Implementing the Code of Practice on International Recruitment in Romania – exploring the current state of implementation and what Romania is doing to retain its domestic health workforce

Worldwide, many countries are experiencing health workforce imbalances that are leading to inequities in terms of access and availability of care. The World Health Organization (WHO) estimates that, in 2006, there was a global shortage of 4.2 million health workers [1]. While sub-Saharan Africa suffers the most critical shortages, Europe is not immune, as the patterns of the global health workforce market are intricately interdependent. At the European Union (EU) level, a shortage of 1 million health workers is expected by 2020 [2].

In response to increasing health workforce migration and its contributions to the shortage of health personnel in source countries, in 2010, WHO elaborated the Global Code of Practice on the International Recruitment of Health Personnel (the Code) [3]. The Code, “establish[es] and promote[s] voluntary principles and practices for the ethical international recruitment of health personnel and facilitate[s] the strengthening of health systems, […] serve[s] as a reference for Member States in establishing or improving the legal and institutional framework required for the international recruitment of health personnel, […] provide[s] guidance that may be used […] in the formulation and implementation of bilateral agreements and other international legal instruments, [… and] facilitate[s] and promote[s] international discussion and advance cooperation on matters related to the ethical international recruitment of health personnel as part of strengthening health systems, with a particular focus on the situation of developing countries” [3, 4]. The Code, which was adopted by all 193 WHO Member States, seeks to redress imbalances among health workers by raising issues of human rights, according to health, equity, and social justice [3]. The Code is voluntary, but “Member States and other stakeholders [such as non-governmental organizations] are strongly encouraged to use the Code” [3].

In 2014, WHO issued the first report on the implementation of the Code, based on the information submitted by its Member States through the related Code National Reporting Instruments [5–7]. Out of the 56 responses received, 40 originated in European countries. Thirty-seven Member States reported having taken actions to communicate and share information across sectors on health worker recruitment and migration issues, and only nine Member States reported good practices that have been encouraged and promoted among recruitment agencies [7]. Overall, the report highlighted that Member States had not systematically applied the Code and that significant gaps still remained in ethical international recruitment and local systems strengthening [7].

Romania, an upper middle-income country and member of the EU since 2007, deals with a health workforce crisis of its own linked to migration. It is currently a key source country for Western Europe, with many Romanian doctors, nurses, and other health professionals migrating to work in the United Kingdom, France, Germany, Italy, and Spain, among others. Despite the ‘brain drain’ having been a common trend since the fall of communism in 1989, the phenomenon seems to have grown after EU accession in 2007 [8]. Indeed, the Romanian College of Physicians reported that “between 2007 and 2013, 14,000 medical doctors left their jobs in the national public health system and choose to practice abroad” [7]. This raises concerns since, in 2012, less than 40,000 medical doctors were licensed to practice in Romania [7]. Romanian health workers’ mobility is affected by both push and pull factors; the push factors generally relate to challenges and insufficiencies within the Romanian health care system, whereas the pull factors relate to the prosperity of Western European health systems, which translate into much higher salary figures than those currently feasible in Romania. Within Romania, internal migration from rural to urban areas persists. Therefore, poor and remote populations are disproportionately experiencing the combined effects of migration patterns and the local shortcomings in health workforce management [9]. Rich segments of the population can seek care in the growing private sector, pay informal charges, or even seek care abroad. However, rural populations, which make up almost half of the total population [10], as well as marginalized urban populations (e.g. the Roma), are left without many options [9].

Romania has approximately 2.5 practicing doctors and 5.8 practicing nurses per 1000 inhabitants; nevertheless, these numbers are low compared to other European countries [11]. Recently, the Romanian College of Physicians warned that Romania had reached critically low numbers of practicing doctors [7]. Moreover, some rural and remote villages, where poverty rates can be twice as high as in urban areas, do not have a full-time medical assistant/nurse or a doctor [12]; for example, in 2005, a family doctor was not available in 98 localities [13]. Further, Romania has an overall surplus of general practitioners, 63 % of whom practice exclusively in urban areas, and yet there is a dearth in cardiology, intensive care, and surgery specialists, with only 20 % of vacancies being filled [13]. Thus, one-third of Romanians do not have access to specialists to treat the increasing burden of non-communicable diseases (e.g. cardiovascular disease, diabetes, and emergency medicine and intensive therapy care) [13]. Health promotion is another important area lacking attention in rural populations. For example, in rural Transylvania, one in two people are not reached by health promotion campaigns [14]. The lack of access to adequate health care, as well as the overall aging trends across Europe, are having detrimental effects on the health of the Romanian population and have led to Romania having some of the worst health and health system statistics in Europe [10].

Despite the current crisis, there is little documentation on whether and how Romania has been following the principles and recommendations outlined in the Code in order to manage migration and to improve health worker retention. Currently, Romania does not have a “valid and reliable monitoring system on health professional mobility” [7, 15]. Furthermore, Romania did not submit a National Reporting Instrument as part of the first round of the Code’s monitoring [7]. Herein, we explore whether and how Romania has adhered to the Code by documenting the policies and measures implemented to strengthen the health workforce and the health system, to incentivize health workers to remain and practice in Romania, and to gather and exchange information at national and international levels. We also reflect on how relevant and effective the Code has been in Romania to date and propose recommendations for advancing efforts to address the health worker crisis in Romania.