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\begin{document}

             \author[1]{Petronela Daniela  Feraru}

             \affil[1]{  University of IaAi, Romania}

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\date{\small \em Received: 15 December 2012 Accepted: 5 January 2013 Published: 15 January 2013}

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\begin{abstract}
        


Migration of doctors in Romania still continues today producing a range of long-term social, economic and demographic effects. Current data on the migration of these specialists from our country shows a negative trend, therefore according to the figures offered by the College of Physicians in Romania, only since 2007 10,000 doctors have chosen to work in the West, and 400 submit applications monthly to the Ministry of Health.This paper brings to the attention issues related to the scale of the Romanian medical migration. For this purpose, we used different statistical data provided by specialized institutions in the country and abroad, information provided by the media, the results of studies published in the field. The goal is a better understanding of the dimensions of the phenomenon, for which the analysis is completed by means of the interactionist and interpretative method according the constructivist perspective. The results obtained in this study consist of the discolure of certain current issues followed by the presentation of social effects and social, economic and demographic dimensions of the Romanian medical system from the perspective of medical migration

\end{abstract}


\keywords{medical migration, brain drain, sanitation system, human resources, performance.}

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\let\tabcellsep& 	 	 		 \par
The Health System in Romania in Terms of Human Resources Management he main problems identified by the Ministry of Health of Romania in the public health system are human resources, finance and organizational details. An effective health system reform involves changing some aspects related to employment, working conditions, degree of decentralization of management skills, salary system and staff motivation. The issue of budgetary constraints may not be solved immediately without finding potential solutions for reorganizing the system, without solving the shortage of health professionals and without efficiency in the procurement field. The role of human resources in the health system is crucial. The quality performance in the field depends on the human resources management. It must comprise aspects mainly related to the development of a coherent training, the development and human resource allocation policy, the increase in the number of medical personnel and career development in the medical field.\par
Poor management of the health system, political duels and the unsuccesful health system reform increases the distrust of young doctors in their professional future in Romania \hyperref[b8]{(Manea, 2011)}. Thus, we can see a major shortage of health workers in many counties due to the migration of doctors and of specialized health professionals. External migration of Romanian doctors is likely to increase even more the overall shortage of doctors in the regions and in some specialties, which are very popular in the European Union (anesthesia, intensive care, surgery, family doctors). Brain drain from Romania, including of the medical staff, is a growing phenomenon, as nationally no decisions are taken to reduce the phenomenon, while developed countries currently use different economic, budgetary and tax strategies in order to attract specialists from all fields coming from economically less developed countries. Ethical procedures of recruitment of health professionals should work as a factor protecting medical resources in developing countries where human resource is deficient (Cehan and Manea 2012:100-109, Dornescu 2012).\par
According to the Dictionary of Sociology migration is a phenomenon that consists in the movement of crowds of people from one area to another, followed by the change of residence and / or by employment in a field of activity in the arrival area (Vl?sceanu and Zamfir, www.dictsociologie . netfirms.com). If we look at the phenomenon with reference to a given population -a perspective mainly adopted by demography -as compared to this population, we can speak of two forms of migration: immigration (all inputs) and emigration (all outputs). In fact, any act of migration is at the same time, migration and emigration.\par
The term "brain drain" is the loss of skilled labor force intellectually and technically qualified through the movement of the labor force to more favorable media from a geographic, economic, or professional perspective (http://www.answers.com/).\par
The performance concept involves getting a great result. This result can be seen particularly in terms of three dimensions (Verboncu and Zalman, 2005, p 6): a result superior to the previously obtained results, a superior result compared with the achievements of others, a result superior to the objectives set and assumed. We can find numerous writings on the importance of human resources in public health organizations. Experts in the field believe that of all health resources, human resources are the most important player. In the health sector, the role that the personnel has is more important than in case of other sectors. The improvement of the performance of human resource in the health sector is a goal pursued by all developed or developing countries (Pup?z?, http://www. utgjiu.ro). a) Migration of Romanian doctors: a motivated act Romanian doctors want social recognition, professional achievement and respect from society. It is surprising that even patients show their dissatisfaction with the level of wages of doctors, and also with the conditions in which they work. The rate of patients' confidence in doctors is high, and even higher in regard to family physicians.\par
Doctors are dissatisfied with their salary, number of employed staff, technical equipment and provision of medicines. In the EU, the average income of a doctor in 12 countries is EUR 12,000 per month and the minimum income of a resident in France is EUR 1200 and EUR 1800 in the UK (http://laurb adea.wordpress.com). For example, several communes in France are willing to spend up to EUR 40,000 for each Romanian doctor brought in the region, after experiencing a phenomenon called by the media "medical desertification": no French is willing any longer to be a doctor in the country. This is specific to the medical situation in Romania. Dornescu and Manea present in a study the high level of polarization of doctors in urban areas  {\ref (Dornescu and Manea, 2013, p.122)}. Thus, statistics are presented (NIS 2012 http://www.insse.ro) showing that in 2011, for example, the number of doctors in urban areas was 46 949 (89\%) and that of doctors in rural areas was 5592 physicians (11\%), which highlights the serious regional imbalances. Thus, the number of inhabitants per one rural doctor is now more than 6 times higher than in urban areas, and 100 towns in the country have no doctor available. The explanation is that urban areas -particularly university centers -absorb doctors from surrounding or rural areas, making them even more disadvantaged. A growing number of medical specialists prefer to work as representatives of drug companies, go abroad or choose to work in other fields than choose rural areas. In other words, in terms of the degree of coverage with medical personnel, Romania is facing a striking situation due to existing regional inequalities in terms of coverage and provision with medical personnel. Following recent analysis it was found that there is a shortage of doctors in remote rural areas where living and working conditions are difficult.\par
The degree of professional satisfaction of physicians depends on the conditions of their work (facilities, adequate labor protection equipment). Many doctors in Romania work in harsh conditions, sometimes they do not even have the medicines or the supplies needed to administer appropriate treatment to patients. To this we can add the poor financing of the public health system, the conditions of stress, the strain at work, the lack of recognition and respect for the importance of the work they perform and the corruption in the system, which motivate emigration. Based on the degree of dissatisfaction of the medical staff in Romania we are dealing today with a challenge, namely the migration of labor force from the health sector. And all this despite the fact that Romania has a third less health personnel per one thousand people compared to the EU average. According to the CPR President Vasile Astarastoae' estimates, today we have more than 20,000 Romanian doctors who save lives abroad, even if the Romanian state paid for their training almost 230 million euros, while those remaining in the country are poorly paid, the responsibility belonging to the Romanian state, which drives them away (http://www.ziaruldeiasi.ro). Astarastoare said that according to statistics, the Romanian state spends with a medical student about RON 5,000 per year, and during his/her residency it pays almost RON 21,000. It follows that for the training of a physician for a period of six years the Romanian state spends RON 30,000, and for specialization, RON 21,000, approximately EUR 11,300 overall. The crisis accentuated the emigration rate, so that in six years over 20,000 specialists have left. A simple calculation shows that this time the state lost over 226 million euros. 
\section[{i. Motivational factors in the emigration of Romanian doctors}]{i. Motivational factors in the emigration of Romanian doctors}\par
The reasons given by doctors who choose to emigrate from Romania are wages, working conditions, promotion, facilities offered by the organization that provides the necessary comfort, socialization opportunities, public recognition of the value of their work. Satisfaction is based on other factors as stated by Abrudan (2010, p.51): satisfaction is achieved when there is a balance between whatever the employee brings to the organization (diplomas, professional experience) and whatever the organization offers (salary, position, level of complexity). Economic motivation represents the decisive factor in the choice of the medical staff of leaving abroad. In Romania, the average salary of a doctor is EUR 500-600 per month and a resident doctor earns between EUR 170 and EUR 340 per month, while abroad we can talk about salaries starting from EUR 2000-3000 per month for resident physicians and wages over EUR 5000 for medical specialists.\par
Another important motivation is the one related to poor working conditions in hospitals that hinder the work of doctors to which we can add the lack of materials, the technological deficit, the old utensils and appliances. Romanian doctors in our country are working on average 5-6 times more in terms of quantity and difficulty than the European average. Although Romania is facing a shortage of medical personnel, very few positions are declared vacant where staff is needed. Although we have a shortage of doctors, Romania specializes a small number of the total number of graduate students from medical faculties (48\% of graduates).\par
Doctors who left Romania did not do it out of pleasure or because they have had enough of their country, but because they were "tired of how things worked." Another reason why doctors leave is the pressure and blaming of the medical staff in Romania. "In Romania there were during the communist period attacks on the medical personnel, but not in such a manner as it began to exist since January 1, 2013. This has to do with Romanian society's reaction and therefore Romania is ill in this regard as well" said the President of CPR (http://www.ziare.com).\par
Also, the level of resources allocated to health care in Romania is low and affects the quality of medical act as it is a decision factor of the doctors' migration. Unfortunately, the health system is chronically underfunded, there is an inconsistency, inequality and lack of fairness in healthcare, Romania still allocating the least amount of GDP on health, less than 3\%, while the EU allocates between 5-6\% of GDP.\par
ii. The Romanian health system financing The resources allocated to health care in Romania is low and it requires finding solutions to increase the level of public health funding because the reduced level of public resources allocated to health directly affects the quality of the medical act and determines more and more Romanian doctors to emigrate. Dornescu and Manea pursue the funding level of the health system by means of the analysis of two important indicators: total expenditure on health and public expenditure on health / capita (Dornescu and   Manea, 2013, pp.123-126).\par
Total expenditure on health, expressed as a percentage of GDP in 2000 and 2007 were in Romania at a level of 5.2 percent, the lowest in the European Union, while the average for the 27 countries of EU has experienced much higher values and increasing values, respectively 8.4 percent in 2000 and 8.8 percent in 2007. According to estimates made by the World Health Organization WHO (2010) the highest values of total expenditure on health share of GDP were recorded in this period in Germany (10.3 percent), France (10.1 percent), Austria (9.9 percent), Belgium (9.1 percent), Sweden (8.2 percent). (See Figure \hyperref[fig_0]{1}). Public expenditure on health / capita in the same period was also the lowest in comparison with EU countries (\$ 202 / capita, \$ 475 / capita respectively), while the average in the European region was \$ 901 /capita, \$ 1.401 / capita, respectively. Much higher levels and increasing levels were recorded in countries such as Luxembourg (\$ 2.800/ capita., \$  Although there are economic differences between EU countries, the data presented as percentages of the gross domestic product shows the percentage of GDP allocated by each government to expenditure on health. These figures show how much the government cares to ensure the right to health of its citizens.\par
The financing degree of the health system directly affects the job satisfaction of physicians. The remuneration level of the medical personnel in Romania can be considered a"push" factor of migration, valid not only for physicians but also for the other categories of the medical staff. The degree of professional satisfaction of physicians in terms of income earned depends on the level of economic development of the country and can be determined by comparing the individual gross income of physicians to the average level of wages on overall economy. 
\section[{II.}]{II.}\par
Migration of Romanian Doctors: Solution or Problem for Romania?\par
We included issues related to the migration of experts, including of physicians in the research conducted for the PhD thesis presented in 2011 which contains a qualitative case study and two integrated quantitative studies conducted in Italy in 2010. Thus, we have the research results with a sample of over 30 interviews and over 120 questionnaires conducted in groups of subjects according to the research objectives  {\ref (Feraru, 2011)}. The case study is published, but without the two integrated studies in a volume that bears its name and contains aspects related to both approaches that refer to the stages of the migration process and to the levels of related analysis \hyperref[b5]{(Feraru, 2011b)}. Thus, the analysis of the research data showed that more than 50\% of those surveyed were determined in their actual migration by objective economic factors out of the wish to earn more in Italy. Men were found to be more motivated than women professionally and educationally and aspired more towards the profession for which they were trained in Romania. Women can be regarded as more likely to accept a profession non-compliant with their training in Romania.\par
Social development can be enhanced by developing motivations for success and prospective motivations and by removing the dependency motivations. The development and evolution of social reality assumes first of all an intervention through programs of selection and guidance of the motivation of the individuals who make up that reality. The motivation for success and the prospective motivation have a positive role and the dependency motivations have a negative role. According to data obtained from the field, most interviewees said to be favored by motivations for success, being active people, passionate by their profession and excelling in the field, others are favored by prospective motivations being primarily concerned with the care for the common welfare of all, with the expansion of the self to the whole society or with altruism. Last were the interviewees underprivileged by dependency motivations, being people who feel the need for protection, help, support.\par
Professional dimension, as an important part of the integration of migrants at destination, is often considered in terms of satisfaction or dissatisfaction with life and work, as compared to the position held in Romania until departure from the country: "... I had worked as a nurse in Romania for three years of which the last year I was a chief nurse in an Emergency University Hospital from Cluj ... It depends on motivation, it depends on training. My chances as a nurse are higher than those of a young man of 20 who had graduated from high school and has other studies, that's the reality here and all over the world, my chances are higher ... Romanian nurses are trained, and anyway, the systems are very different, when you get to work here in a short time you are shocked by the differences, starting from patients and ending with the most complicated operations performed, operations that you cannot imagine in Romania, this is the turth, everything is different ... it is a very well developed medical system, here the patient is protected, here you must see the patient and give him everything ... If I were to return home I could not work in health care for the patient in Romania is not respected, I would probably do something else, but not in medicine, because the Romanian healthcare system doesn't work although the Romanian medical school is very good, the possibilities are great, doctors are very well-trained, but the system does not work effectively". (I.G,. 33, a nurse at the Rivoli Hospital in Turin, for 5 years in Italy). 
\section[{a) Evolution of the migration of doctors since 1989 to the present}]{a) Evolution of the migration of doctors since 1989 to the present}\par
According to data provided by the College of Physicians of Romania, in 1989 Romania had 56,000 physicians with the right to practice, in 2013 their number is 39.896. In the first three months of 2013, 580 doctors left and other 250 requested documents to go abroad in the first two weeks of April, claiming that this wave of departures recorded in 2013 can only be compared with that of 2007 after Romania joined the European Union.\par
According to data held by the College of Physicians, the large number of departures of Romanian doctors abroad is worrying, if we relate it to the number of the ones employed in the national health system. The number of employees in the health system was, on average, in recent years of approximately. 50,000 (52,541 doctors in 2011, of whom 41 171 doctors in the public sector (National Institute of Statistics 2011). Greates departures of doctors in Romania were from the academic centers of the country (from Bucharest 947, 403 Cluj, Iasi 253, Timis 202). (See Figure \hyperref[fig_0]{1}).  It is noted also that the specializations most required by foreign employers were that of general medicine, family medicine, general surgery, anesthesia and intensive care. According to statistics (College of Physicians in Romania 2012), the number of doctors who had left so far is over 20,000, of whom 10,000 doctors have left before Romania's accession to the European Union and over 10,000 doctors left in the period 2007-2011. (See Table \hyperref[tab_1]{1}). Source: Medical College Romania, available at: http://www.cmr.ro Some pessimistic scenarios lead to the idea that if the current migration balance is preserved, in 2021 there will be no doctors in Romania \hyperref[b9]{(News.ro 2011)}. To this we add the demographic factor, Romania's population fell dramatically after 1989, namely with about 3 million people, due to the influence of three important factors, namely: external migration, increase of mortality rates and birthrates rebound, which is below the mortality rate. We can also see a decrease in the number of young people, which further narrowed the age pyramid (National Institute of Statistics 2011).\par
Westward migration of doctors has become a phenomenon in Romania. Studies in the field and predictions made by experts show that if Romania does nothing to keep doctors in the country, if migration and the number of pensioners are maintained at the pace of the last two years, over only 11 years, our country will be left without doctors. The trends of Romanian migration in recent years show a feminization and an aging of migrants which are highest in case of people aged between 26 and 40 years.\par
These developments are also reflected at the level of the medical staff which faces a phenomenon of aging. 
\section[{III.}]{III.} 
\section[{Conclusions}]{Conclusions}\par
Migration of doctors has been discussed ever since 2008 at the Assembly of professional medical organizations in Central and South-Eastern Europe (ZEVA) and raises very serious concerns. At present, all countries of the world face the migration of doctors, whether it is their departure from rural to urban areas, from their country to foreign lands, or migration to other professions.\par
Thus, the present paper attempts to attract attention on the extent and implications of the phenomenon of migration of doctors in Romania. The reasons for migration are always the same: conditions of work, better living and the financial aspect.\par
Along with the human dimension related to the human resources of the health system in Romania, an important role is played by the economic dimension. The migration of doctors has important economic connotations because it represents a loss to the country of origin, namely the cost of human capital training. This loss consists of two components, namely "the cost of training" and "the cost of specialization." In Romania, for example, annual expenditure on training a medical student is currently about RON 8,000 and for one year of residency the Romanian states spends about RON 21.000. It follows that the training and specialization of a physician for a period of 6-11 years (6 years of faculty and 3-5 years of residency) the Romanian state spends about RON 70,000 (about EUR 20,000). If over 20,000 physicians have left Romania so far, this means that the Romanian state lost more than EUR 400 million  {\ref (Dornescu and Manea, 2013, p.132}). The crisis accentuated the emigration rate, so that in six years more than 20,000 professionals have left and their number is growing.\par
The figures showing the performance of health systems in different European Union countries determined the Presidential Commission for the analysis and development of public health policies, established by decision of the President of Romania, to develop a public health policy proposal that can be used as a starting point in improving the functioning of the Romanian health system. However, the results fail to appear and the capacity of the Ministry of Public Health to engage in activities able to determine other sectors to comply with the health status of the population and with a healthy life environment is further reduced.\par
What kind of solutions can be applied to stop the phenomenon of migration of doctors? Firstly, regulations on working time and family situation of doctors can be developed. Here, the state can propose strategies for doctors who move from one area of the country to another in terms of education, mobility, spare time of the doctor and of his/her family. Not only money matters! Secondly, a strategy regarding praxis is required. In the past there was the doctor and his/her medical office and now we must consider the relationship doctor -praxis group, namely the association of several specialists in a medical office. This requires high costs, but the investment in health is the best investment for any country. The entire documentation on the migration of doctors phenomenon, has revealed that there is no European country whose healthcare system can be considered an example for other countries. Advantages and disadvantages can be found everywhere although some countries have managed to make progress as compared to others. For example, there are problems in rural areas everywhere across Europe. If the rich countries in Europe do not to solve the problems so that they can keep their doctors, poor countries of the world will pay a price for this. Thus, both the patient and the doctor will do the same: will leave the system that does not meet their expectations.\par
A negative trend of the kind established in recent years becomes a factor that stimulates the exodus of doctors and aggravates the already critical situation of the health system in Romania.\par
If we look at the figures we find that brain drain from Romania, including of the medical staff, is a phenomenon that cannot be stopped, which is why doctors say that migration is selective, controlled and used for a national interest.\begin{figure}[htbp]
\noindent\textbf{1}\includegraphics[]{image-2.png}
\caption{\label{fig_0}Figure 1 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{2}\includegraphics[]{image-3.png}
\caption{\label{fig_1}Figure 2 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{1}\includegraphics[]{image-4.png}
\caption{\label{fig_2}Figure 1 :K}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{2}\includegraphics[]{image-5.png}
\caption{\label{fig_3}Figure 2 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{}\includegraphics[]{image-6.png}
\caption{\label{figure6}}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{1} \par 
\begin{longtable}{P{0.28732394366197184\textwidth}P{0.5626760563380282\textwidth}}
\tabcellsep 2007-2011\\
Year\tabcellsep No. of people\\
2007\tabcellsep 2.200\\
2008\tabcellsep 1.252\\
2009\tabcellsep 1.900\\
2010\tabcellsep 2.779\\
2011\tabcellsep 2.841\end{longtable} \par
 
\caption{\label{tab_1}Table 1 :}\end{figure}
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