Geographic maldistribution of the physician workforce in Romania: urban-rural divide and need for better planning and retention strategies

Author: , , and
Key words: , , , , ,
Issue: Volume 17, Issue 1, 2023


The spatial allocation of medical resources is closely related to population health outcomes. Health workforce shortage and maldistribution represent significant challenges for health systems functioning in many countries. Romania registers the lowest physicians per patient ratio in the European Union (EU). Despite the increasing number of medical graduates, shortages have become more critical over the past two decades with both out-migration of health professionals and intra-country disparities between large cities and rural areas or between primary and speciality care. Considering these variances in health workforce supply, it is crucial to identify areas with particularly low human resources. This paper focuses on a critical determinant of geographic access to healthcare, namely the availability of health professionals. We identified and analysed the patterns of physicians’ geographic distribution at the lowest spatial level, pointing out their imbalances and factors interrelated with territorial disparities. Gini coefficient calculation and Moran’s I index provided strong evidence for increasing divergences in this distribution. Furthermore, the analysis of the physician/population ratio spatial patterns revealed two areas of opposite clusters on the west-east axis: one of positive spatial aggregation in the west and one negative in the east. Geographical imbalances in the health workforce distribution have adverse effects, particularly on the public healthcare sector. To address the issue of territorial imbalances, we considered that the maldistribution of physicians is contextually created and might cause several dysfunctions in the healthcare system: normative (the dilemma of dual practising in the public and private sector simultaneously), educational (specialized training, enrolment, and logistics), and social (emigration of physicians and retention policies). Therefore, for the effective functioning of its healthcare system, Romania still needs to implement policies to retain medical graduates and reduce physician outflows. Also, specific strategies regarding the size, structure and distribution of the physician workforce are required to alleviate issues related to access to care.

Full text

Permalink (doi)

Authors Affiliations

Liliana Dumitrache*(1), Mariana Nae (1), Gabriel Simion (1), Cristian Cazacu (1)
(1) University of Bucharest, Bucharest, Romania
* Corresponding author


Anselin, L. (2010), “Local Indicators of Spatial Association-LISA”, Geographical Analysis, vol. 27, no.2, p. 93–115.
Anselin, L., Syabri, I. and Kho, Y. (2010), “GeoDa: An Introduction to Spatial Data Analysis” in M.M. Fischer and A. Getis (eds), Handbook of Applied Spatial Analysis, Springer, Berlin, Heidelberg, p. 73–89.
Apostu, S.-A. and Vasile, V. (2020), “The Characteristics of Migrant Physicians from Romania”, Journal of Social and Economic Statistics, vol. 9, no. 1, p. 84–104.
Ariste, R. (2018), “Availability of Health Workforce in Urban and Rural Areas in Relation to Canadian Seniors”, The International Journal of Health Planning and Management, vol. 34, no. 2, p. 510–520.
Astărăstoaie, V., Gavrilovici, C., Oprea, L. and Manea, T. (2014), La drum cu Hipocrate: migrația medicilor din România, Polirom, Iași, Romania.
Benedek, J. (2016), “Spatial differentiation and core-periphery structures in Romania”, Eastern Journal of European Studies, vol. 6, no. 1, p. 49-61.
Benedek, J. and Csilla, V.N. (2013), “Economic disparities and changes in the convergence of the Romanian NUTS 2 and NUTS 3 regions”, Romanian Review of Regional Studies, vol 9, no. 1, p. 86-90.
Blumetithal, D.S. (1994), “Geographic Imbalances of Physician Supply: An International Comparison”, Journal of Rural Health, vol. 10, no. 2, p. 109–118.
Chapman, J., Congdon, P., Shaw, S. and Carter, Y.H. (2005), “The Geographical Distribution of Specialists in Public Health in the United Kingdom: Is Capacity Related to Need?”, Public Health, vol. 119, no. 7, p. 639–646.
Correia, I. and Veiga, P. (2010), “Geographic Distribution of Physicians in Portugal”, The European Journal of Health Economics, vol. 11, no. 4, p. 383–393.
Cromley, E. and McLafferty, K. (2012), GIS and Public Health, The Guilford Press, New York, USA
Cromley, G.A. (2019), “Measuring Differential Access to Facilities between Population Groups Using Spatial Lorenz Curves and Related Indices”, Transactions in GIS, vol. 23, no. 6, p. 1332–1351.
CSFM (2019), Camera Federativă a Sindicatelor Mediclor din Romania, viewed 26 January 2023,
Dellinger, E.P., Pellegrini, C.A. and Gallagher, T.H. (2017), “The Aging Physician and the Medical Profession: A Review”, JAMA Surgery, vol. 152, no. 10, p. 967-971.
Department of Health and Human Services (DHHS) (1998), “Designation of medically underserved populations and health professional shortage areas—HRSA. Proposed rules”, Federal Register, vol. 63, no. 169, p. 46538–46555, USA.
Diallo, K., Zurn, P., Gupta, N. and Dal Poz, M.R. (2003), “Monitoring and evaluation of human resources for health: an international perspective”, Human Resources for Health, vol. 1, no. 3.
Dornescu, V. and Manea, T. (2013), “Migrația medicilor români: dimensiuni socio-demografice și economice”, Revista de Economie Socială, vol. 3, no. 1, p. 121-138.
Dumitrache, L. (2014), “Défis, incohérences et échecs de la réforme sanitaire en Roumanie” in A. Krasteva and D. Vasilcu (eds) Migration en Blanc. Medecins D’est en Ouest, Edition L’Harmattan, Collection Global et Local: Paris, France, p. 21–40.
Dumitrache, L., Nae, M., Dumbrăveanu, D., Simion, G. and Suditu, B. (2016), “Contrasting Clustering in Health Care Provision in Romania: Spatial and Aspatial Limitations”, Procedia Environmental Sciences, vol. 32, p. 290–299.
Dumitrache, L., Nae, M., Simion, G. and Taloș, A.-M. (2020), “Modelling Potential Geographical Access of the Population to Public Hospitals and Quality Health Care in Romania”, International Journal of Environmental Research and Public Health, vol. 17, no. 22, p. 8487.
Dussault, G. and Franceschini, M.C. (2006), “Not Enough There, Too Many Here: Understanding Geographical Imbalances in the Distribution of the Health Workforce”, Human Resources for Health, vol. 4, no. 12.
Eurostat, (2011), Statistics explained Degree of urbanisation classification – 2011 revision, viewed 27 February 2023,
Eurostat, (2020), “Physicians by specialty, 2020”, Health 20, viewed 25 January 2023,
Fotheringham, S. (2000), “Establishing the boundaries” in S. Fotheringham, C. Brunsdon and M. Charlton (eds), Quantitative Geography, Perspectives on Spatial Data Analysis, Sage Publication, London, UK, p. 1-14.
Gettel, C.J., Courtney, D.M., Janke, A.T., Rothenberg, C., Mills, A.M., Sun, W. and Venkatesh, A.K. (2022), “The 2013 to 2019 Emergency Medicine Workforce: Clinician Entry and Attrition Across the US Geography”, Annals of Emergency Medicine, vol. 80, no. 3, p. 260–271.
Guagliardo, M.F. (2004), “Spatial accessibility of primary care: concepts, methods and challenges”, International Journal of Health Geographics, vol. 3, no. 3.
Guagliardo, M.F., Ronzio, C.R., Cheung, I., Chacko, E. and Joseph, J.G. (2004), “Physician accessibility: an urban case study of pediatric providers”, Health & Place, vol. 10, no. 3, p. 273–283.
Gupta, N., Zurn, P., Diallo, K. and Dal Poz, M.R. (2003), “Uses of Population Census Data for Monitoring Geographical Imbalance in the Health Workforce: Snapshots from Three Developing Countries”, International Journal for Equity in Health, vol. 2, no. 1, p. 11.
Hazarika, I. (2013), “Health workforce in India: assessment of availability, production and distribution”, WHO South-East Asia Journal of Public Health, vol. 2, no. 2, p. 106.
Khammarnia, M., Ghiasvand, H., Javadi F. and Safdari Adimi, F. (2021), “Equity in the Distribution of Health Resources: A Case Study in Southeast Iran”, Shiraz E-Medical Journal, vol. 22, no. 8, p. e106392.
Kreng, V.B. and Yang, C.T. (2011), “The equality of resource allocation in health care under the National Health Insurance System in Taiwan”, Health Policy, vol. 100, no. 2-3, p. 203–210.
Kuhn, M. and Ochsen, C. (2019), “Population Change and the Regional Distribution of Physicians”, The Journal of the Economics of Ageing, vol. 14, p. 100197.
Lin, L., Wu, F., Chen, W., Zhu, C. and Huang, T. (2021), “Research on Urban Medical and Health Services Efficiency and Its Spatial Correlation in China: Based on Panel Data of 13 Cities in Jiangsu Province”, Healthcare, vol. 9, no. 9, p. 1167.
Lu, L. and Zeng, J. (2018), “Inequalities in the geographic distribution of hospital beds and doctors in traditional Chinese medicine from 2004 to 2014”, International Journal for Equity in Health, vol. 17, no. 1, p. 165.
Luo, W. (2004), “Using a GIS-Based Floating Catchment Method to Assess Areas with Shortage of Physicians”, Health & Place, vol. 10, no. 1, p. 1–11.
Luo, W. and Qi, Y. (2009), “An Enhanced Two-Step Floating Catchment Area (E2SFCA) Method for Measuring Spatial Accessibility to Primary Care Physicians”, Health & Place, vol. 15, no. 4, p. 1100–1107.
Mantzavinis, G., Theodorakis, P.N., Lionis, C.h. and Trell, E. (2003), “Geographical inequalities in the distribution of general practitioners in Sweden”, Lakartidningen, vol. 100, no. 51-52, p. 4294–4297.
Matei, E., Saghin, D., Dumitrache, L. and Nae, M. (2018), “Multidimensional Approach on Sustainability of Ageing in Romanian Residential Care Centres for Elders”, Sustainability, vol. 10, no. 9, p. 3336.
Meyer, S.P. (2010), “A Geographic Assessment of ‘Total’ Health Care Supply in Ontario: Complementary and Alternative Medicine and Conventional Medicine: A Geographic Assessment of ‘Total’ Health Care Supply in Ontario”, The Canadian Geographer, vol. 54, no. 1, p. 104–122.
Mollahaliloglu, S., Yardim, M., Telatar, T.G. and Uner, S. (2021), “Change in the geographic distribution of human resources for health in Turkey, 2002–2016”, Rural and Remote Health, vol. 21, no. 2, p. e6478.
Mugeot, M. and Naegalen, F. (2018), “Achieving a fair geographical distribution of health-care resources”, Regional Science and Urban Economics, vol. 70, p. 384-392.
Nae, M. (2014), “Le système de santé et sa réforme: représentations dans le cyberspace” in A. Krasteva and D. Vasilcu (eds) Migration en Blanc. Medecins D’est en Ouest, Edition L’Harmattan, Collection Global et Local, Paris, France, p. 45–65.
National Institute for Public Health (NIPH) (2020) Anuar de statistică sanitară, viewed 25 January 2023,
National Institute for Statistics (NIS) (2020), “Activitatea unităților sanitare și de ocrotire a sănătății”, Official Press release no. 167/2022, viewed 25 January 2023,
OECD (2016), Health at a Glance: Europe 2016 -State of Health in the EU Cycle, OECD Publishing, Paris, France.
OECD (2020), Health at a Glance: Europe 2020: State of Health in the EU Cycle, OECD Publishing, Paris, France.
OECD (2021), State of Health in the EU. Romania Country Profile 2021, viewed 26 January 2023,
Ono, T., Schoenstein, M. and Buchan, J. (2014), “Geographic Imbalances in Doctor Supply and Policy Responses”, OECD Health Working Papers, No. 69, OECD Publishing.
Page, N., Langford, M. and Higgs, G. (2018), “An evaluation of alternative measures of accessibility for investigating potential ‘deprivation amplification’ in service provision”, Applied Geography, vol. 95, no. 19–33.
Pál, V., Lados, G., Ilcsikné Makra, Z., Boros, L., Uzzoli, A. and Fabula, S. (2021), “Concentration and inequality in the geographic distribution of physicians in the European Union, 2006-2018”, Regional Statistics, vol. 11, no. 3, p. 3–28.
Pong, R.W. and Pitblado, J.R. (2001), “Don’t take ‘geography’ for granted! Some methodological issues in measuring geographic distribution of physicians”, Canadian Journal of Rural Medicine, vol. 6, no. 2, p. 103–112.
Pong, R.W. and Pitblado, J.R. (2005), Geographic Distribution of Physicians in Canada: Beyond How Many and Where, Canadian Institute for Health Information, Ottawa, Ontario, Canada.
Rój, J. (2020), “Inequality in the Distribution of Healthcare Human Resources in Poland”, Sustainability, vol. 12, no. 5, p. 2043.
Rosenthal, M., Zaslavsky, A. and Newhouse, J. (2005), “The Geographic Distribution of Physicians Revisited”, Health Services Research, vol. 40, no. 6 Pt 1, p. 1931–1952.
Shah, T.I., Milosavljevic, S. and Bath, B. (2017), “Determining geographic accessibility of family physician and nurse practitioner services in relation to the distribution of seniors within two Canadian Prairie Provinces”, Social Science & Medicine, vol. 194, p. 96–104.
Shinjo, D. and Aramaki, T. (2012), “Geographic distribution of healthcare resources, healthcare service provision, and patient flow in Japan: A cross sectional study”, Social Science & Medicine, vol. 75, no. 11, p. 1954–1963.
Silver, J.K., Bean, A.C., Slocum, C., Poorman, J.A., Tenforde, A., Blauwet, C.A., Kirch, R.A., Parekh, R., Amonoo, H.L., Zafonte, R. and Ostebur, D. (2019), “Physician Workforce Disparities and Patient Care: A Narrative Review”, Health Equity, vol. 3, no. 1, p. 360–377.
Silver, M.P., Hamilton, A.D., Biswas, A. and Warrick, N.I. (2016), “A Systematic Review of Physician Retirement Planning”, Health Research Policy and Systems, vol. 14, no. 1, p. 67.
Stahlhut, R.W., Porterfield, D.S., Grande, D.R., and Balan, A. (2021), “Characteristics of Population Health Physicians and the Needs of Healthcare Organizations”, American Journal of Preventive Medicine, vol. 60, vol. 2, p. 198–204.
Suciu, Ş.M., Popescu, C.A., Ciumageanu, M.D. and Buzoianu, A.D. (2017), “Physician migration at its roots: A study on the emigration preferences and plans among medical students in Romania”, Human Resources for Health, vol. 15, no. 1, p. 6.
Sustainable Governance Indicators (SGI) (2022), How many practicing physicians are there per 1.000 inhabitants?, viewed 25 January 2023,
Takayama, A. and Poudyal, H. (2021), “Incorporating Medical Supply and Demand into the Index of Physician Maldistribution Improves the Sensitivity to Healthcare Outcomes”, Journal of Clinical Medicine, vol. 11, no. 1, p. 155.
Theodorakis, P.N. and Mantzavinis, G.D. (2005), “Inequalities in the distribution of rural primary care physicians in two remote neighboring prefectures of Greece and Albania”, Rural and Remote Health, vol. 5, no. 3, p. 457.
Theodorakis, P.N., Mantzavinis, G.D., Rrumbullaku, L., Lionis, C. and Trell, E. (2006), “Measuring health inequalities in Albania: a focus on the distribution of general practitioners”, Human Resources for Health, vol. 4, no. 5, p. 1–9.
Ungureanu, M. and Dietrich, S.K. (2019), “Romania: a growing international medical hub” in Recent trends in international migration of doctors, nurses and medical students, OECD Publishing, Paris.
University of Chicago. Division of the Social Sciences. GeoDa 1.8.16. The GNU General Public License v3.0 – GNU Project – Free Software Foundation. Free Software Foundation, Inc.
Vogt, V. (2016), “The contribution of locational factors to regional variations in office-based physicians in Germany”, Health Policy, vol. 120, no. 2, p. 198–204.
Wan, S., Chen, Y., Xiao, Y., Zhao, Q., Li, M. and Wu, S. (2021), “Spatial analysis and evaluation of medical resource allocation in China based on geographic big data”, BMC Health Services Research, vol. 21, no. 1084.
Watson, D.E. and McGrail, K.M. (2009), “More doctors or better care?”, Healthcare Policy, vol. 5, no. 1, p. 26-31.
Winkelmann, J., Muench, U. and Maier, C.B. (2020), “Time Trends in the Regional Distribution of Physicians, Nurses and Midwives in Europe”, BMC Health Services Research, vol. 20, p. 937.
Wiseman, V., Lagarde, M., Batura, N., Lin, S., Irava, W. and Roberts, G. (2017), “Measuring inequalities in the distribution of the Fiji Health workforce”, International Journal for Equity in Health, vol. 16, no. 115.
Wu, J. (2018), “Measuring inequalities in the demographical and geographical distribution of physicians in China: Generalist versus specialist”, International Journal of Health Planning and Management, vol. 33, no. 4, p. 860–879.
Wu, J. and Yang Y. (2019), “Inequality trends in the demographic and geographic distribution of health care professionals in China: Data from 2002 to 2016”, International Journal of Health Planning and Management, vol. 34, no. 1, p. e487–e508.
Yan, X., He, S., Webster, C. and Yu, M. (2022), “Divergent distributions of physicians and healthcare beds in China: Changing patterns, driving forces, and policy implications”, Applied Geography, vol. 138, no. 102626.
You, W. and Donnelly, F. (2022), “Physician care access plays a significant role in extending global and regional life expectancy”, European Journal of Internal Medicine, vol. 103, p. 62–68.
Zhang, T., Xu, Y., Ren, J., Sun, L. and Liu, C. (2017), “Inequality in the distribution of health resources and health services in China: hospitals versus primary care institutions”, International Journal for Equity in Health, vol. 16, no. 1, p. 42.
Zhu, B., Hsieh, W-C. and Mao, Y. (2022), “Spatio-temporal variations of licensed doctor distribution in China: measuring and mapping disparities”, BMC Health Services Resources, vol. 20, no. 159.
Zurn, P., Dal Poz, M.R., Stilwell, B. and Adams, O. (2002), Imbalances in the health workforce. Briefing paper, World Health Organization Evidence and Information for Policy Health Service Provision.
Zurn, P., Dal Poz, M.R., Stilwell, B. and Adams, O. (2004), “Imbalance in the health workforce”, Human Resources for Health, vol. 2, no. 13.

This post has already been read 5723 times!

About journal

Title: Human Geographies - Journal of Studies and Research in Human Geography
ISSN online: 2067-2284
ISSN print: 1843-6587
Imprint: University of Bucharest
Frequency: Biannual (May&November)
First volume: 1/2007
Current volume: 18/2024
Language: English
Indexed in: SCOPUS, ERIH PLUS, EBSCO (SocINDEX), ProQuest (Social Science Journals, SciTech Journals, Natural Science Journals), Index Copernicus, National Technical Information Service (NTiS), Bodleian Libraries, ExLibris SFX, DOAJ, Gottfried Wilhelm Leibniz Library, Google Scholar, Ulrich
Creative Commons License


Prof. dr. Liliana Dumitrache
University of Bucharest, Faculty of Geography- Human and Economic Geography Department, 1 Nicolae Balcescu Av., 010041, Bucharest, Romania

Dr. Daniela Dumbrăveanu
University of Bucharest, Faculty of Geography- Human and Economic Geography Department, 1 Nicolae Balcescu Av., 010041, Bucharest, Romania

Dr. Mariana Nae
University of Bucharest, Faculty of Geography- Human and Economic Geography Department, 1 Nicolae Balcescu Av., 010041, Bucharest, Romania

Dr. Gabriel Simion
University of Bucharest, Faculty of Geography- Human and Economic Geography Department, 1 Nicolae Balcescu Av., 010041, Bucharest, Romania

SCImago Journal & Country Rank