Persisting inequalities: Variations in financing community health workers in Romania

Abstract Introduction In Europe and globally, community healthcare workers emerge as an important professional group in delivering health and care services to vulnerable populations, particularly in hard-to-reach areas. However, their effectiveness is largely influenced by the level of financing. This case study aims to assess geographical patterns of financing for CHWs work in Romania. Methods We analyzed the following variables for the year 2024: counties (and corresponding NUTS 2 regions), number of CHWs (per counties), estimated state budget, allocated state budget, and local budget. We report absolute differences (maximum value - minimum value) and Gini index per country and per NUTS 2. Results At the national level, the highest absolute difference was 133 for the number of CHWs, €6,675,451.30 for estimated budget, €1,457,298.44 for allocated budget, and €1,451,071.53 for local budget. The Gini index was higher for allocated budget (0.721; 95% CI: 0.473 - 0.804) when compared to the estimated (0.511; 95% CI: 0.363- 0.618) and allocated budget (0.399; 95% CI: 0.308-0.471), as well as to the number of CHWs (0.378; 95% CI: 0.294 - 0.451). For NUTS 2, the highest absolute differences were found in South-Muntenia (€6,504,914.24) - estimated budget, North-East (€1,172,869.14) - allocated budget, and South-East (€1,451,071.53) - local budget. As for the Gini index, higher inequalities were found in South-Muntenia - 0.632 (95% CI: 0.098-0.686) - estimated budget, Centre - 0.335 (95% CI: 0.020 - 0.631) for allocated budget, and in North-East - 0.724 (95% CI: 0.280 - 0.813) for local budget. Conclusions There is increased variation in terms of absolute inequalities expressed either by the difference between the highest and lowest value (at the NUTS2 and national level) or based on the Gini index (as results closer to 1 express higher inequality). This could be explained by the local variation in terms of CHWs as well as financial resources. Key messages • Romania has persistent geographic inequalities in funding CHWs. • Potential sources are available funding and variation in the distribution of CHWs.