Adapting education and health to demographic change can help boost Nord‑Vest’s productivity and partly offset a shrinking labour force. Better integrating public transport across Nord-Vest would improve access to services and enable development patterns that support lower service delivery costs. Ongoing national education reforms provide a major opportunity for Nord-Vest to strengthen its under-performing education system, close achievement gaps and increase young peoples’ participation in training and education. Scaling-up childcare capacity would help attract more young families to Nord-Vest and increase women’s participation in the labour force. Healthcare services need to shift to become more prevention-focused to improve Nord-Vest’s long-term health outcomes and limit the fiscal burden of ageing; while closing coverage and workforce gaps, especially in rural areas.
Preparing for Demographic Change in Nord‑Vest, Romania
Abstract
Adapting public services to align with demographic change will be crucial to support the continued development of Nord-Vest. Across Romania, unequal health and education services have contributed to major disparities in development across regions, and especially between urban and rural areas (World Bank, 2023[1]). Better physical and digital connectivity can support health and education services, which in turn can help boost Nord-Vest’s human capital, improve its attractiveness (OECD, 2023[2]), reduce the rate of youth out-migration, enhance labour mobility and spread agglomeration benefits in Nord-Vest’s growing urban centres.
Demographic change will have a varied impact on different services and places in Nord-Vest. By 2040, Nord-Vest’s population is forecast to shrink by a tenth, with the youth population (less than 18) declining by almost a fifth, while the elderly population (more than 65) grows by almost a fifth. The population is expected to shrink and age throughout Nord-Vest, but with differences across counties and localities (Figure 4.1). All else equal, as the population ages, education demand will likely decrease, while healthcare demand will likely increase. However, the speed and extent to which these trends play out will differ across places in the region. For example, even as the school-age population is forecast to decline overall, this is not true for the secondary school-aged population in Cluj County until almost 2040. Indeed, starker differences exist at the locality level, where both urban centres and rural areas are expected to shrink, while suburban and peri-urban areas are expected to grow. A place-based approach will be needed to adapt different services to future needs and constraints (Box 4.1).
Projected population change by county and age group (2019–2050), indexed to 2019 baseline
Source: Eurostat, Population projections at regional level, https://doi.org/10.2908/PROJ_19RP3
With demographic change, maintaining accessibility and quality of public services becomes increasingly costly. Depopulation, resulting in lower population densities, potentially increasing the per capita cost of providing public transport and healthcare, while declining student cohorts raise the per student costs of delivering education. Ageing further challenges healthcare provision by increasing demand for specialised healthcare and long-term care, as well as raising per capita treatment costs due to the greater complexity of health conditions. As a result, ageing is driving up total healthcare expenditure, a trend that is expected to continue over the short to medium term.
In a context of depopulation and ageing, policymakers need to balance cost containment with service quality and accessibility considerations. Budgetary constraints that restrict investments in infrastructure, workforce retention, professional development and technological innovation can lead to a significant decline in service standards. Conversely, preserving quality while limiting expenditure risks service reductions and facility closures, disproportionately impacting low-income households, particularly in remote areas.
As ageing and depopulation persist, service provision must evolve. Developing resilient public services will require innovative policy solutions that balance cost, accessibility and quality This can include strategies to enhance efficiency through service integration and administrative simplification. Service networks can be restructured and optimised to maintain quality and equitable access while managing costs effectively. Alternatives to physical public provision can be explored, including public-private partnerships, community-based initiatives and the use of digital or demand-based solutions.
This chapter explores how Nord-Vest may seek to adapt public services to better adapt to demographic change. To do so, it first looks at the state of digital and physical connectivity infrastructure, which is essential for understanding the accessibility of public services. Then, it examines the accessibility of five key services – childcare; primary and lower secondary education, secondary education, primary healthcare, and secondary and tertiary healthcare – and assess how demographic change could impact future demand and supply for these services. Finally, this chapter concludes by providing policy recommendations for local, regional, national and EU governments to improve service delivery and tackle demographic challenges in Nord-Vest.
Nord-Vest already has strong digital connectivity but needs to improve physical connectivity (Figure 4.2). Improving connectivity can help people access services by lowering travel times to schools and hospitals, or in the case of digital connectivity, removing the need to travel. Compared to other EU regions, it is more difficult to travel across Nord-Vest through road and rail. For example, Nord-Vest’s road transport performance is 62% worse compared to the EU average in terms of accessibility measured by the percentage of the local population accessible within 1.5 hours by train. At the same time, broadband access is reasonably high, with 50% of Nord-Vest’s population having access to broadband above 100Mbps, compared to the EU NUTS-2 average of 37%.
Nord-Vest performance on select connectivity indicators, relative to average of EU NUTS 2 regions
Note: Road and rail transport performance measured by population accessible within 1.5 hours by road or rail within a 120km radius from a given neighbourhood (2018–2019). Household broadband measured by share of households with broadband access (2021). Enterprise with fixed broadband access measured by share of enterprises connected to internet-capable network or other fixed and mobile broadband technologies (2016–2017). Access to high-speed broadband measured by share of population with access to fixed or mobile broadband speed of at least 100Mbps (2018).
Source: European Commission (2022), European regional competitiveness index 2.0, https://ec.europa.eu/regional_policy/information-sources/maps/regional-competitiveness_en
Roads and highways
The road transport network in Nord-Vest is under-developed by EU standards, undermining access to services. In the average Nord-Vest neighbourhood, only 30% of the total population living in a 120km radius can be reached within a 1.5‑hour, compared to an average of 77% across EU NUTS-2 regions (European Commission, 2022[3]). Communities in mountainous areas face even higher transport times and costs. Road transport performance is the second worst in Romania in terms of accessibility (European Commission, 2022[3]).
Investments are underway to improve road transport. Nord-Vest’s strategic location within Romania and the EU has resulted in significant funding. Many road transport investments are supported through the EU funded Nord-Vest Regional Programme and the Connecting Europe Facility. This includes a section of the A3 Motorway between the Hungarian border and Cluj-Napoca (dark red in Figure 4.3), which is a major ongoing project and will connect across the Carpathian Mountains to Bucharest and the rest of southern Romania as part of the Trans-European Transport Network (TEN-T) Network. In addition to boosting economic performance, these investments will also allow faster travel to service centres, especially between urban and rural areas.
Major ongoing and planned road projects in Nord-Vest
Note: Dark grey lines show county boundaries and light grey lines show locality boundaries.
Source: OECD adaptation of questionnaire response by North-West RDA
Public transport and rail
Public transport services throughout Nord-Vest are of limited quality, resulting in increased congestion and worse access to services. Nord-Vest has a broad range of public transport modes, including trains, trams, buses, trolleybuses and an under-construction metro project. While urban public transport coverage is good compared to that of other Romanian cities (with 82% of people in Cluj-Napoca living within 5 minutes’ walk of a public transport station, and 76% for Oradea) (World Bank, 2021[4]), service levels and quality has room to improve, especially in the rapidly growing periphery areas. While Romania has an extensive railway network, railway infrastructure is often outdated (IFC, 2023[5]). In Nord-Vest, the location of railway stations is not fully aligned with population centres and other transport modes, resulting in rail usage that is primarily long distance, with remaining potential to leverage excess capacity for better metropolitan services (World Bank, 2021[4]). The lack of public transport services disproportionally impacts vulnerable groups (such as youth, elderly people and those with limited means) who face financial and mobility challenges to accessing services and other opportunities.
Better public transport can improve access to services in many ways. First, it can provide direct access to key service facilities (such as the under-construction Cluj Regional Hospital) through alternative travel modes, which can to some extent avoid congested roads if they have right of way. Second, it indirectly relieves congestion across a broader area and can speed up local trips to other service centres, such as hospitals and universities. Third, it can enable transit-oriented development that puts people closer to service facilities and allows more cost-efficient service provision. Several public transport and rail investments are already underway in the region, which are partly supported though the Nord-Vest Regional Programme and the Connecting Europe Facility. Among others these include the Cluj-Napoca metro project (Box 4.2) and a 166km railway line between Cluj-Napoca and Oradea that is being upgraded and electrified, at a total cost of EUR 1 976 million (EIB, 2023[6]).
Cluj-Napoca Metro is an underground light metro system currently under construction in Cluj-Napoca. The initial system will include 19 stations across 21km on an east-west alignment across Cluj-Napoca Municipality and Floresti County. Upon its planned completion in 2031, it would become Romania’s second mass transit system (after the Bucharest Metro). The project has an estimated cost of EUR 2.8 billion, with majority state funding (EUR 2 billion) and around 10% from the EU Recovery and Resilience Facility (Railway Pro, 2024[7]). Aligning future spatial planning and service provision to the updated transport infrastructure will be critical to make the most of this metro investment to support increased access to services. In line with this, the metro is already incorporated in the Cluj PATJ.
Public transport services in Nord-Vest often does not align with functional needs. Public transport routes can be limited to the urban core within an administrative boundary and fail to extend into surrounding functional zones, even as many cities in Nord-Vest continue to expand. For example, while the CTP Cluj‑Napoca runs metropolitan services within the first ring of localities around Cluj Municipality (under the Cluj Metropolitan Association of Public Transport), there are no integrated services beyond the first ring, requiring transfers between different operators with different fare policies (World Bank, 2021[4]). Further, all metropolitan-level public transport uses buses on roads with only very limited stretches of dedicated lanes, resulting in low speeds and capacity. While counties provide inter-locality transport (typically through private concessions), these tend to have limited frequencies and more commuter-oriented schedules, limiting their convenience for rural residents to access services in nearby towns and cities. Overall, the fragmented transport network may reduce people’s access to public services, especially speciality services such as tertiary healthcare and universities predominantly located in city centres.
Digital connectivity
Nord-Vest has good digital connectivity, but digital skills have room to improve. Nine in ten households in Nord-Vest have broadband access, slightly above the average EU region (European Commission, 2022[3]). Furthermore, just over half of people in Nord-Vest has access to high-speed broadband, compared to 37% in the average EU region though slightly lower than 54% in the average Romanian region (European Commission, 2022[3]). However, there are some local gaps – as of 2023, 40% of localities in Nord-Vest only have average broadband speeds of less than the national target of 100Mbps (Figure 4.4). Of these, 93% are rural. Digital skills also pose a challenge, with Nord-Vest ranked the tenth lowest performing out of 234 EU regions in terms of individuals with above average digital skills (though five Romanian regions perform worse) (European Commission, 2022[3]). The North-West RDA has recognised this challenge and is already helping boost digital skills, for example by funding the digitalisation of small and medium enterprises (North-West RDA, 2024[8]).
Number of localities with over 100Mbps fixed internet download speeds, share of total by degree of urbanisation
Note: Using the degree of urbanisation classification of localities (OECD et al., 2021[9]) rather than Romanian national classification of cities, towns, communes and villages.
Source: OECD calculations based on Ookla speedtest of global fixed and mobile network performance, https://registry.opendata.aws/speedtest-global-performance/
Nord-Vest’s education system faces a triple challenge of insufficient quality, low participation rates and rising costs – all potentially worsened with demographic change. By 2050, Nord-Vest’s youth population (under 18) could shrink by a quarter, posing risks to economic dynamism and the financial viability of schools. Furthermore, a more educated and productive workforce will be needed to partly compensate for the economic impact of population shrinkage. Yet, one in seven young people in Nord-Vest leave education and training early, a rate one and a half times that of the EU average. Rising costs per student might complicate efforts to improve quality as by 2035, three in five Nord-Vest localities could have per-student costs above the Romanian average for primary schools. Ageing and insufficient assets will further add to the pressure, with capacity shortages resulting in only 7% of eligible children in Nord-Vest attending nurseries despite the expansion of mandatory childcare.
Policy and institutional arrangements
Education is primarily a central government responsibility in Romania. The Ministry of Education (MoE) oversees the Romanian national education system (Table 4.1). The MoE manages pre-university education through County School Inspectorates (CSIs) to implement national education policies, in collaboration with locality governments. CSIs directly support, monitor and administer schools (OECD, 2024[10]). The MoE is ultimately responsible for most elements of pre-university education, including curriculum design and human resources. Higher education institutions are autonomous and the MoE plays a more limited co-ordination role (Eurydice, 2024[11]).
Source: Eurydice (2025), Overview of the Romanian Education System, https://eurydice.eacea.ec.europa.eu/eurypedia/romania/overview
Subnational governments have a large role to support investment in education facilities. While subnational governments account for little over a fifth of government total expenditure on education, they account for almost three quarters of government investment on education (Figure 4.5). Locality governments primarily provide school infrastructure, have a representative on the administrative council of schools, and may (with CSI approval) oversee education units without legal person statute (Eurydice, 2024[11]). Prior to reforms in the 2010s, locality governments were also responsible for teacher salaries, which has since been centralised (Parliament of Romania, 2011[12]).
Subnational government spending on education (2022), share of general government spending
Note: OECD averages unweighted. EU averages weighted.
Source: OECD National Accounts, Annual government expenditure by function (DSD_NASEC10@DF_TABLE11)
Funding for public pre-university education consists of basic and complementary funding. The MoE, through CSIs, provides basic funding, which consists of most operational costs, such as teacher salaries, training allowances and goods and services. Basic funding is allocated on a per-student basis through a formula funding model, adjusted for education level, type (e.g. vocational, special needs), language of instruction and geography (e.g. urban, rural). As part of this, teachers working in remote or rural areas receive a 20% top-up to their basic salary. Locality governments provide complementary funding, which consists of most capital costs, such as investment in and maintenance of school infrastructure, within their jurisdiction. Complementary funding also includes some operational costs, such as student transport within localities (where necessary, however, the MoE funds transport across localities) and extra-curricular activities (Parliament of Romania, 2023[13]).
Students generally enrol in schools based on their domicile. Enrolment elsewhere is possible at parents’ request and with schools’ approval. Public education at all levels is available free of charge, though with limited positions in higher education. National minorities, mostly Hungarians in Nord-Vest, have the right to receive education in their respective languages (with transport or boarding school fees covered if education is not available locally).
The Ministry of Education regulates education standards and monitors outcomes. Classroom sizes should be 12–25 students for primary, 12–30 students for lower secondary and 15–30 students for upper secondary, though the MoE may approve exceptions (Eurydice, 2024[11]). School units should generally have at least 300 students, or in the case of kindergartens at least 140, nurseries at least 120, technological high schools with dual education at least 80, special education units at least 50 and post-secondary education at least 100 – though exceptions may be authorised by the MoE and are numerous (Parliament of Romania, 2023[13]). The Agency for Quality Assurance and Inspection on Pre-University Education (ARACIIP) accredits, inspects and evaluates schools. The MoE takes the lead on school network re‑organisation, in consultation with local communities.
The education system is undergoing a reform under the Educated Romania project. The Romanian Parliament passed the School Education Law 198/2023 to increase spending on schools and teachers, especially in disadvantaged areas (Parliament of Romania, 2023[14]). For example, it introduces priority investment areas (zone de investitii prioritare) to provide additional funding for schools serving students from marginalised group, such as Roma communities and national minorities. It also includes education reforms to strengthen school evaluation and support, introduce new professional standards and improve education data management (OECD, 2024[10]). On top, a variety of national and EU programmes are providing integrated support to disadvantaged groups through better social, education and health services. For example, the Social Inclusion and Dignity Programme of Romania includes EUR 3.4 billion worth of EU investment to build rural community centres, fund social housing, expand disability support and support migrant integration (European Commission, n.d.[15]).
Current state of education and childcare services
As the workforce of Nord-Vest declines due to demographic change, it will be essential to boost productivity by increasing skill levels, especially among the disadvantaged groups with worse education outcomes. Better education and childcare services can also help Nord-Vest attract young people and families, as well as boost labour force participation, especially for women.
Nord-Vest has low education quality, especially in rural areas
There is room to improve education outcomes in Romania. In 2022, almost half of Romanian students tested did not achieve baseline competency in reading, mathematics or science – considerably worse than that of their OECD peers (Figure 4.6). Further, after a decade of improvement, the performance of Romanian students has declined or flatlined since the mid-2010s (OECD, 2023[16]). Rural students tend to experience worse education outcomes. Eight in ten rural students in Romania have inadequate mathematics skills in 2022, over twice that of urban students, at three in ten (OECD, 2023[17]).
Student performance in reading, mathematics and science (2022), share of total 15 year-old students
Source: OECD, PISA 2022 database, https://www.oecd.org/en/data/datasets/pisa-2022-database.html
Participation in education or training beyond the compulsory lower secondary level is low, especially in rural areas. Compared to their EU peers, young people in the Nord-Vest region are at high risk of leaving education or training early, especially men and those in rural areas (Figure 4.7). Indeed in 2023, one in five people in Nord-Vest aged 25–34 did not complete upper secondary education (Eurostat, 2023[18]), compared with one in seven across OECD countries (OECD, 2024[19]). Low rural participation in education is especially concerning since Nord-Vest remains a relatively rural region compared to the EU average. Indeed, across Romania, early drop-out from education between 2005 and 2024 is estimated to cost EUR 107 billion through lost tax revenue and greater social spending needs, equivalent to 36% of annual GDP (Iliescu et al., 2024[20]).) Despite longstanding recognition of this issue, enrolment rates in Nord-Vest have continued to decline over the past decade – in 2022, two in ten eligible pre-schoolers did not enrol in pre-school (double that of 2013), and 15% of eligible primary and lower secondary students did not enrol in primary or lower secondary schools (compared with less than 10% in 2013) (Romania National Institute of Statistics, 2023[21])). Upper secondary enrolment is even lower, with only 54% of the eligible population in Nord-Vest enrolled in 2022 (compared with 57% across Romania, with Nord-Vest the 6th highest out of nine Romanian regions), down from 71% in 2013 (compared with 71% across Romania).
Early leavers from education and training in Romania (2024) by degree of urbanisation where available, share of population aged 18 to 24 years old
Note: Early leavers refers to the percentage of population aged 18 to 24 having attained at most lower secondary education and not involved in further education and training.
Source: Eurostat, Early leavers from education and training by sex and NUTS 2 region, https://doi.org/10.2908/EDAT_LFSE_16; Early leavers from education and training by sex and degree of urbanisation, https://doi.org/10.2908/EDAT_LFSE_30
Education spending remains low compared to the OECD average. In 2022, total education expenditure in Romania, at under USD-PPP 6 300 per full-time equivalent (or 2.5% of GDP), is less than half of the OECD average at USD-PPP 14 000 per full-time equivalent (or 4.9% of GDP) (OECD, 2024[19]). As a share of GDP per capita, primary and lower secondary school teachers in Romania earned 90% compared to their EU peers, and upper secondary school teachers only 86% of their EU peers in 2022. However, pre-school teachers in Romania earn 7% more than their EU peers as a share of GDP per capita. In 2022, Nord-Vest had almost 20 primary school students for every primary school teacher, compared to 18.5 for Romania overall and 14 across OECD countries (Figure 4.8). Though the impact of class sizes on education outcomes remains an area of debate, smaller class sizes are considered more beneficial for childcare and primary education than for secondary education (OECD, 2022[22]) – the opposite of what is observed in Nord-Vest (Figure 4.8). While spending is on track to increase as part of the Educated Romania programme, the planned increases in education spending will take time to roll out and deliver outcomes given lead times needed to train teachers, improve school infrastructure and deliver education programmes.
Student-teacher ratio in Nord-Vest by level of education (2022), number of enrolled students per teacher
Source: Romanian data from TEMPO (SCL103D Enrolled population by level of education; SCL104A Classroom teachers by level of education). OECD data from OECD education indicators (Ratio of students to teaching staff by institution, DSD_EAG_UOE_NON_FIN_PERS@DF_UOE_NF_PERS_STR)
Access to secondary education and childcare is especially challenging for rural communities
Demographic change will decrease the number of students, reducing the viability of education facilities in some places. This will potentially require adjustments to the school network to maintain school viability while maintaining accessibility of education facilities to prevent a further reduction in education participation rates. Low participation in education is linked with, and could further entrench, socio-economic disadvantage. The gap in education outcomes between socio-economically advantaged and disadvantaged students in Romania is among the largest in OECD and EU countries, with a gap of 41 points on PISA mathematics tests compared to an OECD average of 9 points (OECD, 2023[17])). Students failing to achieve their full potential become even more of an issue as the workforce declines. In this context, reducing urban-rural education inequities is essential for Nord-Vest to achieve its full development potential. Across many European countries, research suggests that reducing travel time to post-compulsory education can increase participation rates, especially for students from disadvantaged backgrounds and those on the margins of graduation (Dickerson and McIntosh, 2013[23]; Lange, 2024[24]; Falch, Lujala and Strom, 2013[25]). Improving access to education can therefore help Nord-Vest boost education enrolment rates, even in the face of demographic change (Petre et al., 2025[26]; Miron and Mistran, 2024[27]; Ivan et al., 2012[28]). While boosting access alone is unlikely to close this gap, it is a necessary condition.
Upper secondary schools are sometimes difficult to access in Nord-Vest, especially for rural communities. Analysis of access across the region indicates that the average driving time (without congestion) is almost 10 minutes on average, but almost 13 minutes for rural areas, compared with under 4 minutes in cities (Figure 4.9). While accessibility is better in urban areas on average, certain urban and suburban areas also face challenges due to rapid urbanisation and congestion, meaning the existing school network cannot fully serve growing areas, requiring longer commutes that can even worsen urban congestion. For example, Floresti commune (the fastest growing commune in Romania), currently has no high school (though a new one is under construction), resulting in high travel times to Cluj Municipality, worsening congestion, especially during peak hours (World Bank, 2021[4]). Students also travel to schools in other ways, notably school buses, which provide important connections but take even more time than direct driving routes.
Average driving time (assuming no congestion) to closest education facility in Nord-Vest, minutes
Note: Based on latest data available (2017 for primary and secondary education from GISCO Basic Services dataset (2020 version), 2024 for childcare from OpenStreetMap, 2024 for road transport network from OpenStreetMap, and 2021 population grid data from Eurostat).
Source: OECD calculations, with methodology detailed in Annex 5.A.
Residents of Nord-Vest have good access to primary and lower secondary education. Assuming no congestion, the average Nord-Vest resident is 5 minutes’ drive away from their nearest primary school (Figure 5.9). Access is reasonably equal within Nord-Vest. In terms of average travel time, the urban-rural difference is less than 3 minutes and the difference between counties less than 1.5 minutes without congestion.
Accessing formal childcare facilities is difficult outside urban areas. Assuming no congestion, the average resident in cities can access a childcare facility in under 5 minutes’ drive, while for rural residents it takes over 23 minutes. This partly explains the low rural attendance in early childcare and education, even though this is potentially partially compensated by informal forms of childcare. Private childcare is also difficult to access – enrolment rates in private childcare in Romania is 3% for nurseries and 7% for pre-school, compared to OECD averages of 50% and 32% respectively (OECD, 2024[29]). Though children are legally entitled to a place in (free) public kindergartens from age two onwards, limited places mean that access remains low especially at the nursery level, with enrolment rates of less than 7% of the eligible age-group in Nord-Vest. Childcare shortages are a major impediment to Romanian women’s participation in labour markets (OECD, 2024[30]) and ability to have children, which risks further worsening the demographic challenge.
Access to higher education in Nord-Vest is limited outside of Cluj-Napoca and Oradea. All main higher education campuses are based in either Cluj-Napoca or Oradea. Notable institutions include Babes-Bolyai University in Cluj-Napoca (ranked first in Romania), Iuliu Hatieganu University of Medicine and Pharmacy in Cluj-Napoca (ranked fourth), Technical University of Cluj-Napoca (ranked ninth) and the University of Oradea (ranked nineteenth), among others (Ministry of Education, 2022[31])). These universities are an important draw for the region, attracting students from across Romania and Europe. In 2023, three‑quarters of tertiary students in Nord-Vest were enrolled within Cluj-Napoca Municipality, with Oradea Municipality making up another fifth. Less than 7% of total enrolment in Nord-Vest was outside these localities (Romanian National Institute of Statistics, 2024[32]). Nonetheless, satellite campuses exist – for example, Babes-Bolyai University has 11 satellite campuses across Romania, including two in Bistrita‑Nasaud County, one in Maramures County, one in Satu Mare County and one in Salaj County (Babes-Bolyai University, n.d.[33]). The satellite campuses typically have more limited course offerings, but often reflect local needs by providing subjects such as teaching and tourism. Nonetheless, given the specialised nature of higher education and their role in agglomeration economies, limited physical access to higher education is likely to remain a reality for many places, which is likely to worsen youth out‑migration, especially outside of Cluj-Napoca and Oradea.
Demographic impact on education and childcare services
While declining youth population will decrease education demand in the long run, boosting enrolment could help sustain student numbers in Nord-Vest in the medium-term and make the education system more sustainable. Nonetheless per student costs are expected to rise in most places, requiring a focus on providing more efficient education services and supporting targeted updates to the school network in some places. Meeting childcare enrolment targets will also require significant investment in childcare facilities, especially at the nursery level.
Enrolment in education is likely to shrink as the population ages, which could be partly offset by increasing enrolment in childcare and secondary education
School enrolment is expected to shrink in Nord-Vest, with the under-18 population forecast to reduce by a fifth by 2040 compared to 2024. At the county level, by 2030, the school aged population is expected to decline in all but Cluj County, and by 2040 even in Cluj County (Figure 5.1). All else equal, this will result in smaller schools and classrooms. Recent net inflows of international migration could temporarily boost enrolment, with young people aged under 30 making up 54% of total international immigration to Nord-Vest in 2023 (Romania National Institute of Statistics, 2023[34]). However, this will benefit a few places such as Cluj-Napoca, and to a lesser extent Oradea, which have together absorbed most of the in-migration. Other than an underlying need for additional childcare facilities, the number of school units in Nord-Vest has remained relatively stable over the past decade (Figure 4.10). This is in line with relatively stable eligible population, and to a lesser extent, enrolment numbers. Going ahead, however, the eligible-age population is expected to further decline, meaning schools may see fewer students, unless enrolment rates improve.
Higher enrolment rates could potentially offset declining youth population for childcare and upper secondary schools. By 2035, the eligible population for childcare could decline by over a fifth compared to 2023. However, given low existing enrolment rates and the expansion of mandatory childcare, enrolment numbers might remain stable if enrolment rates increase (Figure 4.10). Similarly, the eligible population for upper secondary schools is expected to remain relatively stable, and indeed could potentially further increase should drop-out rates reduce. By 2030, boosting the upper secondary enrolment rate in Nord-Vest to EU levels could increase the number of upper secondary students by over 27,000. This would represent a 45% increase in upper secondary enrolment compared to a base case of maintaining Nord-Vest’s 2023 upper secondary enrolment rate, more than enough to compensate for the projected 18% decline in eligible population numbers between 2023 and 2030 (Eurostat, 2021[35]).
School units, student enrolment and eligible population in Nord-Vest, relative to 2023 baseline (=100)
Note: Population projections in dashed lines.
Source: Past population, school units and enrolment based on TEMPO (POP105A Usually resident population; SCL101C Education units by level of education; SCL103D Enrolled population by level of education). Population projections based on Eurostat population projections at regional level, https://doi.org/10.2908/PROJ_19RP3
By contrast, declining youth population in Nord-Vest will especially impact primary and lower secondary enrolment. By 2035, the eligible age-population for primary and lower secondary education is expected to decline by 15% compared to that of 2024. Declines could be especially sharp in rural areas and secondary cities. There are more limited opportunities to boost enrolment numbers since enrolment rates among the eligible population are already high, reaching 85% in 2023, though admittingly a decline from 89% a decade earlier in 2013. This could necessitate further adjustments to the primary and lower secondary school network to align with changing demand due to demographic trends.
Smaller schools risk providing lower quality education and being more expensive per student. To some extent, reduced class sizes can have the potential to boost education quality by increasing per capita teaching resources, helping relieve existing challenges around large class sizes. However, beyond some threshold, smaller schools can also adversely impact education experiences and outcomes, especially for those in rural and remote areas (OECD, 2018[36]). For example, schools may find it more difficult to offer specialised classes or extra-curricular opportunities due to lower total demand. Accommodating special needs students and academically gifted individuals could be especially difficult in small rural schools. Limited education opportunities also hurt professional development opportunities for teachers, which can lower teacher recruitment in rural areas (OECD, 2018[36]). Larger class sizes also need not necessarily suffer from worse quality if other aspects improve, such as the quality of teachers, equipment and the curriculum.
Demographic change will bring higher per-capita costs for some communities
The per-student cost of education in Nord-Vest is projected to increase overall, with an especially large impact in some localities (Figure 4.11). Overall costs could also rise despite falling demand due to reduced scale economies (OECD/EC-JRC, 2021[37])). Commitments to improve education quality are needed but will also likely involve higher spending. The evolution of costs will differ across places depending on local demographic trends, enrolment rates and infrastructure networks (Box 4.3). Even without planned increases in education funding, modelling suggests that between 2011 and 2035, the median increase in per primary student cost (in real terms) in Nord-Vest would be around 3% (compared to 3.3% across Romania). However, some localities in Nord-Vest could experience per student cost increases of over 30% (11% at the 75th percentile), while others could see declines of almost 13%. By 2035, almost 60% of localities in Nord-Vest could be above the Romanian median for primary school costs per student. The per student cost of secondary education is also modelled to increase, with a median increase of 1.3% across Nord-Vest localities. However, there are fewer concentrated increases for secondary education, with the worst-off locality in Nord-Vest experiencing a cost increase of 9.7% per student (OECD/EC-JRC, 2021[37]).
Modelled per student cost of primary education by locality, percent change between 2011 and 2035 (left) and 2035 costs relative to median Romanian locality (right)
Note: Assuming the school network remains the same as that of 2011. See Box 4.3Box 4.3 for more information.
Source: OECD calculations based on OECD-EC/JRC (2021), Access and Cost of Education and Health Services, https://doi.org/10.1787/4ab69cf3-en
The OECD and EC-JRC has modelled the per-student cost of education and health services at a granular level in EU countries. It is based on three principles – that cost stem from facilities not areas; that services are consumed locally near where people live; and, that costs increase from lack of scale economies and need for transport. To do so, the modelling first simulates likely school locations based on the distribution of school-age population; then it estimates the number of students at each school; and finally, it estimates school costs based on their size. The costs are based on observed school costs in England, assuming a normal distribution of student-teacher ratios, teacher salaries, non-teaching staff salaries and other non-staff costs (e.g. support services, materials, meals, etc.). Importantly, the modelled cost is current expenditure only, excluding capital expenditure.
Across Europe, the study found that costs are generally the highest in remote regions and lowest in metropolitan regions. By 2035, cities could need more education capacity as demand is modelled to shift from rural to urban areas. The presence of small schools is a major driver of high costs. Countries with high degrees of municipal fragmentation have a large share of municipalities with no schools or small schools.
While the study includes two scenarios – one where the school network is optimised based on 2035 population, and another where it is the same as the 2011 network – this chapter exclusively uses the latter to illustrate a “business-as-usual” scenario where the school network is static and operating off existing assets, with potential inefficiencies as the population distribution changes.
Source: OECD/EC-JRC (2021[37]), Access and Cost of Education and Health Services, https://doi.org/10.1787/4ab69cf3-en
Some schools might face sharp costs increases as enrolment declines and fixed assets need to be renewed. Fixed costs, such as school building costs will likely remain steady even as enrolment declines. This especially impacts locality governments as they are responsible for maintaining school infrastructure, compared to the central government which has a greater role in operational costs, such as wages. Almost half of school units in Romania have fewer than 50 students, yet these units only serve 6% of total enrolment, meaning that many schools do not fully benefit from scale economies (Table 4.2). In many smaller and rural communities, shrinking and ageing will also reduce locality government education revenues, making it more difficult to provide the same level of school infrastructure. Opportunities to consolidate schools – while taking into account accessibility – may exist in some, but not all areas (Box 4.4).
Number of satellite, rural and small schools in Romania and their enrolment numbers
Source: Adapted from World Bank (forthcoming), Deliverable 3: Functional Analysis of the Pre-university System (P178400)
Opportunities exist to achieve savings without compromising access to and quality of education in Nord‑Vest. For example, some primary schools (mostly in rural areas) have per capita cost above the 75th percentile (Box 5.3), and are also within 5 minutes’ drive from another school with lower cost (Figure 5.11). The figure shows – for each locality – the travel time between the closest pair of schools on the horizontal axis; and, the modelled per-student cost of primary education on the vertical axis. The upper-left quadrant (in orange) shows the localities that have both high costs and multiple nearby schools, suggesting opportunities for consolidation to seek efficiencies without hurting access.
Consolidating such facilities could improve the quality of education by widening the curriculum offering and increasing the range of extra-curricular opportunities. At the same time, cost savings could be achieved by expanding lower cost schools to host students enrolled from the higher cost school, which can introduce scale economies. Overall, school consolidation needs to be considered on a case-by-case basis considering community feedback, alternatives for students and funding realities.
Modelled 2035 per student primary school cost by locality in Nord-Vest, compared with population density and travel time to nearest alternative facility
Note: Travel time assuming driving at speed limit with no congestion (See Annex 5.A for more information). Costs assuming school network remains the same as that of 2011.
Source: OECD calculations based on OECD-EC/JRC (2021), Access and Cost of Education and Health Services, https://doi.org/10.1787/4ab69cf3-en
The existing formula funding system will struggle to fully cover cost differences. The formula system includes correctional coefficients for rural students and students learning minority languages (Parliament of Romania, 2023[14]). For primary schools, modelled per capita education costs suggest that, by 2035, the rural top-up (+15.1% based on the current funding formula) is modelled to cover only three quarters of the median cost premium (+20.7%), and less than half of the third quartile cost premium (+30.4%) between cities and rural areas (Figure 4.13). For secondary schools, the difference is less pronounced, with the rural top-up (+17.4% based on the current funding formula) largely matching the third quartile cost premium (+17.6%) (OECD/EC-JRC, 2021[37]). Given varied cost differences across places, there could be room to improve the allocation of basic funding to become more efficient and targeted, especially for primary education. Other cost off-setting options should also be considered to close potential funding gaps, such as network updates or by providing more granular grant funding.
Modelled per student cost premium of education in Nord-Vest (2035), relative to median per student cost in cities and rural funding top-up (dashed line)
Note: Assuming 2011 primary school network
Source: OECD calculations based on OECD-EC (2021), Access and Cost of Education and Health Services, https://doi.org/10.1787/4ab69cf3-en
Insufficient and ageing assets will put further pressure on investment capacity, especially for childcare
Education infrastructure quality needs to improve. While many schools will need to adapt to declining enrolment, others will need to invest in capacity to match growing demand and meet existing gaps. For example, many childcare, primary and lower secondary school units are overcrowded, more so than upper secondary or vocational education (Figure 4.14). Indeed, infrastructure needs differ not only by education level but also by geography, with Maramures alone accounting for the majority of overcrowded education units in Nord-Vest. Plans to extend mandatory early education will require greater capacity on top of an already limited system. Growing urban areas will also need to expand education capacity to cope with increased demand, especially in Cluj County where the school age population is forecast to grow for the next 15 years.
Number of overcrowded education units in Nord-Vest by county, 2020
Source: North-West RDA response to OECD questionnaire
More childcare capacity in Nord-Vest will be needed to handle planned rise in enrolment, especially in nurseries. Based on current trends, childcare enrolment rates in Nord-Vest are expected to rise for both nurseries and pre-school. However, while enrolment rates in Nord-Vest already reach 90% for pre-school, in line with the RRF goal by end-2025 (Council of the European Union, 2021[38]),), enrolment rate for nurseries lag at 6.7%, well below the 19% RRF goal by end-2025 (Figure 4.15). Indeed, by 2026, the enrolment rate for nurseries in Nord-Vest would be only 8.6% should current trends continue. A large increase in nursery capacity is needed to enable greater enrolment to the target rate. There is room to increase investment – the Nord-Vest Regional Programme currently includes only one childcare project, representing 1.7% of total funding within Priority 6 (An Educated Region) (Nord-Vest Regional Development Authority, 2024[39]). Despite the legal guidance that childcare units have at least 120 pupils (Parliament of Romania, 2023[13]), many smaller childcare facilities exist – out of the 491 public childcare facilities in Bihor County for the 2023/24 school year, 461 had enrolment below the 120 pupil threshold (County School Inspectorate of Bihor, 2023[40]))..
Modelled enrolment in childcare in Nord-Vest based on continuation of 2014–2023 enrolment trends, number of enrolled pupils and enrolment rate among eligible population
Note: Projections assuming enrolment numbers based on average growth rate from 2014 to 2023, and population projections based on 2019 version of Eurostat population projections at NUTS-3 level.
Source: OECD calculations based on TEMPO (SCL103D Enrolled population by level of education; POP105A Usually resident population by age group) and Eurostat regional level population projections, https://doi.org/10.2908/PROJ_19RP3
Demographic change risks exacerbating health challenges already faced by the Nord-Vest region. Health outcomes in Nord-Vest are already relatively low, with Nord-Vest residents experiencing mortality rates one and a half times that of the EU average. An aging population will increase pressure on the healthcare system. By 2050, the elderly population (above 65) is expected to grow by a third in Nord-Vest, a steeper rate than the Romanian average. Nord-Vest’s health system is not fully prepared for this. Under-spending in public health, community care and primary care – among the lowest of EU countries – has already resulted in high rates of preventable and treatable mortality. Furthermore, the Nord‑Vest’s healthcare workforce, especially in primary care, is not on track to meet the needs of ageing citizens and large geographic disparities remain – 47 rural localities in Nord-Vest did not have a family doctor in 2023.
Policy and institutional arrangements
Health is largely a central government responsibility in Romania. The Ministry of Health (MoH) and the National Health Insurance House (NHIH) oversee a relatively centralised and predominantly public healthcare system (Vladescu et al., 2016[41]). At the county geographic level, district public health authorities (Direcțiile de sănătate publică județene) (sub-ordinated to the MoH) implement national public health policies, while district public insurance houses (sub-ordinated to the NHIH) maintain contract with health providers (see Chapter 2). County and locality governments have a more limited role, although some manage local public hospitals (Vladescu et al., 2016[41]) and provide community healthcare (European Committee of Regions, n.d.[42]). County and locality governments also set regulations in area relevant for public health, such as sanitation, waste management and transport.
Subnational governments do have a major role in investing in health infrastructure. Subnational governments account for almost three quarters of total investment in health in Romania, compared to 35% in the average OECD country (Figure 4.16). Much of subnational government investment relies on external funding (such as EU funds), while the MoH is responsible for most central government investment in health. Major health investments are underway in Romania and Nord-Vest (Box 4.5). Romania’s Recovery and Resilience Plan included around EUR 1.7 billion for healthcare, primarily spent on modernising hospital infrastructure (European Parliament, 2024[43]). Further, the Health Program (Programul Sanatate) includes EUR 5.88 billion of ERDF and ESF+ funding across Romania, which in Nord-Vest is implemented by the North-West RDA through its role as an Intermediate Body for Health (North-West RDA, n.d.[44]).
Subnational public expenditure and investment in health (2021), share of general government in same category
Source: OECD National Accounts, Annual government expenditure by function, DSD_NASEC10@DF_TABLE11
Cluj-Napoca is building the new Cluj Regional Hospital to replace the multiple existing facilities of the Cluj County Clinical Emergency Hospital. With a cost of EUR 455 million (including EUR 305 of EIB financing), the hospital aims to improve access to emergency and specialised services, as well as support preparedness against future pandemics. It will have 849 beds, 19 operating rooms, 60 emergency beds, 70 outpatient care rooms and 60 diagnostic rooms across 150 000 square metres.
The hospital is part of a EUR 1.6 billion project to improve regional healthcare infrastructure across Romania (with new hospitals in Craiova, Cluj-Napoca and Iasi), with support from EU funds. The project led to the establishment of the National Agency for the Development of Health Infrastructure (ANDIS) in 2022, which manages major public health infrastructure and provides technical assistance to local authorities. In Nord-Vest, the RDA is managing the project as an Intermediate Body for Health.
The Regional Hospital will help improve access to speciality services in Cluj and reduce the need to travel to Bucharest. The under-construction Cluj-Napoca metro also includes a station near the hospital to help people access healthcare.
Source: European Investment Bank (2021), Cluj Regional Hospital Project, https://www.eib.org/en/projects/all/20200892
Healthcare is largely funded through payroll contributions via the mandatory social health insurance system. Various exemptions mean only a third of the covered population paid into the social insurance system (OECD/European Observatory on Health Systems and Policies, 2023[45]). Additional funding comes through alcohol and tobacco taxes.
Current state of healthcare services
Nord-Vest’s health system requires reforms and investments to boost the quality of care and put greater emphasis on preventative and public health approaches to prepare for an ageing population. Closing rural coverage gaps in health and ensuring a sufficient workforce are also priorities for Nord-Vest’s health system.
Health outcomes are poor by EU standards, partly due to and an under-funded and hospital-centric health system
Health outcomes are below EU averages, with high rates of preventable and treatable diseases. Nord‑Vest residents experience higher mortality rates than the Romanian average and over one and a half times that of the EU average (Figure 4.17). Treatable and preventable mortality rates in Romania are both double EU averages, driven by high rates of cardiovascular diseases and alcohol-related diseases. Public health and preventative outcomes are poor, with behavioural and environmental risk factors (notably, dietary risks, tobacco and air pollution) making up around half of deaths (OECD/European Observatory on Health Systems and Policies, 2023[45]).
Age-standardised mortality rate by region of residence (2017–2021), per 100 000 people
Note: Age-standardised mortality rates based on rolling three-year average weighted to the European standard reference population by age.
Source: Eurostat, Cause of death – standardised death rate by NUTS 2 region of residence, https://doi.org/10.2908/HLTH_CD_YSDR2\
Health spending in Romania is low, and the health system is highly reliant on hospitals by EU standards. In 2021, per capita health spending in Romania, at EUR 1 633, is the lowest of all EU countries at less than half the EU average. The Romanian healthcare system is notable for its reliance on inpatient care, which accounts for 44% of total health expenditure, compared to 28% across the EU. While hospitals can bring scale economies, they can also be more difficult to access. Lower use and availability of family doctors (and other primary care facilities) makes it more difficult to reduce avoidable mortality, such as through behavioural change, early screening or preventative measures (OECD/European Observatory on Health Systems and Policies, 2023[45]). Indeed per capita spending on preventative care in Romania is only 12% of the EU average (Figure 4.18).
Health spending by category in Romania, share of EU average per capita (left) and share of 2021 total spending (right)
Source: Eurostat, Health care expenditure by function, https://doi.org/10.2908/HLTH_SHA11_HC; OECD/European Observatory on Health Systems and Policies (2023), Romania: Country Health Profile 2023, https://doi.org/10.1787/f478769b-en
Limited access to healthcare outside of cities is worsened by high reliance on hospitals
Access to hospitals is limited outside of cities. Assuming no congestion, the average travel time for city residents to the nearest hospital is under 7 minutes, but this rises to almost 25 minutes for those living in towns and suburbs, and almost 30 minutes for those in rural areas (Figure 4.19). Indeed, one in six rural residents are more than half an hours’ drive away from their nearest hospital without accounting for congestion. This reflects the location of public hospitals in county seats (capitals).
Average driving time to nearest healthcare facility in Nord-Vest by degree of urbanisation (assuming no congestion), minutes
Note: Based on latest available data (2021 for pharmacies from ESPON Database, no data provided for hospitals from GISCO Basic Services database (2020 version), 2024 for road transport network from OpenStreetMap and 2021 for population grid from Eurostat)
Source: OECD calculations, with methodology detailed in Annex 5.A.
Access to family doctors is limited, especially in rural areas. It is difficult to obtain robust accurate estimates for access to primary care given limited data on their locations. Yet access is likely to be low outside county capitals where major hospitals are located, as one would expect for rural areas. Even where primary care centres are present, limited hours of operations can increase barrier to access (European Observatory on Health Systems and Policy, 2024[46]). Since the Romanian healthcare access tends to bypass primary care in favour of directly accessing hospitals, rural communities are especially burdened by high travel times and limited opening hours. Lack of institutional collaboration between primary and secondary care is cited as a driver behind preference for directly accessing secondary care (Coman et al., 2022[47]))..
The medical workforce is growing in Nord-Vest, but there is a primary workforce shortage. The primary care workforce has remained small and is rapidly ageing even as other categories of healthcare workforce have grown (Figure 4.20). By 2030, Romania could face a family doctor shortage equivalent to 18% of its current stock due to retirements and insufficient replacement (Coman et al., 2022[47]). Recent salary increases have reduced the doctors’ wage differential between Romania and other EU countries and could to a certain extent alleviate out-migration of medical professionals. Although primary care doctors in Romania earn a higher base salary than specialist doctors (Federatia Sanitas, 2024[48]), there is limited information available on their overall income given high rates of informal payments and greater opportunities for private practice afforded to specialists (Petre et al., 2023[49]). The framework contract for family doctors includes a 50% income increase to new doctors practicing in rural areas, among other locality-specific benefits, such as subsidised housing (European Observatory on Health System and Policies, 2023[50]).
Medical staff-population ratio in Nord-Vest by type, per 1000 usually resident population (left) and relative to Romanian average (right)
Note: Includes public and private health workers.
Source: TEMPO, SAN104A Healthcare staff by categories
Elderly people face particularly high barriers to accessing healthcare. Localities with a greater share of elderly people are on average further away from healthcare services (Figure 4.21). While this partly reflects the demographic reality that rural areas are on average older than urban areas where hospitals are typically sited, this nonetheless introduce service delivery challenges, worsened by the high dependence on tertiary healthcare. Indeed, on top of greater distance, elderly people are more likely to face cost, knowledge and mobility challenges around accessing healthcare, including lower digital skills for telemedicine.
Average locality travel time (assuming no congestion) to nearest pharmacy (left) and hospital (right) in Nord-Vest, by locality share of elderly people
Note: Travel times based on latest available data (2021 for pharmacies from ESPON Database, no date provided for hospitals from GISCO Basic Services database (2020 version), 2024 for road transport network from OpenStreetMap and 2021 for population grid from Eurostat)
Source: OECD calculations, with methodology detailed in Annex 5.A.
Healthcare affordability remains a concern. In 2023, around 7% of Romanians reported unmet healthcare needs, of which over half reported unaffordable care as the main barrier, well above the EU average (Figure 4.22). High waiting times and travel times also represent implicit costs due to the need to take time off work and afford travel to hospitals. Dissatisfaction with waiting times also partially results from increased pressure on hospitals due to under-utilisation of primary care facilities. Despite the mandatory social health insurance system, 12% of Romanians remain un-insured. Out-of-pocket spending, at 21% of total spending, is higher than the EU average, at 15% (OECD/European Observatory on Health Systems and Policies, 2023[45]).
People reporting unmet medical needs (2023), share of population aged over 16
Source: Eurostat, Self-reported unmet needs for medical examination, https://doi.org/10.2908/HLTH_SILC_08
Demographic impacts on healthcare services
Healthcare demand is set to increase. Ageing societies will have higher spending burden, all else equal, due to greater healthcare needs and a smaller labour force, among other factors. Nord-Vest has a large share of working-age population relative to Romania and the EU, but this cohort is ageing and could result in a significant rise in healthcare needs in the coming years (Chapter 2). Adapting the health system to ageing will not only support healthier people, but also limit the fiscal burden of health and free up resources for other productivity- and wellbeing-enhancing investments.
Adapting to ageing calls for scaling up healthcare capacity and taking a more preventative approach
Under-use of preventative and outpatient care threatens health system performance and outcomes as the population ages. Romania has a high rate of chronic diseases that increase the long-term burden of ageing, such as dementia, diabetes and cardiovascular diseases. Further, important public health and preventative measures are not fully adopted. Only 1% of Romanians aged 65 years or over meet WHO guidelines on physical activity, compared with 27% on average across the EU (OECD/European Commission, 2024[51]).
Making integrated care more accessible for ageing people with chronic conditions will likely require increasing availability of primary care and community care providers. Despite the increasing importance of outpatient care and public health in an ageing society, Romania under-invests in these facilities (Figure 4.23). In 2022, public investment in outpatient care made up 0.2% of total public investment in health in Romania, compared to 10.3% on average in the EU. This is despite similar levels of public investment in health as a share of GDP. Similarly, public investment in public health accounted for 6.6% of total public investment in health in Romania, compared to 13.0% on average in the EU. Health risks differ greatly by place, meaning there is considerable room to mobilise local knowledge and opportunities to design place-based public health strategies.
General government direct investment in health by category, share of GDP
Note: Based on COFOG level 2 data.
Source: OECD National Accounts, Annual government expenditure by function, DSD_NASEC10@DF_TABLE11
Larger workforce is needed to serve rising and different healthcare demand
More healthcare professionals are needed, especially in primary care. To illustrate how ageing could impact health workforce demand, this chapter considers a simple model whereby the need for health workers increases linearly with the rise in the old-age ratio, all else equal. The actual demand is likely to be even higher since rising living standards will further increase demand for healthcare services (Liu et al., 2016[52]), while healthcare demand tends to rise exponentially (rather than linearly) with ageing (Lorenzoni et al., 2019[53]). With these in mind, this simple model projects that, by 2050, Nord-Vest could require a net increase of almost 3 000 physicians to keep up with its rising old-age ratio, equivalent to a third of the 2023 workforce, or an average growth rate of 1% per year (Figure 4.24). So far, the physician workforce in Nord‑Vest has grown faster than this rate – between 2012 and 2021, it grew at an annual rate of almost 1.9%. Despite the growth in overall healthcare professionals, primary care doctors have not increased. Between 2012 and 2021, there was a net loss of 164 primary care doctors in Nord-Vest, equivalent to a net decrease of 1.1% per year (Romania National Institute of Statistics, 2023[54]). Yet by 2050, a net increase of 500 primary care doctors could be needed to keep up with the rising old-age ratio in Nord-Vest. Should current trends continue, there could be a shortfall of almost 1000 primary care doctors in Nord-Vest by 2050.
Modelled need for physicians and family doctors in Nord-Vest to align with rising old-age ratio
Note: Projections assuming 1. Workforce needs – the physician-population ratio scales linearly with the old-age ratio; 2. Workforce trajectory – continuation of average growth rate between 2011 and 2021; 3. Surplus – balance between needs and trajectory.
Source: OECD calculations based on TEMPO SAN104A Healthcare staff by categories; Eurostat population projections at regional level, https://doi.org/10.2908/PROJ_19RP3
Geographic gaps in primary care could persist in Nord-Vest, especially in some rural areas. As of 2023, 47 localities in Nord-Vest – all rural – did not have a family doctor (Figure 4.25). This represents a sharp rise from 16 Nord-Vest localities in 2019, suggesting that attracting and retaining medical professionals remains a challenge in many rural areas. The family doctor-population ratio also varies across counties, with the median locality in Bihor and Cluj counties (0.54 and 0.52 family doctors per 1000 people) out‑performing Bistrita-Nasaud (0.38), Maramures (0.44), Satu Mare (0.37) and Salaj (39) counties. Indeed, the median urban locality in Bihor enjoys a family doctor-population ratio two-and-a-half times as high as the median rural locality in Salaj. Given an older and rapidly ageing population in Nord-Vest’s rural areas, inequalities could significantly hinder health outcomes in Nord-Vest, making it harder for citizens to access community care, routine check-ups and health information.
Source: OECD calculations based on TEMPO, SAN104B Healthcare staff by localities; POP107D Legally resident population by localities.
Brain drain will likely remain a risk for the health workforce despite recent salary increases. Out-migration of healthcare professionals has long contributed to workforce shortages in Nord-Vest and across Romania. Over 570 physicians from Cluj County permanently migrated to overseas between 2017 and 2022, with family doctors making up the second largest group at almost one in ten emigrees (Stancu et al., 2024[55]). Since 2018, a series of increases in healthcare worker salaries have partly stemmed out-migration, with wage differences becoming less of a problem (Deliu et al., 2022[56]). Nonetheless, health workers continue to cite high workload, rigid training opportunities and poor workplace relations as reasons for out-migration. A 2024 survey suggested that 58% of young doctors (aged under 35) intend to migrate overseas for better working conditions (Romania Insider, 2024[57]). Further, there is a risk that out-migration could worsen as other EU countries continue to age and increase incentives for healthcare professionals to move. Indeed in 2022, just over one in five doctors in Romania are aged 55 or over, versus one in three across the EU (OECD/European Commission, 2024[51]). Reducing outmigration rates will require better working conditions for healthcare professionals in addition to higher wages. However, it could remain challenging for Nord-Vest to compete with wealthier EU regions and countries given widespread workforce shortages across almost every EU country.
Attracting healthcare professionals to rural areas will become more challenging. As rural areas continue to shrink and age, they are likely to become less attractive to healthcare professionals. Overall, professional development opportunities will become scarcer, the variety of local community amenities will become more limited and healthcare facilities will struggle to modernise. The Multi-annual Strategy for Human Resources Development in Health seeks to address regional disparities in the healthcare workforce (Romania Legislative Portal, 2022[58]). However, since Nord-Vest enjoys a higher-than-average doctor-population ratio compared to other Romanian regions, efforts to address the unequal distribution of healthcare workers at the national level could have adverse impacts on the Nord-Vest region.
Access to essential public services remains challenging for many communities in Nord-Vest, which could be worsened by demographic trends. Residents in many communities, especially in rural areas, already find it difficult to access at least some essential services. Population shrinking and urbanisation are likely to make maintaining service access and quality in rural and depopulating areas more challenging. At the same time, increasing urbanisation could make services cheaper to provide and easier to access in urban and suburban areas. Balancing the different needs of urban and rural areas in the face of demographic change will be key to providing services in an equitable way to reduce urban-rural disparities in Nord-Vest – and help the region make the most of the human capital it has.
Improve public transport to better reflect and shape demographic trends
Public transport can both help people access services directly and support a built environment where services are cheaper to provide and easier to access. While significant investments are underway for road transport in Nord-Vest, there is further room to improve public transport services, both within urban areas and between urban and rural areas.
Create inter-municipal co-ordination structures to provide public transport at a functional level (locality level). Public transport is currently generally planned at the locality level, resulting in fragmented public transport networks and high reliance on private vehicles outside of the urban core. The RDA should incentivise inter-municipal bodies that provide public transport at a functional level, jointly overseen by localities in the functional urban area (Box 4.6). For example, the RDA might prioritise funding investment projects proposed by inter-municipal co-operation bodies.
Facilitate urban-rural connections at a service basin level (locality and regional level). Outside of private vehicles, medium- and long-distance travel between localities relied on private bus operators largely operating on market-driven schedules. While there is merit to this approach, many communities are cut off due to their limited size, and a smaller network also risks fragmentation of routes and ticketing systems, lowering patronage. Routes and hours tend to be commuting oriented, which may limit their use for accessing services. County governments should consider exploring minimum standards for inter-locality travel between settlements above a certain size and their nearest regional service centre and help co-ordinate transport schedules and payment systems to ensure the system functions as a whole. While not all such routes will be financially viable, county governments might wish to also consider routes’ broader social benefits. Vulnerable groups, such as people with low incomes, could be given further discounts to help them access public services, and indeed other work and leisure opportunities.
Explore on-demand transport solutions (locality and county level). On-demand transport could be an option in areas with insufficient density to offer scheduled public transport routes but have high enough demand to justify transit solutions beyond private vehicles. They can especially help those with mobility issues access essential services. The increasing roll-out of electric vehicles and autonomous driving technology could ultimately decrease the fiscal and environmental cost of on-demand transport. Locality and county governments and the North-West RDA should closely monitor the progress of autonomous driving technologies and consider trailing on-demand transport when the technology becomes more mature and affordable.
TPBI is an association of 42 administrative units (Bucharest City, Ilfov County and 40 localities in Ilfov County) mandated to plan, regulate, operate and manage surface public transport services across the Bucharest-Ilfov region. Formed in 2017, TPBI manages over 190 local public transport lines on buses, trams and trolleybuses in one of Europe’s largest public transport systems. Surface services are primarily operated by four contracted operators across the region. Rail services (including Bucharest Metro) are directly managed by the Ministry of Transport through the state-owned Caile Ferate Romane and Metrorex.
TPBI implements the Bucharest-Ilfov Sustainable Urban Mobility Plan that was approved by localities in 2017. As an association, TPBI supports integrated planning and operations across the entire Bucharest functional urban area, with regional transport demand modelling and traffic management systems, integrated ticketing across operators and real-time passenger information systems.
Source: TPBI, Who we are, https://tpbi.ro/en/homepage/; World Bank (2020), Implementation of the Sustainable Urban Mobilty Plan for Bucharest-Ilfov, https://documents1.worldbank.org/curated/en/099310407082225773/pdf/P16957700589e00860a3710cfba4bc9e7ec.pdf
Enhance education services to improve social and economic outcomes and offset the negative economic impact of demographic change
Better education can improve labour productivity to partly offset the impacts of demographic shrinking and ageing on economic growth in Nord-Vest. Boosting participation rates and closing urban-rural achievement gaps are two key avenues to not only boost education outcomes but also make the education system more sustainable and limit potential school closures. More childcare capacity is also needed in Nord-Vest to support the ongoing expansion of mandatory childcare and make the region more attractive to young people and families.
Develop and test inter-municipal co-operation for primary education in areas facing population decline. The Ministry of Education might explore developing a pilot project to encourage sharing of education facilities between local authorities in areas impacted by a declining school age population where alternate schools are located nearby and where students have access to appropriate reliable transport. This could allow pooling of funding to improve the quality of school facilities. While school closures and mergers should be a last resort option, this pilot could then be used by the central government to develop a fit-for-purpose governance framework for supporting intermunicipal cooperation on schools. To encourage collaboration, the North-West RDA could consider additional investment to in schools where collaboration takes place, including student transport.
Develop national guidelines for school network re-organisation (national level). The MoE is responsible for maintaining and updating the school network in consultation with local authorities. However, this process is somewhat ad-hoc and local communities do not always feel they have sufficient input into decisions, despite their extensive knowledge of local situations. While existing laws around minimum school and classroom sizes could in principle form the basis of network re-organisation, in practice numerous exceptions are made with unclear justification. The MoE should work closely with locality, county and regional authorities to develop guidelines setting out the process around school network re-organisation, including indicators that inform decisions, stakeholder consultation requirements, and a menu of potential options going ahead. Transportation times will be an important consideration as it is a major risk for community opposition (Abalde, 2014[59]).
Review potential for a digital correspondence education system (national and EU level). It is not realistic for schools to be physically accessible to every student given the high costs involved. Yet all students deserve access to quality education. A correspondence education system can offer online education to students who are not able to travel to schools within a reasonable time. It can also offer a greater variety of subject choices for students attending schools with a limited curriculum. To make use of scale economies and its quality digital infrastructure, the MoE should consider establishing a correspondence education system either at the regional level or support such a system at the national level. This aligns with the goal of creating an “Online School” of digital textbooks and resources under the Educated Romania project.
Develop an education disadvantage index to inform funding for dis-advantaged communities and target support to increase engagement and improve outcomes (regional and national level). Reaching equitable education outcomes could require further funding on top of unit cost differentials. Greater funding could go towards social support (e.g. school counsellors and psychologists) and tailored education experiences (e.g. collaboration with local employers, greater extra-curricular opportunities) to reduce high rates of drop-out in rural areas. The region should develop such an index to identify potential gaps in education services, drawing upon international reform experiences such as that of New Zealand (Box 4.7), but also serve as a broader tool to inform investment across other sectors and their potential impact on disadvantaged areas. This could be built upon existing indices such as the Composite Vulnerability Index for Early School Leaving could serve as a basis to adjust school funding. These could inform the current review of school funding as part of the Educated Romania project and help secure sufficient funding for disadvantaged communities. The North-West RDA could use the index to identify potential gaps in education services and inform investment across other sectors. Funding for other national and EU programmes, such as the Social Inclusion and Dignity Programme of Romania, could also be informed by such as index.
Develop an investment pipeline for childcare facilities (national, regional and EU level). Greater childcare supply is urgently needed given low current enrolment rates, high rates of overcrowding, and expected increase in demand from the planned expansion of mandatory childcare. The North-West RDA should work with municipalities to identity shortages and develop a pipeline of childcare facilities to seek further funding for investment in childcare capacity. Given expected falls in childcare-aged population, it will be important not to overshoot demand, which could result in over-capacity. This will require careful modelling of local childcare demand, tracking existing capacity and understanding other barriers to childcare. Multi-use facilities and multi-service centres for childcare can also help improve supply flexibility and optionality over time given inherent uncertainties in future childcare demand. Taking a place-based regulatory approach to childcare facilities will be important, for example being flexible around minimum classroom sizes in rural areas where larger classes are not possible.
Review the unit cost of education that can inform the ongoing update of the school funding formula to ensure costs are accurately reflected. County directorates for education in Nord‑Vest, or the Ministry of Education, could review the unit cost of education across schools in Nord-Vest and identify funding deficits. In particular, they should consider differences in teacher and infrastructure requirements, as well as student transport costs. The results of the unit cost review could inform the current review of school funding as part of the Educated Romania project and help secure sufficient funding for disadvantaged communities.
Expand funding to develop the education workforce, especially in disadvantaged communities (regional level). The North-West RDA could fund professional development and training for teachers as part of its investment in human capital. This could be funded through priority six or the technical assistance component of the Regional Programme. The North-West RDA should collaborate with the re-organised County Education Directorates to identify strategic opportunities to tackle disparities and trail new approaches, such as a stronger mentorship system for teachers in rural areas or management training for leaders of newly formed school clusters.
Provide pilot grants for employers to support the roll-out of dual education and enhance workforce participation (regional level). The North-West RDA could provide one-off conditional grants to support employers that are considering providing training opportunities within the dual education system. This could be funded through priorities one or six of the Regional Programme. Such grants could require employers to train a certain number of students in a community over some time. This would help offset the risks and set-up costs employers might face when first engaging with the dual education system and help foster a larger ecosystem of community-business partnerships across schools. A similar approach could also apply to tertiary students, where the North-West RDA could provide pilot funding for internships or graduate programs, especially in rural areas facing the most youth out-migration.
The Equity Index (EQI) estimates socio-economic barriers to education achievement in New Zealand. In use since 2022, the EQI is a 266-point scale based on 37 indicators (such as parental education, household income and eligibility for social benefits) to calculate barriers faced by enrolled students. It was developed based on a statistical model between these indicators and education outcomes, drawing from anonymised administrative data. The EQI replaced an earlier “decile” system which used indicators based on neighbourhood characteristics rather than student data.
The EQI is used to allocate Equity Funding to schools. Compared to the previous system, the schools facing the greatest barriers are expected to receive 16% more funding per student overall. Equity Funding consolidates several existing funding mechanisms, such as the Targeted Funding for Education Achievement and the Targeted At-Risk Grant, to simplify funding decisions.
Source: New Zealand Ministry of Education (2024), Equity Index, https://www.education.govt.nz/our-work/changes-in-education/equity-index
Improve the quality of the regional healthcare system to better meet the needs of an ageing population
Better preventative care and public health are needed to support healthy ageing in Nord-Vest and manage the impact of ageing on the health system and public finances. Major existing investments in health infrastructure are welcome, but opportunities remain for Nord-Vest to improve primary and community care, strengthen the health workforce and reduce geographic coverage gaps.
Collect granular health data to implement the workforce planning strategy (regional and national level). The Multi-annual Strategy for Human Resources Development in Health identifies the lack of robust data a major challenge for workforce planning, especially providing comparable data across local authorities and independent family doctors (James et al., 2025[60]). Better data for workforce planning is especially relevant for Nord-Vest given its status as a medical hub. Potential datapoints on top of the Multi-annual Strategy could be the geographic location and operating hours of primary care facilities, which would provide a more granular and accurate measure of health access, which could be integrated in the planned Health Atlas (WHO, 2024[61]). Once the data is in place, one important way to strengthen the workforce is to strengthen the service obligation program, whereby local authorities may support medical students training in return for students committing to work in local hospitals for some time. However, penalties of breach of contract are limited, and some students choose not to return after training in Cluj. Reinforcing the integrity of such programmes could make them more effective for meeting skill shortages in towns and smaller cities.
Invest to improve the quality and accessibility of the health care network throughout the Nord-Vest to improve health outcomes and ensure accessibility in shrinking places. The Ministry of Health could undertake a further review of the primary care system, identify drivers behind under-use of primary care and propose reforms needed to transform the healthcare system. The North-West RDA could continue to invest the upgrade the hospital network and explore opportunities to increase investment in the primary and secondary healthcare network by mobilising EU funds and in its role as an intermediate health body, in collaboration with the county directorates for health.
Further develop local public health and preventative health programmes to reduce the fiscal impact of an ageing population. The North-West RDA could prioritise funding for public and preventative health measures and encourage local authorities to develop concrete and evidence-based proposals for investment in this area. The Ministry of Health could increase capacity building and technical assistance for localities and support the development of digital solutions to increase awareness of public health and simplify access to primary care providers.
Address barriers to medical training in county and rural health centres to help fill service gaps in small communities. The county directorates for health in Nord-Vest could benefit from closer collaboration with local medical universities to understand and tackle barriers to training in regional hospitals and explore extending rural service obligations to other forms of practical training (such as internships) and other healthcare workers (such as nurses). The central government could support this reinforcing the integrity of the service obligations requirement to make them more effective at attracting specialised skills in towns and smaller cities.
Scale up investment in community health centres and long-term care facilities outside urban centres (regional level). The North-West RDA could invest more in community health and long-term care centres to relieve the burden on hospitals and facilitate healthy ageing through greater access to health services. However, delivering such infrastructure investments at scale will need to be accompanied by long-term staffing and operational resources, funding for which will likely depend on the central government.
Strengthen and innovate local public health and related programmes to support healthy ageing (regional, county and locality levels). County and locality governments could trial programs that promote public health and health ageing. While public health is primarily a central government responsibility, county and locality government could support these efforts through locally tailored programmes on active recreation and mobility. Stronger public health components could also be embedded in locality-run services, such as education, social services and elderly care. Digital training programmes and targeted investments could also support elderly people’s access to telemedicine. The North-West RDA could provide support to localities, counties or local community groups seeking to pilot innovative public health and healthy ageing measures.
Increase investment into public health and preventative health measures (regional, national and EU level). Low levels of public health investment are partly responsible for high levels of preventable and treatable diseases. Better public health (and related measure such as early screening) can be considered an investment that yields benefits through better long-term health outcomes, lowering the healthcare spending required as the population ages. Though local and regional-level investment in health tends to draw from EU funds, only a limited amount goes towards public health. As of 2023, healthy and active ageing accounted for only 1.6% of total health allocation (ERDF and ESF) in the 2014–2020 cohesion policy round across the EU, with none for Romania specifically (Cohesion Open Data Portal, 2023[62]). The EU could consider placing a greater role for public health in cohesion policy investment, as high rates of preventable and treatable diseases are prevalent across many EU regions. This could be complemented with capacity building and technical assistance given currently low levels of public health resources. Digital solutions can increase awareness of public health and simplify access to primary care providers (Box 4.8).
Oulu Self Care is an online health platform focusing on guided care in the City of Oulu (Finland). It offers a range of services, including appointment bookings, online support for urgent issues, e-prescriptions, home monitoring, communication of lab results, and information on preventative health. It is integrated with KanTa and Taltioni, national platforms that provide access to personal health data and records. Together, these help improve access to primary healthcare by simplifying the process of finding and booking appointments and improves public awareness of public health and preventative health interventions.
Oulu Self Care has been available since 2010. It was developed between 2007 and 2009 at a total cost of EUR1.16 million, co-funded by the City of Oulu and the Ministry of Social Affairs and Health. As of 2018 it had 110 000 registered users (around half of the Oulu’s population), with estimated operational savings of EUR4 million between 2015 and 2017. It has since been rolled out to other municipalities in Finland.
Source: OECD (2022), Guidebook on Best Practices in Public Health, https://doi.org/10.1787/4f4913dd-en
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This annex provides methodological details on measuring physical access to services.
Physical access to services depends on how people, transport infrastructure and service locations are distributed across space. In this report, accessibility is measured based on travel times between people and services along road networks according to a three-step process:
Population grids are used to approximate the distribution of people.
Routing algorithms are used to estimate travel times between each population grid and the nearest service facility (Annex Figure 4.A.1).
For a given geographic unit (such as a municipality or region), accessibility is calculated as the population-weighted average of travel times for all population grids within its boundaries.
Source: OECD illustration
The time needed to drive from the grid centroid to the nearest service facility is calculated for each 1x1km census grid. The R5py library is used to obtain fastest driving routes between locations, assuming travel at the legal speed limit on each road segment. Locations not on public roads are snapped to the nearest road within 1.6km (or otherwise considered to be unreachable).
Travel times at the grid level are aggregated to the relevant areas of interest, which include local and regional administrative units and other categories such as urban and rural areas. Unless otherwise stated, all aggregate indicators (within an area of interest) are population-weighted averages, as calculated by the formula below:
For example, the average travel time to schools in a municipality is calculated by measuring the travel time between each grid (wholly or partially within the municipality) and the nearest school, weighted by the grid’s population. For grids on the municipality’s boundary that might only partially fall in the municipality, their population is further weighted by how much if it falls within that municipality.
Population grids are sourced from the Eurostat Census Grid 2021, which contain population statistics for each 1x1km area across the EU aligned with 2021 census data. Public road networks (including service roads) within each region are sourced from OpenStreetMap, as of late 2024. The locations of service facilities are obtained through national statistics offices, information provided by the region and private sector sources. Annex Table 4.A.1 below contains a full list of data sources used in this region.