Regional Factbooks

Over the last three years, Romania has seen a substantial change in the way its health-care sector is financed, namely, a shift towards the funding of health-care by means of an insurance system. The introduction of health insurance increased the amount of public funding available for that sector. Yet despite this positive development in terms of revenue, at least half the users of the health services report making additional out-of-pocket payments. Moreover, although the budget has benefited from a surplus of revenue from the health sector, the quality of service is increasingly viewed as inadequate, and the system's performance is poor in terms of equal access.

Public funding for health-care, a trend that compares favorably to other social services, should be interpreted against a history of tight control on sector expenditure and inputs until 1998. At 3.8% of GDP (1999), public expenditure on health in Romania remains among the lowest in the ECA region: the only countries with a lower share are those where tax collection has virtually collapsed.

Resolving the imbalance created by the improvement in the funding of health-care following recent reforms, and the inefficient use of resources – as indicated by the persistent low marks for services and the anecdotal evidence of large, private out-of-pocket payments – is becoming an increasingly important part of reforming social service provision more generally. If the health sector can be made to respond to health-care needs more effectively and equitably after the introduction of an insurance system designed to enhance revenue performance, then lessons may emerge for other parts of the social service delivery systems. If, on the other hand, the rationalization of the financing side corresponds to a continued deterioration, and not to improvements, in the allocation of spending, the main benefits of the reform are in doubt.

The state budget was the only public source of health-care funding until 1991. The Ministry of Health, as well as other ministries with their own health service provider networks (e.g., Defense, Interior, and Transport) administered these funds. In the early 1990s the move towards diversifying the sources of funding gained support within Romania as a way of spreading the burden of allocating resources for the health sector. As part of this trend, the Government introduced partial reimbursement of prescription drugs for outpatient care in 1992. The move was accompanied by the establishment of the Special Health Fund, also administered by the Ministry of Health and Family and based mainly on a two percent payroll tax, but also including revenues from small taxes on tobacco and alcohol sales, and advertising. In 1993, responsibility for funding material expenditure other than for drugs, as well as utilities and current maintenance, was transferred from the state to local budgets.

The adoption of the Law on Social Health Insurance in 1997 initiated the transformation of the Romanian health-care system from a Semashko state-financed model to an insurance-based system. Since the law came into force in 1998, earmarked payroll contributions have become the main source of health sector revenue. Key provisions of the law regulate health sector revenue generation and redistribution, as well as the allocation of funds. The 1997 law made insurance membership mandatory and linked it with employment. Contributions depend on income and are paid in even shares by the insured and the employer. Children and young people, disabled persons, and war veterans as well as dependents without income have free access to health insurance. For conscripted soldiers and people serving prison sentences, insurance contributions are paid from the budgets of the Ministry of Defense and Ministry of Justice.

Health insurance covers ambulatory, inpatient, and dental care, including clinical preventive services and drugs. A framework contract, agreed upon annually by the National Health Insurance Fund (NHIF) and the College of Physicians and approved by the Cabinet, defines the benefits package, conditions for service delivery, and payment mechanisms. Co-payments are required for drugs and allowed for other services. Family physicians play a gatekeeper role.

The framework contract sets the terms for health-care services using a variety of parameters. This contract is the basis of the contracts between the District Health Insurance Funds (DHIFs) and health-care providers (hospital and their outpatient units, diagnosis and treatment centers, health centers, basic clinics, and medical offices).
The most important features of the health insurance contract are as follows:

• Insurance benefits include medical services from the first day of sickness or the date of accident until the patient is fully recovered.
  
  
• Medical services include preventive health-care services, ambulatory health-care, hospital care, dentistry services, medical emergency services, complementary medical rehabilitation services, pre-, intra-and post-birth medical assistance, home-care nursing, drugs, health-care materials, and orthopedic devices.
  
  
• The insured are entitled to choose a family doctor for primary health-care services and, once referred by the family doctor, can have the choice of a specialist ambulatory care provider. Inpatient care includes full or partial hospitalization with medical examination and investigations, diagnosis, medical and/or surgical treatment, nursing, drugs, and health-care supplies, accommodation, and food.
  
  
• Health insurance covers 40 to 60 percent of the cost of dental care, taking into account previous use of prophylactic dental check-ups. In accordance with the framework insurance contract, these treatments are fully covered for children aged less than 16.
  
  
• The Ministry of Health and Family and the NHIF, using recommendations from the College of Physicians and the College of Pharmacists, compile a list of prescription drugs on a yearly basis with reference prices. Pharmacists must sell the cheapest available drug, if only the generic name is on the prescription, and must mention potential substitutes.
  
  
• The insured are entitled to prescription drugs; health-care materials needed to correct eyesight and hearing, and prostheses of the limbs are also either partially reimbursed by the insurance funds or free.
  
  
• Coverage of medical rehabilitation, home-care and transportation related to medical treatment and housekeeping support during illness or disability are also regulated by the framework insurance contract.

Health insurance does not cover professional risks and diseases, certain high-tech health-care services, various dentistry services, curative health-care assistance in the workplace, and luxury accommodation services in hospital, all of which must be paid for directly by the patients or from other sources (employer, professional risk insurance, and private insurance).

Health expenditure from public sources in Romania between 1990-1999 varied between 2.8 and 3.8 percent of GDP, equivalent to $28-58 per capita.

Out-of-pocket Payments

Based on data from the Integrated Household Survey of the National Commission for Statistics, private spending on health-care in 1996 was estimated at 1,306 billion Lei ($432 million) or about 29 percent of total health expenditures.
An important part of this sum goes directly or indirectly to public providers or their staff through charges for services and/or under-the-table payments (illegal payments to providers for services that are nominally free). This level of out-of-pocket payments is higher than the average level of private expenditure in the OECD countries, but lower than in countries such as Australia and the United States. Compared to other ECA countries, Romania seems to be in the middle group where out-of-pocket payments and the frequency or level of informal payments are concerned.

Health care delivery system

The Ministry of Health is the central authority in public health, responsible for setting organization and functioning standards for public health institutions, developing and financing national public health programs, data collection, empowering public health officials and drawing up reports on the population's health status.
The Institute for Maternal and Child Care (IMCC) advises the Ministry on standards for maternal and child health and takes part in health programs. As well as compiling epidemiological data and setting standards, it is involved in the National Program of Family Planning, in training obstetricians, and in supervising midwifery training. The National Advisory Board for Epidemiology and the National Advisory Board for Health Care Management and Public Health are created within the Ministry of Health.
Their advice is taken when the Ministry of Health is faced with specific topics of strategic importance for setting public health issues.

Family planning

Family Planning and Sexual Education unit has been set up within the Department for Maternal and Child Health of the Ministry of Health. Since 1992, eleven reference centers for reproductive health have been established. Nine of these centers are based in university clinics and two are at district level. They provide information and technical assistance, family planning, abortion, and cancer-screening services. They also train staff for other centers: since July 1995, it has been possible to grant accreditation in family planning. The project was assisted by WHO, UNFPA and the Department of Continuing Education of the Ministry of Health, and it was funded by the World Bank Project. A parallel network for family planning has also been created through various nongovernmental organizations. Permanent contraceptive methods are not yet promoted as there is no law permitting voluntary sterilization. Previous legislation, which only allowed sterilization for medical reasons, for mothers of five or more children, or for women over 45 years old, is as yet unchanged.

Primary health care

Until 1999, primary health care was mainly performed through a countrywide network of about 6000 dispensaries. The dispensaries belonged to the Ministry of Health and Family and were administered through the local hospital which also held territorial funds for both primary and secondary health care. Community-based clinics provided health care for children under the age of five, housewives, pensioners and the unemployed living within a specific area. There were also enterprise-based clinics for employees (sometimes for a number of adjacent enterprises) and school clinics providing medical care for anyone in full-time education. Patients were not allowed to choose their dispensary, but were assigned one according to their place of employment or residence. Starting from 1998, patients were allowed to choose their basic clinic, i.e. their family doctor. The Health Insurance Law stipulates that a family doctor may be changed after a minimum of three months after initial registration with that doctor.

According to new legislation related to the implementation of the health insurance system, general practitioners moved from being state employees to independent practitioners, contracted by the (public) health insurance funds, but operating their medical offices privately.

Since 1990, there have also been private medical offices staffed by general practitioners or specialists. The physicians who work in these generally divide their time between the public and private sectors.

Access to outpatient clinic and hospital specialty services now officially requires a referral by the family practitioner, but since 1989, the referral system has increasingly been bypassed and the frequency of primary health care consultation has declined.

Ambulatory secondary care

Ambulatory secondary health care is delivered by the network of hospital outpatients departments, centers for diagnosis and treatment and office-based specialists.
Physicians working in private medical offices need a free practice license and an authorization for the medical unit. Private outpatient services may be accredited for all specialties including outpatient surgery.

Inpatient care

There are four main categories of hospitals in Romania:

• Rural hospitals, which have a minimum of 120 beds and provide internal medicine and pediatric services.
  
  
• Town and municipal hospitals, with at least 250 and 400 beds, respectively, and departments of internal medicine, surgery, gynecology-obstetrics and pediatrics.
  
  
• District hospitals in larger have, in addition, departments for orthopedics, intensive care, ophthalmology and otorhinolaryngology.
  
  
• Specialized units for tertiary care such as the Institute for Mather and Child, the Institute of Oncology, The Neurosurgery Hospital, the Institute of Balneophysiotherapy and Recovery, the Institute of Pneumophysiology and a number of cardiovascular and other surgery departments in teaching hospitals.

In terms of ownership, except for few small hospitals, all hospitals are publicly owned and are under state administration. They are led by a council board and a general director who holds executive power. This appointment is made by the relevant district public health directorate and is usually held by a physician. There are two deputy directors, a physician and an economist. The council board is appointed by the general director and usually includes representatives of the different departments within the hospital: health care, nursing, pharmacy, administration and accounts.

Social care

There is not yet a proper community-based social care network in Romania, but a number of organizations may be considered as starting points in its development. The ministries involved in social care are the Ministry of Health, the Ministry of Labor and Social Solidarity, the Ministry of Education and Research, Department for Child Protection, and the State Secretariat for Handicapped People.

According to different research, as many as 40% of patient days in Romania's acute-care hospitals are devoted to social cases. These are patients with minor medical problems who cannot be discharged because suitable alternatives are not readily available. Long-term and convalescent care facilities, hospice units for cancer and AIDS patients, home care, and other community care programs are still underdeveloped. As the health reform program is implemented, hospitals will be under increasing pressure to discharge these patients. The health insurance funds, for example, while authorized to purchase community care services, are under no obligation to pay for care provided inappropriately in facilities or to create or finance alternative community care.

The most recent Ministry of Health data indicate that Romania has one practicing physician for every 580 people, or 17.7 per 10.000 people.

Source: US Dept. of Commerce

Demographics & Economic Situation

Source: Factbook.net