Management in Health, Vol 13, No 4 (2009)

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Migration of Nurses: The Case of Romania

Prof. Cristian Vlădescu, MD, PhD
NSPHHSM - National School of Public Health and Health Services Management, Bucharest, Romania

Victor Olsavsky, MD, PhD
WHO Country Office, World Health Organization

 

 

Abstract: In healthcare sector, human resource is the main category of resources absolutely necessary to ensure the provision of healthcare services. In Western countries, providing an optimal rate of specialized medical staff is one of the health policies subjects and development and quality improvement in nursing field is a major component of government health policies.

In Romania, it highlights a lack of regulation in this area and also territorial inequalities and a shortage number of nurses determined by the inadequate planning of the medical staff and also by the increase of the phenomenon of migration to countries where their profession and human being are respected and where they can live in better conditions.

 

Keywords: nursing, density of nurses, legal framework, training capacity.

 

THE HEALTH WORKFORCE IN ROMANIA

Before 1989, Romania had a Semashko-type health system which was totally centralized, command-and-control, publicly financed and owned. Although health coverage was universal, the system was plagued with problems, including a disgruntled workforce, low quality services, deteriorated health facilities, and a general dissatisfaction of the public and of health workers. After the regime change, major reforms started, and the system became more decentralized and pluralistic, with new stakeholders such as the Social Health Insurance Houses and professional organizations [1]. Even though many health indicators have shown improvements, Romania still has some of the worse indicators among the EU member states. A baby is 6 times more likely to die before his first birthday in Romania than in Sweden, and life expectancy is 6 years less than the EU average. Romania has one of the lowest density of health personnel in Europe. According with WHO data [2], Romania, with 1,9 doctors per 1000 inhabitants, is ranking 31 out of 33 countries from Europe, only Albania and Bosnia-Hertegovina having lower ratios. The same is true for nurses (3,89 per 1000), dentists (0,22 per 1000) or pharmacists (0,06 per 1000). There is also an important imbalance between the different regions; there are 98 communities (villages) without any doctor or nurse. In one third of the territory more than 30% of the medical specialities are not covered at all (cardiology, emergency care, intensive therapy care, diabetology, etc.) and the same for nurses [3]. The accession of Romania to the EU made the situation even more difficult, as around 10% of doctors are seeking to work outside Romania [4], as well as 20 % of nurses [5]. This resulted in increasing inequities between rural and urban populations in access to health services, a challenge which the Romanian authorities have now to deal with.

 

Profile of nursing profession in Romania

Nurses are present in all structures of the Romanian health services system, being by far the largest group of healthcare workers. The evolution of the nursing profession during the second part of the 20th century has followed the pathway that was common to all the Central and Eastern Europe Semasko-type systems. Two aspects of nursing in Romania differ slightly from their Western European counterparts: professional autonomy and education. Except for some community nurses, all others practise under the supervision and responsi-bility of a doctor. Nursing education has been aligned on EU requirements, especially during the accession process. Before that, the curriculum and the period of training was shorter than the one in the EU (two years post high school and then vocational high school). There are also some differences in the content of daily activities and responsibilities.

 

Numbers, age, sex

Romania reported a number of 85,785 nurses and midwifes in 2006 (WHO 2008). A similar figure was reported also in 1989 the year of political change in Romania. Between the two dates, there was an increase and then a decrease of over 10,000. The highest number (99,685) was recorded in 1996, and afterwards it decreased to figures similar to those from the late 80s (Graph 1).

 

Graph 1: Total number of nurses and midwifes in Romania, 1978-2006

Source: WHO HFA database (2008)

 

 

The initial increase and the following decrease are explained by the reforms of the health sector and the development of the private sector. As the numbers reported to WHO do not include the private health sector, the important observed decrease after 1996 reflects the rapid development of the private sector, which has no obligation to report numbers of staff to the health authorities. Conse-quently, the exact number of nurses and midwifes employed in the whole healthcare system was not known until two years ago.

 

In 2004, new legislation on nursing and midwifery gave their professional association the authority to self-regulate and introduced compulsory licensing. A national registry was introduced, and now all nurses and midwifes are registered regardless of where they work or if they work at all. Their total number was 127,155 in 2006 according to the national registry of nurses and midwives(5), a difference of about 41,000 with the figures reported to WHO for the same year.

 

The number of nurses per 100,000 inhabitants was about 400 in 2006,. This was almost half of the EU average. Midwifes were about 25.6 per 100,000 compared 38.9 in EU countries where this profession exists. However, according to the national registry of nurses and midwives their number is around 578 per 100,000, but with an unknown number of those still working in Romania.(Graph 2)

 

Graph 2: Number of nurses/100000 inhabitants, Romania compared with EU, 1978-2006

Source: WHO HFA database (2008)

 

 

The evolution of the total number of midwifes in Romania reflects an important decreasing trend that started in 1978 when midwifery education was abolished. In 1989, there were 12,479 midwifes, in 2006 only 4,913 were reported. The function of the midwife was passed to nurses, who worked under the label of nurse specialized in obstetrics and gynecology. Statistics of midwives to persons trained prior to 1978. The geographical distribution of nurses specialized in obstetrics and gynecology between districts is highly skewed as it ranges from 264 to 964 per 100,000,.

The number of male nurses is about 8,000 (less than 7%). The population of nurses and midwifes is rather young (Figure 1): 37.1% are between 26-35, 29.1% between 36-45 and 22.3% between 46-55. The small number aged over 55 (7%) results from the retirement policies of the past 15 years [6]. Immediately after the political changes in 1989, early retirement was common during the first decade. Women could retire at 56 and men at 63.

 

 

 

 

 

 

Figure 1: Distribution of nurses and midwifes by age groups in Romania, 2006

Sursa: Romnia, Ministerul Sănătăţii, 2008

 

The law on nursing and midwifery (307/2004) defines 18 specialties for the nursing profession. The majority of nurses are generalists (69%), followed by pediatric (10%) and obstetric-gynecology [1] (7%). The rest are divided between more technical specialties as radiology, laboratory, nutrition, dentistry or public health.

There is no midwifery post-graduate specialization. During their career, nurses and midwifes can move up one professional step called principal degree by passing an exam organized yearly, accessible to nurses and midwifes with at least 5 years experience.

 

Regulatory framework

Until 2004, the legislative framework that regulated the profession was very restrictive, as regards the scope of practice. Once the EU accession process started, Romania had to implement the directives on free movement and mutual recognition of qualifications. In 2004, the new law strengthened professional autonomy and aligned nursing education with EU standards and set up the professional association of nurses. The law defines who has the right to practice, defines the two professions and describes the contents of their respective activities. The right to practice is given by the Ministry of health through its district authorities, with the approval of the professional association.

The scope of practice in nursing is defined by law and includes treatments prescribed by doctors, evaluation of care needs, education for health, health promotion, research. A recent study [5] reported that less than 30% of nurses have activities related to assessment of health care needs, promoting a healthy environment or health protection of vulnerable/risk groups. Only 6% are involved in research.

 

Training capacity, education

Before 1990 there were several different training schemes in nursing. Since 1990 nurses have been trained exclusively in nursing colleges a non-university form of education. Current training takes three years of study after completion of high school. In the early 1990s, the Ministry of Health conducted an intense retraining program to update the skills of nurses who graduated from specialized nursing high schools, which was the only form of training in the 1980s. The Nursing University Colleges have been established in 2003, with a four-year training, in compliance with Romanias EU accession agreement.

Admission to nursing schools is based mainly on school results, and skills such as social behavior and motivation are little considered. There are limited possibilities for nurses to upgrade their academic qualifications. Admission to private schools, about which no official statistics exist, is less strict, i.e there are no admission tests or the school results are not eliminatory.

The number of students entering University Colleges and public nursing colleges is strictly regulated by the Ministry of Education, which fully funds nurses tuition. The number of students entering the private schools is not controlled. There are an estimated 35,000 graduates per year, compared to the 2,000 which the Ministry of Health estimates to be needed, based on the absorption capacity of the public health care system. Comparing the number of graduated nurses per 100,000 inhabitants with EU average and other EU countries, Romania still has a low number of graduates. (Figure 2)

 

Figure 2: Nurses graduated per 100,000, last year available, various European countries

 

However, this number from WHO HFA database corresponds only to graduates from public nursing colleges and do not count nurses graduating from private schools.

The necessity to implement EU requirements in nursing training led to some important changes. Since 2003, all state training programs are based in university colleges and the curriculum is compliant with the EU directive. All type of schools now need to be approved by the National Accreditation Committee. In 2008, the EC accepted also the non-university based nursing schools, but with stronger requirements for their accreditation and for quality control. Eleven public universities and an unknown number of private universities and nursing schools compete in the field of nursing education.

 

Migration

There is no official data about number of nurses migrating. The Ministry of Health has accurate data only about nurses who requested the certificates for mutual recognition of their diplomas within EU. These show that from 1 January 2007 (date of Romania membership to EU) to 31 December 2008, 4608 nurses and midwifes (3.8% of total) requested the certificate for the recognition of their diploma in the EU. Out of those, only 3525 have received their certificate, the others either were not compliant or dropped the request. (6). It is now known if those receiving their certificates have migrated or not.

 

A recent study (5) estimated intentions to migrate of a national representative sample of nurses. 55% gave a negative answer, 22% did not to answer, and 21% expressed a desire to work abroad (Table 1).

Their age distribution shows that the majority of the nurses who expressed desire to work abroad are from the 26-45 years age group (Table 2).

 

Table 1: Intention to work abroad among Romanian nurses 2007

Q: Do you plan to work abroad?

Number

%

No

315

55.9

NA

126

22.3

Yes

123

21.8

Total

564

100.0

Source: Olsavszky 2008

 

Table 2: Intention to work abroad among Romanian nurses by age groups, 2007

 

Desire to work abroad

Age group

Yes

No

NA

26-35

52

120

37

36-45

34

82

48

46-55

23

70

33

Over 55

7

29

5

18-25

6

7

0

Total

122

308

123

Source: Olsavszky 2008

 

The majority of respondents menti-oned that they know at least one colleague who migrated; 39% said the knew more than 10 (Figure 3) .

 

 

 

Figure 3: Nurses who reported knowing a colleague working abroad, 2007


Source: Olsavszky 2008

 

In some districts in the North-East of the country, the poorest area, emigration seems to be more intense. The profile of the Romanian nurse with a high potential of migration could be described as follows: general nurse graduated from a nursing college, aged between 26 and 35 years, living in an urban area in North-East or South of the country.

The social status of nurses can be described as modest compared to less qualified workers. Their wages in both the public and the private services do not exceed 300 Euros (net) per month. Nurses are still regarded as doctors assistants and not as independent and autonomous health workers. Changes in their professional training system may have future benefits, as an increasing number of nurses and midwives with university training will enter the labor market, and training at college level will disappear.

 

Policies and strategies to address imbalances in the nursing workforce

The main shortage of nurses, as well as the other health personnel, seems to be in rural areas where almost half of the Romanian population leaves. In order to tackle these inequalities, the Government adopted different policies [7]. Criteria were introduced to define and rank remote areas with chronic shortage of nursing and medical personel. According to this ranking, these workers could receive different incentives such as:

         Free housing, with expenses paid from local and central funds

         Instalation fee for health professionals, including nurses ,willing to work in remote areas (equal to 2 average salaries)

         Monthly bonuses of up to 50% of the basic salary

         Subsidies for the acquisition of new medical equipment

         Reduced local taxes

However, as a recent World bank Review (8) points out, Human Resource for Health has been largely left out by all health reforms, with no official document or policy on this issue; it is suggested that a strategy is needed at least to: (i) attract young Romanian to enter the health professions, (ii) encourage graduates to practice in rural and remote areas, and (iii) limit the exodus of health professional after EU accession.

 

References

1.                   VLADESCU C, SCINTEE G, OLSAVSZKY V, ALLIN S and MLADOVSKY P., Romania: Health system review. Health Systems in Transition, WHO, 2008

2.                   WHO HFA database, accessed in January 2008

3.                   VLADESCU C, PASCU O, ASTARASTOAIE V. et al, Report of the Presidential Commission for Romanian Public Health Policies Analysis and Development, Bucharest, 2008, available at http://www.presidency.ro/?lang=ro

4.                   DRAGOMIRISTEANU A, FARCASANU D., GALAN A., Physicians migration in Romania, National College of Physicians Bulletin, Bucharest, 2008

5.                   OLSAVSKY, V, Human resources in transition period: role of the nurses in the Romanian Health System, PhD Thesis, University of Medicine and Pharmacy, Timisoara, 2008

6.                   Ministry of Public Health, Statistical Yearbook, 2008, Bucharest

7.                   Ministry of Public Health, Elements of Reform Strategy, 2008, available at http://www.ms.ro

8.                   World Bank, Health Sector Policy Note, Bucharest, January, 2009.



[1] Midwifery schools were abolished in 1978. The role of midwife was taken over by the general nurse with a short period of on-site training in obstetrics and gynecology. In 2004, the Ministry of Health reintroduced the midwifery profession and the first midwifery program at university level was established with a curriculum and training period in compliance with EU requirements.



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