Institutional Determinants of Public Health Directorate Capacity During the COVID-19 Crisis: A Comparative Analysis of Romanian Counties

Romanian county Public Health Directorates (PHDs) were central to local COVID-19 crisis management, yet subnational differences in institutional response capacity remain insufficiently quantified. This study aimed to examine institutional characteristics associated with COVID-19 response capacity among Romanian PHDs. An observational comparative design included 20 PHDs—10 from counties with university medical centers (UC) and 10 from non-university counties (NUC)—using 2020–2022 averages derived from public activity reports and official statistical databases. Seven indicators were analyzed: county population, area, number of employees, institutional budget, personnel density, prior health crisis experience, and diversity of COVID-19 response measures. Group differences were assessed using the Mann–Whitney U test, and associations using Spearman’s rank correlation. UC PHDs had larger workforces (133 vs. 67 employees, p = 0.001), higher budgets (24.3 vs. 7.6 million RON, p = 0.001), greater prior crisis experience (2.4 vs. 0.8 crises, p = 0.001), and broader response portfolios (5.6 vs. 3.0 measure categories, p < 0.001). Personnel density did not differ significantly (17.80 vs. 18.59 employees/100,000 inhabitants, p = 0.614). Response diversity correlated strongly with workforce size (ρ = 0.87), budget (ρ = 0.88), and prior crisis experience (ρ = 0.81; all p < 0.001). These findings suggest that absolute institutional resources and accumulated experience may be more relevant to crisis response capacity than population-adjusted staffing alone.