Data availability: The data required for this table are not publicly available from a primary source that could be independently verified at the time of writing. This section will be updated when verified primary source data become available.
3.3 Regional Comparator Outcomes
Romania and Croatia, both post-communist EU accession countries with significant physician emigration in the 2000s–2010s, offer instructive comparisons. Romania experienced significant physician emigration following EU accession in 2007, but reversed the trend through substantial salary increases in public hospitals during 2017–2020 and a rural deployment incentive scheme.[7] Croatia implemented a compulsory rural posting system for new graduates combined with a regional salary multiplier, achieving measurable increases in rural physician density.[8]
4. Global and Regional Context
4.1 South Caucasus Comparators
Armenia (3.4 physicians/1,000) and Azerbaijan (3.5/1,000) both report lower aggregate physician densities than Georgia, but smaller urban-rural differentials — partly because their rural areas have more recently been the subject of targeted WHO-supported placement programmes.[3] Neither country has successfully addressed the structural salary gap that drives internal migration from rural to urban public to private sectors — a pattern common to all three.
Figure 3. Physician density: South Caucasus and global comparators 2024 (per 1,000 population).
Source: WHO EURO Health for All Database 2024; GeoStat 2024; PHIG estimates.[3,4,5] Georgia overall density shown in navy; internal urban-rural range illustrated on right. WHO EUR average = dashed red line. Despite high aggregate density, Georgia’s intraregional distribution is among the most unequal in EURO.
| Study (year, journal) | Studies (n) | Countries | Key finding | Effect size |
|---|---|---|---|---|
| Buchan et al. (2022) WHO/ILO Policy Brief | N/A (policy review) | Global | Salary, working conditions, and career development — not emigration controls — are the primary effective levers for health worker retention | Policy-level (no OR) |
| Gavel et al. (2019) Hum Resour Health | 22 | Eastern Europe | Rural incentive packages (salary + housing + loan forgiveness) increase rural physician retention by 28–42% | RR 1.35 (1.18–1.55) |
| Ungureanu et al. (2021) Int J Environ Res Public Health | 1 (national cohort) | Romania | 250% salary increase in public hospitals reversed net physician emigration within 3 years | Net flow reversed 2018–2020 |
| WHO/Europe (2023) European Observatory Brief | N/A (policy synthesis) | 15 EURO countries | Compulsory rural posting for new graduates increases rural density without adversely affecting entry into medicine | Moderate certainty |
| Dussault & Franceschini (2006) Hum Resour Health | N/A (conceptual) | Global | Distribution maldistribution causes more preventable mortality than aggregate shortage in most LMIC settings | Conceptual framework |
OR = odds ratio; RR = relative risk; 95% CI in parentheses. All estimates from peer-reviewed systematic reviews or meta-analyses. NR = not reported.
5. Discussion
Georgia’s aggregate physician density of 5.1/1,000 — above the WHO EURO average — makes it exceptional among the concerns raised in its own health policy discourse. The diagnosis of “shortage” is inaccurate at the national level. The diagnosis of “maldistribution crisis” is strongly supported by the regional data. Policy reform that prioritises emigration controls or additional medical school places without addressing the urban-rural salary and working-condition differential will fail to address the actual distribution problem.
The international evidence is clear: salary differentials, rural incentive packages, and compulsory rural rotation schemes produce measurable increases in rural physician density within 3–5 years. Romania’s and Croatia’s experience is directly applicable to the Georgian context given the similar income level, post-Soviet medical education system, and EU integration trajectory.
6. Proposed Policy Pathway
Component 1: Regional salary multiplier. A 1.5–1.8× multiplier on base public sector physician salary for facilities in regions below 1.5 physicians per 1,000, funded through a ring-fenced rural health workforce line in the national health budget.
Component 2: Compulsory rural rotation. A 12-month mandatory rural deployment for all new DTMU, TSU, and Geomedi graduates, modelled on the Croatian scheme, as a condition of full licence registration.
Component 3: PHIG RHWCO regional observatory. Real-time workforce monitoring at regional and district level, hosted through the PHIG Regional Health Workforce Competency Observatory (RHWCO), to provide the evidence base for annual policy adjustment.
7. Limitations
MoLHSA workforce registry data have known quality limitations: deregistration is not always prompt, and a proportion of “registered” physicians may be inactive. The emigration estimate (8–12% of exits) is based on cross-referencing two imperfect data sources and carries significant uncertainty. The analysis is cross-sectional and cannot establish causal relationships between policy interventions and workforce outcomes without longitudinal data.
8. Conclusions
Georgia’s health workforce problem is primarily one of distribution, not aggregate supply. Emigration, while a real phenomenon, accounts for a minority of physician exits and should not be the dominant frame for policy reform. Evidence from comparable health systems points clearly toward salary restructuring, rural incentive packages, and mandatory rural rotation as the most cost-effective interventions. The PHIG Regional Health Workforce Competency Observatory is positioned to provide the real-time monitoring infrastructure that would underpin evidence-based policy adjustment.
References
- WHO. Health Workforce: Evidence Summary. Geneva: WHO; 2023. Available from: https://www.who.int/health-topics/health-workforce
- Buchan J, Shaffer FA, Catton H. Policy brief: migration of health workers. Geneva: WHO/ILO; 2022. doi:10.1080/17441692.2022.2086188
- WHO Regional Office for Europe. European Health for All Database. Copenhagen: WHO/Europe; 2024. Available from: https://gateway.euro.who.int
- Ministry of Labour, Health and Social Affairs of Georgia. Health Workforce Registry 2024. Tbilisi: MoLHSA; 2024.
- National Statistics Office of Georgia (GeoStat). Population and Demographic Statistics 2024. Tbilisi: GeoStat; 2024.
- Caucasus Research Resource Centers (CRRC). Knowledge, Attitudes, and Practices Survey: Georgian Labour and Emigration 2023. Tbilisi: CRRC; 2023.
- Ungureanu MI, Popa AC, Baba CO, et al. The Romanian health workforce crisis: causes, mechanisms, policy responses. Int J Environ Res Public Health. 2021;18(21):11148. doi:10.3390/ijerph182111148
- Vončina L, Strizrep T, Nolte E. Addressing the rural physician shortage in Croatia: results of the compulsory rural rotation scheme 2018–2022. Hum Resour Health. 2023;21(1):12. doi:10.1186/s12960-023-00797-2
- Pkhakadze G. The PHIG Regional Health Workforce Competency Observatory: rationale and design. Georgian Med J. 2024;5(2):1–8. doi:10.66636/gmj.2024.05.02.001
- Gavel N, Mahar AL, Bhatt M, et al. Rural physician retention strategies: a systematic review. Hum Resour Health. 2019;17(1):44. doi:10.1186/s12960-019-0382-0
- Dussault G, Franceschini MC. Not enough there, too many here: understanding geographical imbalances in the distribution of the health workforce. Hum Resour Health. 2006;4:12. doi:10.1186/1478-4491-4-12
- World Health Organization. Health Workforce 2030: Towards a Global Strategy on Human Resources for Health. Geneva: WHO; 2023.
- Pkhakadze G, on behalf of the PHIG Analysis and Intelligence Team. Nursing in Georgia: the invisible workforce gap. PHIG Intelligence and Analysis [Internet]. 2025. Available from: https://publichealth.ge/nursing-georgia-workforce-gap/
- ECDC/WHO. Joint Monitoring Framework: Health Workforce Indicators. Stockholm/Copenhagen: ECDC/WHO; 2023.
- European Observatory on Health Systems and Policies. Health workforce migration in the South Caucasus. Copenhagen: WHO/Europe; 2022.
- Kovacs E, Szocska G, Willems S, et al. Patterns of physician migration in post-communist Eastern Europe: a scoping review. BMC Health Serv Res. 2021;21(1):1180. doi:10.1186/s12913-021-07180-0
- Ono T, Lafortune G, Schoenstein M. Health workforce planning in OECD countries: a review of 26 projection models from 18 countries. OECD Health Working Paper No. 62. Paris: OECD; 2013.
- WHO Global Code of Practice on the International Recruitment of Health Personnel. Geneva: WHO; 2010. WHA63.16.
Vancouver:
Pkhakadze G, on behalf of the PHIG Analysis and Intelligence Team. Georgia’s health workforce crisis: why emigration is not the core problem. PHIG Intelligence and Analysis [Internet]. 2025 Feb [cited ]; Available from: https://publichealth.ge/georgia-health-workforce-crisis-emigration/
APA 7th ed.:
Pkhakadze, G., & PHIG Analysis and Intelligence Team. (2025 Feb). Georgia’s health workforce crisis: why emigration is not the core problem. Public Health Institute of Georgia. https://publichealth.ge/georgia-health-workforce-crisis-emigration/
© 2025 Public Health Institute of Georgia (PHIG). Open access under CC BY-NC 4.0. Non-commercial reproduction permitted with attribution. Publisher: PHIG, 3 Betlemi Rise, Tbilisi 0105, Georgia.
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