Quantitative analysis results
The indicators of interest to this research study, according to the medical deserts’ definition are the number of professionals, facilities, waiting times, cost of services and other socio-cultural barriers. Due to the lack of data, no statistical indicators were identified concerning waiting times, cost of services and other socio-cultural barriers. Overall, a scarcity of data was identified.
To ensure the comprehensibility of the analysis for the HRH, we have included all categories of professionals delivering cancer care: oncological MD, radiotherapy specialists, family doctors (FD), psycho-oncology therapists, and palliative care specialists. No data was identified for psycho-oncology therapists and palliative specialists, and they were not involved in the analysis. For facilities, we have included in the analysis the number of hospitals, hospital beds, beds for day cases and FD offices.
Table 1. Number of oncology specialists, family doctors and radiotherapy specialists in the North-West region
Human resources in health
|
Bihor
|
2009
|
2011
|
2012
|
2015
|
2016
|
2017
|
2018
|
2019
|
2020
|
2021
|
2022
|
Radiotherapy
|
1
|
3
|
3
|
3
|
4
|
4
|
5
|
5
|
5
|
5
|
5
|
Oncology
|
6
|
11
|
10
|
11
|
11
|
12
|
18
|
29
|
33
|
40
|
52
|
Family doctors
|
453
|
559
|
501
|
398
|
404
|
400
|
417
|
421
|
456
|
450
|
458
|
Bistrița-Năsăud
|
Radiotherapy
|
0
|
0
|
0
|
0
|
0
|
0
|
0
|
0
|
0
|
0
|
0
|
Oncology
|
3
|
3
|
3
|
3
|
4
|
4
|
3
|
4
|
6
|
5
|
6
|
Family doctors
|
148
|
153
|
149
|
145
|
141
|
143
|
142
|
141
|
137
|
134
|
133
|
Cluj
|
Radiotherapy
|
25
|
25
|
33
|
52
|
52
|
56
|
60
|
73
|
75
|
80
|
83
|
Oncology
|
53
|
72
|
82
|
108
|
106
|
102
|
106
|
109
|
113
|
122
|
132
|
Family doctors
|
520
|
558
|
496
|
423
|
409
|
414
|
423
|
413
|
451
|
453
|
491
|
Maramureș
|
Radiotherapy
|
5
|
6
|
2
|
2
|
2
|
1
|
2
|
4
|
3
|
4
|
4
|
Oncology
|
6
|
6
|
6
|
8
|
9
|
9
|
10
|
12
|
13
|
13
|
15
|
Family doctors
|
270
|
268
|
265
|
260
|
254
|
251
|
252
|
246
|
247
|
247
|
244
|
Satu-Mare
|
Radiotherapy
|
0
|
0
|
0
|
0
|
0
|
0
|
0
|
0
|
0
|
0
|
0
|
Oncology
|
3
|
5
|
8
|
8
|
9
|
10
|
10
|
10
|
9
|
8
|
7
|
Family doctors
|
194
|
200
|
201
|
193
|
202
|
197
|
185
|
182
|
178
|
177
|
174
|
Sălaj
|
Radiotherapy
|
1
|
1
|
1
|
1
|
1
|
1
|
0
|
0
|
0
|
0
|
0
|
Oncology
|
2
|
2
|
2
|
3
|
5
|
4
|
5
|
5
|
5
|
6
|
6
|
Family doctors
|
113
|
120
|
122
|
121
|
120
|
116
|
118
|
115
|
114
|
109
|
108
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Specialist numbers have steadily increased over the years. Bihor has seen a notable rise in oncology specialists since 2018, reaching 40, alongside consistent growth in Maramureș and Satu-Mare. Bistrița-Năsăud shows fluctuations, while Sălaj has steadily increased to six oncology doctors by 2022. Conversely, the number of FDs has slightly decreased from 1,698 in 2009 to 1,608 in 2022. While Cluj maintains a steady increase to 491 FDs, Bistrița-Năsăud, Satu-Mare, and Sălaj experience modest declines. Cluj also leads in radiotherapy specialists, while Bihor has seen a consistent rise, reaching five specialists in 2018. Maramureș remains stable with four specialists in 2022, but Bistrița-Năsăud and Satu-Mare consistently lack specialists, and Sălaj transitioned to none in 2018, persisting since then.
Table 2. Number of healthcare units, oncological beds for day cases, oncological hospitalization beds and family doctor offices in the North-West region
Facilities
|
Bihor
|
2009
|
2011
|
2012
|
2015
|
2016
|
2017
|
2018
|
2019
|
2020
|
2021
|
2022
|
Units
|
16
|
12
|
13
|
14
|
14
|
14
|
14
|
14
|
14
|
14
|
13
|
Beds day cases
|
10
|
12
|
13
|
21
|
21
|
21
|
21
|
36
|
37
|
37
|
39
|
Hospitalization beds
|
100
|
101
|
102
|
104
|
104
|
104
|
114
|
97
|
93
|
99
|
111
|
Family doctor offices
|
339
|
360
|
355
|
364
|
361
|
365
|
372
|
372
|
344
|
334
|
334
|
Bistrița-Năsăud
|
Units
|
4
|
4
|
4
|
4
|
4
|
4
|
4
|
4
|
4
|
4
|
4
|
Beds day cases
|
2
|
5
|
10
|
10
|
8
|
8
|
8
|
8
|
8
|
14
|
16
|
Hospitalization beds
|
40
|
40
|
40
|
40
|
40
|
40
|
40
|
40
|
30
|
46
|
46
|
Family doctor offices
|
148
|
145
|
145
|
140
|
138
|
138
|
138
|
137
|
134
|
118
|
118
|
Cluj
|
Units
|
26
|
32
|
32
|
40
|
41
|
42
|
35
|
36
|
37
|
36
|
36
|
Beds day cases
|
62
|
72
|
72
|
99
|
107
|
106
|
134
|
134
|
128
|
125
|
126
|
Hospitalization beds
|
504
|
590
|
602
|
605
|
605
|
610
|
610
|
611
|
600
|
577
|
601
|
Family doctor offices
|
360
|
344
|
344
|
348
|
349
|
349
|
349
|
340
|
343
|
332
|
332
|
Maramureș
|
Units
|
11
|
10
|
10
|
12
|
12
|
12
|
13
|
13
|
13
|
13
|
14
|
Beds day cases
|
2
|
6
|
14
|
13
|
13
|
13
|
26
|
26
|
27
|
35
|
34
|
Hospitalization beds
|
75
|
75
|
75
|
60
|
60
|
60
|
60
|
67
|
67
|
73
|
73
|
Family doctor offices
|
270
|
262
|
260
|
260
|
256
|
254
|
254
|
245
|
244
|
233
|
233
|
Satu-Mare
|
Units
|
5
|
5
|
5
|
5
|
6
|
6
|
6
|
6
|
6
|
6
|
6
|
Beds day cases
|
9
|
14
|
14
|
13
|
15
|
16
|
16
|
15
|
17
|
17
|
18
|
Hospitalization beds
|
55
|
55
|
55
|
55
|
55
|
55
|
55
|
55
|
55
|
55
|
55
|
Family doctor offices
|
183
|
148
|
148
|
143
|
138
|
133
|
130
|
128
|
126
|
123
|
123
|
Sălaj
|
Units
|
7
|
6
|
6
|
6
|
6
|
6
|
6
|
6
|
6
|
6
|
6
|
Beds day cases
|
0
|
1
|
1
|
1
|
1
|
1
|
1
|
1
|
1
|
1
|
1
|
Hospitalization beds
|
25
|
25
|
25
|
25
|
25
|
25
|
25
|
25
|
25
|
25
|
25
|
|
Family doctor offices
|
113
|
113
|
115
|
114
|
112
|
111
|
111
|
108
|
107
|
99
|
99
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Cluj maintains the highest number of offices, while Bistrița-Năsăud experiences a gradual decrease, and Satu-Mare and Sălaj show stable figures with slight declines. Family doctor offices in Bihor, Cluj, and Maramureș exhibit a modest decline, while Satu-Mare demonstrates a consistent decline. Cluj has 36 units in 2022, Bistrița-Năsăud remains at four units, and Maramureș shows gradual growth to 14 units, with Satu-Mare and Sălaj consistent at six units each.
Oncological day cases beds data reveals gradual growth across counties, with Cluj having the highest count and Maramureș experiencing remarkable growth. Other counties show steady increases, while Sălaj remains stagnant.
Regarding hospitalization oncological beds, Bihor demonstrates gradual growth to 111 beds, while Bistrița-Năsăud sees a slight increase to 46 beds. Cluj maintains a relatively high count, and Maramureș, Satu-Mare, and Sălaj maintain stable bed counts at 73, 55, and 25 beds.
Qualitative analysis results
Upon the analysis of the fifteen interviews, three themes and six sub-themes have emerged:
1. Medical deserts in the North-West region in cancer care
1.1. Human resources in health in oncology
1.2. Oncology facilities
1.3. Waiting times
1.4. Cost of services
1.5. Other socio-cultural barriers
2. Experiences within the health system
2.1. The pathway to access to cancer care
3. Recommendations for improvement.
The interviews had an average of 32 minutes and included eight patients and seven health professionals, working as psycho-oncology therapists, oncologists, and FD.
Table 3. Demographic characteristics of participants
Demographic characteristics of the studied sample
|
Patients
|
Professionals
|
Age
|
<65
|
7
|
<65
|
6
|
≥65
|
1
|
≥65
|
1
|
Gender
|
male
|
2
|
male
|
3
|
female
|
6
|
female
|
4
|
County
|
Bihor
|
1
|
Bihor
|
1
|
Bistrița
|
1
|
Bistrița
|
1
|
Cluj
|
3
|
Cluj
|
1
|
Maramureș
|
1
|
Maramureș
|
2
|
Satu-Mare
|
1
|
Satu-Mare
|
1
|
Sălaj
|
1
|
Sălaj
|
1
|
Type of care
|
Public
|
4
|
|
Private
|
0
|
Private-Public mix
|
4
|
|
|
|
|
|
|
|
|
|
|
1. Medical deserts in the North-West region in cancer care
The interviews conducted have underscored the prevalence of medical deserts at both national and regional levels, particularly within cancer care. Each interviewee provided distinct rationales affirming the existence of medical deserts, with the most prevalent factor being the inadequacy of HRH in terms of number, distribution, quality, training, empathy, collaboration, communication. This was closely followed by deficiencies in essential services and facilities, prolonged waiting times, disproportionate costs relative to patient purchasing power, and patient education- “If we think about the whole county, it seems to me that this (e.g. medical deserts) is exactly the definition of the health service in Romania, that, unfortunately, yes, there are places where the medical service is of very good quality, it exists, it is within reach, but, unfortunately, there are areas where, even if patients want it, it is quite difficult to access medical services.” (male, MD, <65years old, Zalău).
Additionally, participants highlighted patient perspectives on disease and treatment, as well as the apprehension associated with receiving a cancer diagnosis, as contributing factors to the observed medical deserts.
1.1. Human resources for health in oncology
HRH emerged as a critical domain warranting enhancement within the field of oncology. The discourse centred on various categories of personnel, encompassing medical, nursing, allied health, administrative, and support staff. Revisions to personnel regulations per bed are deemed imperative to align with the complex care needs of cancer patients- “We lack staff in terms of numbers, as well as in terms of training. And I don't know how this could be remedied, I think they leave for financial reasons, but mostly for emotional reasons, you know?” (female, MD, <65years old, Cluj-Napoca).
It has been confirmed that augmenting HRH, in terms of number, distribution and training, is essential to ensure the delivery of high-quality care to cancer patients. In instances where HRH levels were deemed adequate, the escalating patient influx imposed an increasingly concerning strain. Concerns surrounding both the quantity and calibre of HRH have been raised, particularly in smaller counties devoid of medical training facilities. An additional important point was made concerning the younger generation of HRH, which should receive more empowering and development opportunities.
1.2. Oncology facilities
Overall, participants reported the absence of critical care services such as radiotherapy and palliative care in several counties, or of materials, equipment and medications– “And the ward is quite large and the day hospitalizations are quite numerous, but the number of patients is increasing and it is possible that in a year, in two, in three years there will not be enough. And you have to develop. In terms of number of hospitals, clinics, professionals in all categories and space.” (female, pharmacist, <65years old, Maramureș).
1.3. Waiting times
The experience with waiting times in the six counties has been highly polarized, with patients receiving diagnosis and commencing treatment within a week, while others endured waits exceeding a year for diagnosis. Instances were noted where appointment times for check-ups or chemotherapy were frequently delayed by several hours due to the high patient volume “For treatment when you go, you wait until you hate yourself. I went last month, I waited for two hours, just for two words.” (female, patient, >65years old, Bistrița-Năsăud); “It seemed that all the doors were opened for me. […] In exactly 10 days I got the diagnosis from the biopsy, on 10 July I got the result, on 19 July I started the treatment.” (female, patient, <65years old, Cluj-Napoca).
A prevalent strategy among patients to mitigate prolonged waiting times involves opting for certain investigations within the private healthcare system, albeit at an additional out-of-pocket cost.
1.4. Cost of services
An unexpected finding from the interviews is the participants' readiness to assume any expenses accrued, resorting to borrowing money, or crowdfunding campaigns. While none of the participants reported forgoing accessing a service due to financial constraints, it was acknowledged resorting to borrowing funds or seeking sponsorships to meet expenses. “For the radiotherapy, we did a fundraiser, we got some sponsorship and then it was ok. There is human solidarity that alleviates the costs, but if I were to pay by myself 250,000 lei, I couldn't.” (male, patient, <65years old, Maramureș). One participant disclosed awareness of other patients cutting certain investigations due to cost considerations.
The bulk of incurred expenses were attributed to medication, imaging investigations, and nutritional support. Participants noted that the introduction of the "Monitor 2" program, which facilitates access to medical investigations, necessary to monitor patients diagnosed with oncological diseases, has led to decreased costs and improved access to investigations (30).
1.5. Other socio-cultural barriers
The primary socio-cultural obstacles identified encompassed psychological factors, specifically apprehension regarding the detection of a cancer illness and attitudes toward the disease and its treatment- “The main factor is the fear of discovering something more serious. If it can't be dealt with at the GP, it means it's something more serious” (male, MD, >65years old, Satu-Mare). Health literacy emerged as a notable barrier, involving comprehension of one's condition and the requisite investigations and treatments. “My patient doesn't have a very good understanding of his disease and the importance of his treatment, and for him, it's somehow more bothersome to ask his son to help him get an imaging appointment until he comes back to us. Somehow, he stops there.” (female, MD, <65years old, Cluj-Napoca).
2. Experiences within the health system
The experiences within the health system among the sample exhibited notable variability, spanning from highly positive experiences to considerations of discontinuing treatment. While no singular influencing factor was discerned, our analysis suggests that these diverse experiences are likely the outcome of a combination of individual and systemic factors that have accumulated over time, which influenced the individuals’ pathway to access to cancer care.
2.1. The pathway to access to cancer care
The pathway to receiving cancer care is highly individualized and influenced by various factors, including the patient's attitude towards the disease, its stage, the healthcare professional overseeing treatment, the healthcare facility, as well as the patient's city of origin and treatment. Interviewee experiences vary widely, ranging from relatively smooth experiences to challenging pathways characterized by multiple HRH exchanges, prolonged waiting periods, and financial burdens stemming from service costs.
A common pathway identified in the interviews is the adoption of a public-private mix, where patients predominantly receive care within the public system but opt for selected consultations or investigations in the private sector to circumvent waiting lists. Another common trend is the utilization of multiple healthcare facilities across different cities, wherein patients initiate their care journey in their city of residence but subsequently seek specialized or higher-quality services in university centres or other locations offering services unavailable locally.
The pathway to accessing cancer care has been described as particularly challenging until specialists for treatment are identified. However, once specialists are engaged, the navigation of the care pathway is described as more manageable.
3. Recommendations for improvement
A recurrent recommendation entailed the revision of treatment protocols to provide patients with innovative therapies, alongside enhancing the availability of palliative care services. Strategies focusing on the prevention of cancer diseases, early screening initiatives, and patient education were consistently advocated, as were efforts to promote formalized collaboration among healthcare professionals and units, and empowerment of the younger HRH. Additionally, there was a recommendation for the digitalization of the healthcare system and the adoption of Electronic Health Records.
Table 4. Respondents’ perspectives on possible improvements in cancer care
Recommendations for improvement
|
“It would be very good if there were some people whose role is to talk to the patient, as nurses do in England, for example, to talk to the patient about the psycho-emotional aspects of his illness, to explain very clearly and after you have explained it to the doctor, to spend some time with him, to make sure that he understands the possible adverse reactions, to have, not only on paper, psychological counselling, nutritional counselling, to have many of the problems that end up afterwards being evident in the system, because of the education, the lack of health education of each of the people. Of course, I have a lot of patients who say that, I don't know, they got cervical cancer because they raised too much in the garden or whatever. One thing would be, I don't know, I would really like a social worker to help me with cases that just don't know what to do when they walk out the hospital door.” (female, MD, <65years old, Cluj-Napoca);
|
“Yes, from my point of view, it could be improved and brought to European and international standards this whole part of medication, the oncology medication circuit, both for staff and patient. That is to say, if we manage to bring the medication circuit up to international standards, then we will be able to provide the patient with medication without the slightest problem.” (female, pharmacist, <65years old, Maramureș);
|
“absolutely everything should be carried out, including the initiation of treatment, if necessary, because we should not put the patient on the roads, the first part of the treatment is done in Cluj, the second in Timisoara and the third and fourth in Satu-Mare.” (male, MD, >65years old, Satu-Mare);
|
“So, first of all, if one would think of things as making, not making life easier for us, but making life easier for us in all these respects, we help the patient in the end. [...]
I don't know, there's no point in saying we need to build more hospitals. Because if it's the same system at NHIH, the computer system we work with and the system we use to draw up treatment schedules, then it's all for nothing. And if we still don't have the people to put in it and well-trained people, then it's also useless.
And I work with a lot of good and dedicated people and they stay overtime, but you can't do that forever and you can't help the patient as you would like and as you know every human being deserves in the end and then you go home with a lot of sadness.
Now with the costs, I don't know if that's necessarily where you need to intervene the most.
What bothers me from a financial point of view is access to treatments that are approved by the EMA, the European Medicines Agency, but are not reimbursed in Romania, and it would be wonderful if we were not in the last place or the last places in terms of the time it takes for a reimbursed medicine in Europe to be available in the country.” (female, MD, <65years old, Cluj-Napoca);
|
“to increase the number of HRH and decrease the number of papers needed to be filled in” (female, psycho-oncologist, <65years old, Bistrița-Năsăud);
|
“It seems very complicated to me, but I think not all GPs are trained to talk to the patient and not to make them scared from the beginning that they are going to die, because now there are a lot of treatments and not everybody dies. [...] The number of doctors seems to me to be small compared to the number of patients, but I think that this thing with dual practice is not good, and it makes the doctor... I mean, it doesn't seem normal to me that you are a university professor, you teach, you go to the public hospital and then you go to private practice.” (female, patient, >65years old, Satu-Mare);
|