration pattern or on the destination countries (Galan 2006).
Before the moment of Romania’s accession to EU in January 2007, nurses were more likely
than physicians to be practising the same profession in the country of destination, due to the
bilateral agreements for nurses between Romania and different EU countries (like Greece,
Spain and Italy) for diploma recognition that were not in place for physicians. After January
2007, the situation changed with physician diplomas recognised in the EU area and now more
Romanian physicians are willing to emigrate.
The destination countries have changed during the years (Table 1). Nevertheless, after
Romania’s accession in 2007 EU countries became most preferred destination for Romanian
health professionals. According to Vlădescu et all. (2008), France, Germany and the United
Kingdom are the most popular countries with Romanian physicians for emigration, as they
have active policies in recruiting external personnel, including from Romania. In these
countries, the most popular specialisations are general medicine, intensive medicine and
psychiatry.

Table 1 Trends in preferred destinations for Romanian health professionals

General Health professionals out-migration
out-migration Doctors Nurses Dentists Pharmacists
1990s
Italy USA No data No data No data
Hungary Hungary
USA Canada
Austria France
Canada Australia
France
Early 2000s
Permanent: USA USA USA Hungary
USA Hungary Hungary Hungary USA
Canada Canada Canada Canada Canada
Germany France Australia Australia
Italy Sweden Greece
Austria Sweden
Switzerland
2004-2007 (Romania enters Schengen in 2002)
Temporary: USA, Greece, No data No data
Italy Germany Spain
Spain United Kingdom Italy
Germany France
Hungary Italy
Portugal
United Kingdom
2007 and later: EU entry
Spain France Spain No data No data
Italy Germany Italy
United Kingdom Germany
Italy United Kingdom
Belgium France

The migration of young physicians is an important concern. Because mainly young doctors
are leaving Romania, the health system may lose part of its best stock of young human
resources together with its innovative capacity. The College of Physicians in Romania has
asked the Ministry of Health to elaborate a strategy of human resources in health system that
takes into consideration the high rates of emigration, especially among young physicians.
Lately, there have been many indications of this concern in the media. Recently most media
reports voiced concerns that the expected outflows of health workers to West European
countries could have negative effects on the health service delivery in Romania. In 2009, the
president of the Romanian College of Physicians announced that in the last two years 5,000
Romanian physicians have left the country. The physicians who emigrate are mainly
specialists, between 25 and 36 years old and prefer to work in hospitals in France, Italy,
Belgium and the United Kingdom (Evenimentul Zilei 2009). The president of the College of
Physicians warned that the shortage of physicians may bring the whole Romanian health
system to collapse.
One of the possible measures of migration potential or at least of intention for migration
relates to certificates issued to competent authorities. Following January 1, 2007, the
Romanian physician’s diplomas were recognised within the EU. Starting January 15, 2007 the
Ministry of Health in Romania issues, on demand and after they were previously tested, a
certificate which attests the physician’s, nurse’s and midwifery’s diplomas. This information
gives an overall idea of how many certificates were issued in respect of professionals who
were considering moving to another country.
The Ministry of Health reported that by the end of August 2007 there have been submitted
3,500 applications for attesting the physician diplomas (including dentists and pharmacists),
of which 2,800 were approved and other 700 are being analysed. Also there were
approximately 2,600 applications for obtaining the conformity certificate for nurses and
midwives, and 1,550 have already been settled (Galan 2007). According to Ghinea (2009),
4% of Romanian physicians have requested documents allowing them to leave the country to
work abroad. In the first nine months of 2008, 957 physicians requested the certificates in
order to be able to work abroad. They are willing to leave the country because of low wages,
poor conditions and lack of modern technology in Romanian hospitals.
Nevertheless, not all the persons who obtained such a certificate emigrated. These numbers
may serve as roughly estimations of the health professionals who intend to leave the
Romanian health system. It is also possible that health professionals, who are not yet verified,
may still migrate and work either in position that do not require verification of their
professional qualifications (e.g. care assistants) or in other sectors.

6. Results from qualitative study – interviews on macro level

The study on macro level was realised in two rounds:
1. First round was conducted in 2009. The interview guide includes 40 questions, divided in
10 sections. Unfortunately, all our attempts to conduct interviews were unsuccessful.
Many of the places we have refused, on the other received no response. The main reasons
were the political crisis in the country and lack of security. Many experts in the ministries
and other institutions were changed and others remain embarrassed and sceptical about
their workplaces. During this phase one interview with an expert of the Ministry of Health
was hold. The respondent was interviewed face-to-face.
2. Second round was conducted in 2010. The interview guide includes 17 questions. During
this phase 6 respondents were interviewed via e-mail and Skype-sessions. The sample
includes:
 an expert of the Ministry of Health;
 a representative of the NHIF;
 a regional coordinator of the Romanian College of Physicians;
 a representative of the Romanian Order of Nurses and Midwives;
 a professor in medical university;
 an assistant in scientific institute.
All interviewees agree that the Romanian health professionals, who are emigrating the most,
are physicians and nursing professionals (especially nurses and midwifes). Other health
professionals, who are willing to emigrate, are dentists, dental technicians, laboratory
assistants and X-ray laboratory assistants, rehabilitators and staff who is working abroad in
the research area. So, all health professionals emigrate, but intensity and frequency of
physicians’ and nurses’ emigration is the highest. This confirms the fact that the emigration is
one of the leading prerequisites for health professionals’ deficit in Romania.
It can be distinguished two main periods with a greater dynamic of emigration for medical
doctors, which do not seem to be linked to reforms of the health system:
 the first one, after 1989 when the free movement of persons came in place;
 the second period, after the accession of Romania to the EU, when the mutual recognition
of qualifications had begun to operate.
All respondents were agreed with the statement that emigration reduces the chances of the
health system to meet effectively the health needs of the population. Interesting view shared
one of the experts who said that emigration disturb the continuity between generations in a
certain specialty. Young professionals are more active and efficient, but also more willing to
take risk and seek work abroad. Moreover, the emigration leads to deficit of health
professionals and cause problems with recruiting the necessary personnel. The healthcare
establishments couldn’t meet the quality requirements. Another interviewee pointed that “we
train specialists but we do not satisfy our needs”.
The prevailing opinion is that the main influence of the emigration on the national health
system is a negative one as a whole, because generates mainly a health workforce deficit. The
migration, especially leaving Romania to establish into other countries has negative
consequences on the expenses for educating health care workforces (because most of the
migrating health care workers are graduated from the public medical schools). Also this type
of emigration has negative consequences as fewer specialised services are available for the
population, less research and developments of public health services can be achieved and
knowledge transfer for the existing health care personnel is disturbed. It limits the
opportunities of providing medical care, restricting the access of the population to health
service, cause imbalance between the specialties and deterioration of medical care. Moreover,
one expert mentioned that “emigration creates tension in the system because shortage of
qualified and experienced professionals reduces the quality of services”. The trend has no
major consequences on level of the salaries, competition between the employers and also no
consequences on working conditions.
The results from the interviews with representatives of key Romanian stakeholders lead to
following conclusions:
 A serious problem in Romanian health system is the shortage of health professionals
(especially physicians and nurses), largely due to the processes of migration - both
internal migration and emigration.
 All of the respondents pointed that the emigration is very widespread trend and it is a
problem yet. The experts on macro level expressed the opinion that strategies and
programs to retain the local health professionals have to be elaborated.
 There are steady trends of migration from rural to urban areas. The other types of internal
migration, i.e. from public to private health care establishments and from health sector to
other economic sectors, are not so well expressed. The immigration is not so important
concern, yet. There are immigrants from Moldova and Arab countries; some of them
come in the country to obtain EU recognised diplomas and use Romania as transit country
to the Western Europe.
 According to the interviewees, migration processes have mainly negative impact on the
health system. But very surprising is the fact that despite these opinions of key
stakeholders’ representatives, there is not national policy regarding human resources in
health care and in particular regarding the migration of health professionals.
 The main reasons for emigration (pull factors) for Romanian health professionals are:
higher remuneration, better working and living conditions and opportunities for career
development. But in general the emigration is driven from economic factors and financial
reasons. These have to be observed as “cornerstones” in developing a national policy
regarding migration of health professionals.
 Stick factors are family, friends, professional status and age. As barriers for emigration
the respondents pointed insufficient language skills, fear of change and unknown.
 According to the respondents, the foreign agencies play an important role in recruitment
of Romanian health professionals especially physicians, dentists and nurses.

7. Results from qualitative study – interviews on micro level

On the micro level of the research 41 interviews were conducted, including:
 15 health professionals working in Romania;
 12 students in medicine and nursing care studying in the country and
 14 Romanian health professionals working abroad.
The interviews are hold via e-mail and Skype and for some of the respondents – via phone.

Interviews with health professionals working in Romania

In order to study migration potential more precisely we included in the sample on micro level
15 health professionals working in Romania. They were asked about their intentions to work
abroad, about the reasons for these intentions and about the obstacles for emigration they
personally have. The questions also are connected with assessment of their present position
and satisfaction with the working and living environment in the country, as well as the
opportunities for professional realisation and development.
The sample consists of physicians and nurses predominantly due to the results of the macro
level research. According to data and interviews on macro level, these health professionals
emigrate the most. The other health professionals’ groups are represented too. More precisely
described the sample includes:
1. 7 physicians and 1 dentist, of which:
 females - 5 respondents and males - 3;
 between 20 and 30 years old – 3 respondents, between 31 and 40 years old – 2,
between 41 and 50 years old – 2 and up to 50 years old – 1 respondent;
 with specialty – 5 of the respondents, without specialty – 2 (but they are specialising
in the moment) and 1 dentist;
 4 of the respondents are working in hospitals, 1 – in outpatient care, 1 – in emergency
care and 1 physician is working in pharmaceutical company; the dentist has private
practice;
 6 of the respondents are married and 4 of them have children.
2. 7 nursing professionals, of which:
 5 nurses, 1 midwife and 1 laboratory assistant - all females;
 between 20 and 30 years old – 2 respondents, between 31 and 40 years old – 2,
between 41 and 50 years old – 3;
 4 of the respondents are working in hospitals, 2 – in outpatient care and 1 – in
emergency care;
 5 of the respondents are married and 3 of them have children.
All of the interviewed physicians, except one, declared willingness and intentions to work
abroad. Some of the respondents shared their willingness without doubts and thought that
emigration would be better choice for their professional development and for the future of
their children. It is not surprising but it’s a fact that many of the respondents rely on their
friends to help them to find a work. Only one of the interviewed physicians hasn’t intentions
to emigrate and shared the satisfaction with the current job. Interesting is that this physician
actually work in pharmaceutical company on managerial position and isn’t engaged in
provision of health services in the moment. This is confirmation of the observed processes of
cross-industry migration - data show that young resident physicians choose to leave the health
system, going mainly to the pharmaceutical field offering attractive salaries.
Regardless of nuances in the replies, all respondents stated as reasons for emigration desire
for better payment, better working and living conditions. Other reasons are insecurity of
present work due to frequent reforms and changes in health system and social recognition of
medical profession. But the leading incentives for work abroad are financial (higher
remuneration) combined with higher standard of living. Even the dentist with successful
private practice shared the same motivation and attitude to seek work abroad.
The main obstacles for emigration of Romanian physicians are language barrier, the age and
achieved social status including also managerial position at work. Factors that keep them in
the country are predominately the family and responsibilities to elderly parents, as well as
ongoing education and specialisation for the younger respondents. As pull factors in host
countries the respondents considered higher remuneration, security of work place and other
working conditions. Other mentioned factors are:
 better opportunities for the family and children’s education;
 higher standard of living, better economic situation;
 social status including social recognition of medical profession;
 social relations and way of living.
The most of the interviewees shared the view that there are difficulties for their future
professional development in Romania. They found difficulties with specialisation,
organisation and frequent changes in the health system. One of the respondents pointed the
fear for forthcoming dismissal. All of them think that their work is not adequately assessed.
They are dissatisfied with their remuneration and with the recognition of their work.
The most attractive countries for the respondents are France, Belgium, UK, Germany and
Switzerland. They gave preference to EU countries but also the USA and Australia are
desired destinations. Work abroad could be of benefit for working conditions, career
development, living conditions, and scientific activity, as well as provides better opportunities
for the family. These statements together with the dissatisfaction with career development,
remuneration and working conditions in Romania, suppose a significant emigration potential
among physicians and dentists.
All of the interviewed nursing professionals, except one, declared willingness and intentions
to work abroad, just like the interviewed physicians and dentists. The answers of the nursing
professionals are identical and show great dissatisfaction with the nursing job and with
professional development in the country. All respondents pointed financial motives for
emigration. Factors that keep the interviewed nursing professionals in the country are only
family duties. The main obstacles for emigration are lack of foreign language skills and fear
of the unknown.

Interviews with students in health education

We are of the opinion that the migration of young health professionals is an important
concern. That is the reason for including also students in the sample on micro level. We asked
them about the general patterns of migration in Romania. More important for our study are
their intentions to specialise and/or to work abroad after graduation, reasons for these
intentions and obstacles for emigration they personally have.
The sample includes 12 students in health education, studying in last courses, between 21 and
26 years old:
1. 7 students in medicine, dentistry and health administration:
 4 students in medicine – 2 males and 2 females;
 2 students in dentistry – male and female;
 1 student in master course in health administration – female.
2. 5 students in nursing care and midwifery:
 3 students in nursing care – females;
  2 students in midwifery – females;
Just like practicing health professionals, the students are familiar with the issues of migration.
According to the respondents in this group, emigration is the most important mobility process
in Romania, which contributes significantly to the observed deficit of health professionals in
the country. The most important health professionals’ deficit is of physicians and nurses and
among these professional groups emigration is very intensive. Some of the interviewed
students pointed also midwives and dentists as health professionals who prefer to work
abroad.
The answers of the question “Where would you like to work after your graduation?” are
polarised. Some of the interviewed students has thought to work abroad – one of them isn’t
satisfy with the way of life and interpersonal relations in Romania, others would work abroad
because of financial reasons and the rest prefer to work in other country due to better
opportunities for career development. One student stated that there aren’t advantages for stay
in Romania and he doesn’t have stimuli to work and live in the country. The students give
preferences to UK, Netherland, Switzerland or the USA. The other students haven’t intentions
to work abroad. Although they prefer to work in Romania, some of them mentioned that they
would work abroad for higher salary and better job.
Factors that would retain the respondents in the country are family, friends and homeland.
Interesting is the fact that students pointed patriotism as one of the most significant factors
hindering their emigration – one of them expect that the economic and political situation in
the country will improve, other said that “the country needs health professionals”. That is the
main difference between the students and the practicing health professionals as the latter are
more dissatisfied and much less enthusiastic and optimistic about their future in Romania. The
main obstacle for emigration is fear of change.
Factors attracting the respondents to other countries are higher remuneration, better working
and living conditions. Other motives are opportunities for career development, better
economic situation, better life and higher assessment of the profession. But regardless of their
future plans, all respondents think that there will be difficulties with their future professional
career in Romania, as well as the work of Romanian health professionals is not adequately
assessed. They consider the payment and the recognition of the profession as unsatisfactory.
Moreover, all interviewees thought that working and living conditions and career
opportunities are significantly better abroad than in Romania.

Interviews with Romanian health professionals working abroad

Very important for the general objective of the study are the migrants. Because in Romania
the emigration is the leading mobility process, we tried to reach Romanian health
professionals, which are working abroad. They were asked about their personal experience as
emigrants – reasons for emigration, difficulties, etc. Some questions concerning the general
patterns of migration were also included in the interviews.
The sample includes 14 respondents divided into two main groups – Romanian citizens
working in EU countries and Romanian citizens working outside the EU. We choose the
countries, which were rated as the most preferred for emigration in other interviews,
conducted in macro- and micro level of the research. These are the USA and Canada and
Germany, UK, France, Italy, Spain, Switzerland. Unfortunately we couldn’t contact with
Romanian health professionals in Switzerland and Spain and we didn’t receive answers or
consents for interviews from health professionals, working currently in France and Italy. We
succeed to reach health professionals in Germany and UK and they helped us to establish
contacts with other Romanians, working there. More precisely described the sample includes:
1. 4 health professionals working outside the EU - 2 in the USA and 2 in Canada:
  physician, working in the USA in public health program, male, 30 years old, 7 years in
the country;
 physician with specialty, working in the USA in hospital, male, 50 years old, 12 years
in the country;
 dentist, working in Canada as medical assistant in private clinic, female, 28 years old,
2 years in the country;
 dentist, practicing the same profession in private dentistry practice in Canada, female,
35 years old, 8 years in the country.
2. 10 health professionals working in EU countries – 6 in Germany, 3 in UK and 1 in
Austria:
 physician, specialising in hospital in Germany, male, 31 years old, 2 years in the
country;
 physician, specialising in hospital in Germany, female, 25 years old, 1 year in the
country;
 physician, specialising in hospital in Germany, male, 28 years old, 1 year in the
country;
 physician with specialty, working in hospital in Germany, female, 41 years old, 2
years in the country;
 physician with specialty, working in hospital in Germany, male, 44 years old, 3 years
in the country;
 physician with specialty, working in outpatient clinic in UK, male, 41 years old, 2
years in the country;
 nurse with additional qualification in health administration, working in UK in public
health program, female, 27 years old, 2 years in the country;
 nurse, working in hospital in UK, female, 46 years old, 4 years in the country;
 professional in health administration in Germany, not working in the moment, female,
28 years old, 3 years in the country;
 laboratory assistant, working in Austria outside healthcare, male, 33 years old, 7 years
in the country.
Interesting fact is that the most of the respondents, working in the EU, emigrated after
Romania’s accession in 2007. The diplomas’ recognition in the EU countries accelerates the
mobility processes not only for work but also for specialisation (combined with work).
In order to study in-depth factors, which push the Romanian health professionals to work
abroad, we asked several questions, concerning Romanian health system and working
conditions. Only three of the respondents pointed explicitly the unsatisfactory remuneration of
health professionals in Romania. That’s a major difference between these, who work in
Romania and health professionals, working abroad. According to the respondents, main
problems in Romanian health system are as follows:
 corruption;
 problems with organisation and financing of the system, unsatisfactory health policy;
 necessity of “special relations and contacts” for career progress;
 lack of professional development opportunities and post-graduate education.
Other statements are that there aren’t clear-cut rules and stimuli for work in Romania. The
young physicians underlined the problems with specialisation in the home country and
insufficient places for specialisation. In this connection it is not surprising that the most of the
interviewed health professionals found the health systems in chosen country as better
organised, well-financed and providing better opportunities for professional and career
development, as well as more transparent and less bureaucratic.
Except with the Romanian health system, the interviewees aren’t satisfied with the life in the
home country as a whole. They pointed as unsatisfactory living standard, social security,
working place security, “lawlessness and misrule”.
Very important for the purposes of the study are so called “pull factors”. The respondents
ranked as more important for them economic and financial factors, namely better economic
situation, higher living standard and higher income (salary) in destination countries. The
financial and economic factors, connected mainly with remuneration, are the driven forces of
migration concerning Romanian health professionals. That’s why the conclusion is confirmed
that in Romania there is mainly economic emigration among health professionals. In this
connection the respondents pointed as attractive for them also health system financing and
possibility for remittances to the family in home country. Other important pull factors are
better way of life and opportunities for family (for example children’s education), better
employment opportunities, better working conditions and opportunities for career
development and qualification enhancement. The latter is particularly important for the
younger health professionals. As attractive in the chosen country the respondents also pointed
better organisation of health system as a whole, working place security and profession
recognition.
In regard with difficulties, which the interviewees encountered in finding a job, the answers
are divided into two groups. Part of the respondents declared that they didn’t encounter
difficulties; one even mentioned that “there is a lack of health professionals in Germany” and
that facilitate foreign professionals in finding a job. Another part of the respondents pointed
that they had experienced difficulties due to the language, lack of personal professional
experience and diplomas’ recognition. The latter apply to the interviewees, working in the
USA and Canada and to one of the respondents who is laboratory assistant, live in EU country
but had moved there before the Romania’s accession in 2007.
Most of the respondents are satisfied with their choice to work and live abroad. Other stated
that although some problems and disappointments, they are satisfied in general. One of the
interviewees said that he is satisfied with his work but not with the life abroad and another
one stated that he is satisfied only with the payment. The respondents’ expectations regarding
remuneration, working and living conditions, as well as regarding professional career
development are met. Nevertheless, there are some nuances in the responses – several
interviewees declared that their expectations regarding working and living conditions were
met to some extent; other aren’t content with living conditions or with their professional
career development. The respondents aren’t satisfied with the different aspects of life abroad.
Some of them specified as follows:
 social contacts and relations;
 discrimination and lack of tolerance toward foreigners in the society as a whole;
 “weather and food”.
Most of the respondents don’t intend to return in Romania or don’t intend to return for the
present. Only three respondents said that they will definitely return; other two intend to return
“but not soon”; one respondent said that she would return but only if she found good working
place in the homeland and one interviewee don’t have plans for the future. What retain the
interviewed health professionals in the respective countries, are the following stay factors:
 higher remuneration;
 better way (standard) of living;
 family (including new established) and better opportunities for the children;
 social security, including security at working place and respectively insecurity in
Romania;
 career development and professional opportunities;
 better working conditions;
  current education and specialisation;
 “work only”.
We can summarise the results from the interviews with emigrants as follows:
 In general the interviewees are satisfied with their work and life abroad.
 Most of the respondents work in healthcare but some of them are employed in other
sectors (services).
 Host countries attract the interviewees with higher income (salary), higher standard of
living, better employment opportunities, better way of life and opportunities for family
and better working conditions; for the younger respondents the leading pull factors are
also opportunities for qualification improvement (specialisation) and better career
development. But in general the emigration is driven from economic factors and financial
reasons.
 Among push factors more important are the organisation of the Romanian health system,
corruption and lack of clear-cut rules in the home country.
 Main difficulties for the emigrants in the USA and Canada were the recognition of their
diplomas and for the emigrants in the EU – the language; the both have difficulties with
the new culture and the way of living in the host countries.
 Some of the respondents don’t intent to return and the others declared that they have
intention to return in the home country but this intention is related with the indefinite
future. Leading stay factors are higher income (salary) and standard of life in host
countries.
As a general conclusion from the interviews on micro level we summarised push, pull, stick
and stay factors (Table 2). Push factors are these which drive the Romanian health
professionals to work abroad and are connected with the working and living conditions in
home country; pull factors are these which attract health professionals to work abroad and are
connected with destination countries; stick factors are these which retain health professionals
in Romania; and stay factors retain Romanian health professionals in destination countries
and “prevent” them to return home.

Table 2 Push/pull and stick/stay factors for Romanian health professionals

Push Factors Pull factors
Corruption, unstable economic situation Better economic situation and economic
development
Low salaries Higher income (salary)
Lack of professionals opportunities (career Professional development opportunities
development)
Poor working conditions Better working conditions, organisation and way
of work
Insufficient places for specialisation and problems Educational and training opportunities
with training
Lack of resources (especially modern medical Better equipment and modern medical
equipment) technologies
Low social status of the health professionals Higher living standard
Unsatisfactory health system organisation and Security at working place (protection from the
financing Unions)
Necessity of “special relations” for career progress Assessment of personal qualities
Under-funded health system Health system financing
Poor professional prestige (for nurses and Recognition and image of the medical profession
midwives)
Better employment opportunities and opportunities
for the family
Stick factors Stay factors
Family, social contacts and relations Financial security (attractive remunerations)
Language Standard of living
Age Family (including new established) and better
opportunities for the children
Visa and work authorisation restriction outside the Social security
EU
Diploma recognitions (outside the EU) Current education and specialisation
Career paths
Possibility for remittances to the family in home
country

8. Conclusions
Findings of our study have showed that in general, receiving countries had better information
about inflows than about outflows. In Romania, as in most other countries data on health
worker migration are not available. There are some estimations that provide just a rough idea
about this phenomenon. Data on internal and external migration of the health care workers are
scarce and there are no established procedures for collecting them.
Moreover, there is no policy regarding the migration of health professionals and there are no
special references to this issue in the health policy. Interviews with representatives of key
stakeholders also indicate that the role of migration of health workers is missing from the
Romanian discussion on health policy. It is mainly the professional associations that discuss
the situation and the importance of the migration of health professionals. According to the
interviewees, it is urgent to develop such policy. In 2009, a senior expert of the Ministry of
Health said:
“… there is an urgent need to look more carefully on this problem (gathering more
evidence about the health professionals’ migration, research on the factors determining the
migration processes and development policies and programs to address the problem).
Research is needed in order to have the necessary data for the development of policy.”
The suggested measures include incentives (such as salary increases, access to training and
professional enhancement opportunities) and restrictive ones (for example, reimbursement of
expenses for the professional studies financed from public funds, if the professional did not
practice for a minimum period of time in home country).
The findings from the research lead to following recommendations:
1. Reliable data is needed to provide a basis for evidence-based policy measures on
migration. An electronic pan-European Register of health professionals (at least at the EU
level) could be a very practical step to facilitate this process.
2. Developing measures to retain the health workforce in the country is very important. A
strategy for human resources, which is addressed to migration, should be elaborated,
including improvement and development of the issues below:
 provision and quality of basic education (medical schools education, nursing schools);
 professional enhancement and more continuous training opportunities, i.e. professional
development;
 financial and social motivation - higher level of salaries/wages;
 moral motivation - respect and recognition of the profession;
 organisation, way of work - without stress and dramatic changes every year;
 working conditions;
 access to modern technology, advanced research and achievements in medicine;
 temporary professional mobility opportunities and experience exchange;
 benefits policies (health insurance, scheme pensions, etc.).
Although permanent emigration is assessed mainly negatively, temporary mobility may have
positive impact on the health system. It is related with return migration and shared experience
and knowledge acquired abroad. Besides measures to retain health professionals, there are
some useful proposals for facilitating temporary mobility of health professionals as follows:
  more student exchange and professional exchange programmes;
 simplification of the procedures and less bureaucracy;
 abolish the restrictions to labour markets in the EU for Bulgarian and Romanian
citizens;
 shortening of terms and simplification of legislation in approbation of specialists;
 better organisation within recruitment agencies.

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