An Analysis of the Current State of Health Services in Romania

An analysis of the current state of health services in Romania

Monica Alexandru1, Adina Baciu2,*, Alexandru T. Ispas2,3

______Abstract: The general objective of this paper is to analyze from the sociological, legal and economic point of view the current state of health services in Romania, as well as to propose some innovative measures to improve them. Methods. The study was conducted at the national level, from September 2018 to July 2019 and was based on quantitative and qualitative research aimed at providing a global understanding of public and private health services at the national level, as well as the needs of change in the medical field. The questionnaire used included 28 questions, 68 semi-structured interviews were applied and 12 focus groups were organized. Results. In the field of legislation, it has been observed that the law is cumbersome, inconsistent and does not have an integrated character. The access of disadvantaged people to health services is unequal, due to the lack of adequate legislation to solve the health insurance problems for disadvantaged groups and other exposed categories. In the field of palliative care, it is necessary to supplement the legislation regarding the length of hospitalization that is correlated with the real needs of patients' care, as well as the completion of the list of diagnoses that can benefit from palliative care services. Regarding the problems faced by the medical service providers and the accessibility of the population to quality medical services, several problematic aspects were identified. Conclusions. For the patients from the rural areas to access the health services, it is necessary to make the community service system more efficient by developing Multifunctional Integrated Community Centers that provide integrated community services and use mobile medical technologies (screening, telemedicine, mobile blood donation centers). Community medico- social assistance can become an important component both for the health system and for the sustainable development of collaborative relationships between the public and the private sector. Key words: Informed consent, medical facilities, ethics, patient, healthcare professional.

INTRODUCTION in Spain and the Netherlands, 0.4% in Germany, 11.8% in Estonia and 10 % in Greece). After the life expectancy at The Romanian health system, the object of an birth (75.3 years), Romania is placed in the penultimate extensive reform process, must ensure the quality of the place in the EU, the last places being Bulgaria, Lithuania, medical sector and the patient's confidence in the health and Latvia (74.9 years) [1]. services to be benefited. The Euro Health Consumer Index (EHCI) According to Eurostat, an effective health system 2018 report shows that Romania is facing problems must meet the needs of the beneficiaries. In Romania, the in managing the entire public sector, in healthcare, self-reported percentage of unmet health care needs in discriminating against minority groups such as Rroma the entire population is 4.7% in 2017 (compared to 0.41% (3½ - 4% of the population), ranking 34th out of 35 EU

1) University of Bucharest, Faculty of Sociology and Social Work, Bucharest, Romania 2) Institute of Anthropology “Francisc I. Rainer” of the Romanian Academy, Bucharest, Romania * Corresponding author: “Francisc I. Rainer” Institute of Anthropology of the Romanian Academy, House of the Romanian Academy, Calea 13 Septembrie, No. 13, P.O. box 24, 3rd Floor, Room 3244, 5th District, 050711, Bucharest, Romania, Tel./ Fax: +4021 317 50 72, E-mail: [email protected] 3) “Carol Davila” University of Medicine and Pharmacy, Department of Anatomy, Bucharest, Romania

405 Alexandru M. et al. An analysis of the current state of health services in Romania countries, the last place in this ranking being Albania. of financial resources predominantly to hospitals Also, Albania, Romania, and Bulgaria suffer from an old (45.11%), a small percentage being destined for out- health structure, with a high and costly report of patient of-hospital care (outpatient medical payments 14.96%, care regarding external health care [2]. home care payments 0.24%, outpatient services payments Romania has one of the lowest coverage rates, pre-hospital emergency and sanitary transport (0.16%) with medical staff per 1000 inhabitants, with 2.5 doctors [9]. "The increased use of hospital services is attributed and 5.8 nurses per 1000 inhabitants, compared to the to the reduced capacity of the out-of-hospital sector and European average of 3.4 doctors and 8.0 nurses per 1000 mainly to the failure to provide the "gate-keeping" role of inhabitants. The lack of medical staff is also accentuated primary care, while the sub-optimal levels of some key by the high rate of emigration of doctors and nurses [3]. indicators of the effectiveness of public health programs Although it is considered that there are enough can be attributed to a failure of primary care as a vector family doctors to cover the general needs of the of public health and preventive medicine interventions” population, they are unevenly distributed between the [10]. rural and urban areas, which makes it difficult for the Greater attention should be paid to palliative care, population from rural areas to get access to a doctor. which has social, psychological and spiritual implications There are disparities in the provision of health services in [11]. Romania, both in terms of primary and secondary care, Although the National Health Strategy 2014- as well as between the different Development Regions 2020 has the role of a catalyst document aimed at and counties, or between rural and urban areas [4]. stimulating the progress and development in the Infant mortality (0-1 year), a sensitive barometer Romanian health system in the priority areas, it remains of inequality in health status, decreased with 0.4 in 2016, a source of dissatisfaction for the citizens in general. compared to 2015, continuing the downward trend in The present National Study is conducted in the recent years. Infant mortality is significantly lower in context of the project "Alternative public policies in the urban (5.9 / 1000 live births) than in rural (9.0 / 1000 field of health", SIPOCA 245 / MySMIS 111413, co- new live births), although in rural areas child mortality financed by the Operational Program Administrative decreased by 0.5% in the year 2016 [5]. Capacity 2014-2020 and destined to the development of According to the Family Budget Survey (ABF) of the organizational capacity of the member organizations 2018, in the third quarter of the year, the expenses of the of the Philanthropy Federation. families with health represented 4.7% of the total family The study aims to analyze the current state of expenses, coming after the expenses of food, clothing/ health services in Romania as a general objective. The footwear, recreation, and culture, but overtaking the analysis is a sociological assessment, but it does not expenses. of education. Romania is placed in the ignore some judicial and economic aspects. penultimate place in Europe, according to the EHCI 2018 The specific objectives that the project proposes report from the perspective of the consumer of health are: services, correlated with the level of financial allocation - Analysis of the legislation that regulates the for health per capita. Higher scores were given to the activity of the medical service providers; chapters that address patients' rights and information and - Analyzing the problems faced by healthcare accessibility and lower in terms of outcomes, prevention, providers, public and private; and range of services. - Identification of the solutions for improving the Romania currently allocates less than 6% of health system in Romania / the medical services offered GDP for health, compared to the European average of to the population. 9.8% [6]. The national health insurance system gives The research questions to which the present the population a comprehensive "basic service package". study aims to answer are the following: Although health insurance is in principle obligatory, in - What are the problems facing the health system practice only about 86% of the population is insured. in Romania? Uninsured persons are entitled to a "minimal service - What would be the solutions to improve the package", which covers only emergencies, diseases accessibility of the population to quality health services? with a potential epidemic, assistance during pregnancy and perinatal [7]. Between 2012 and 2014, the cost of METHODS medication in the four national health programs varied according to the program and ranged from RON 855 / The study was conducted at the national level, patient/year to RON 58 thousand / patient/year [8]. from September 2018 to July 2019 and was based on The health services in Romania are characterized quantitative and qualitative research aimed at providing by an oversize of the specialized assistance in the a global understanding of public and private health hospitalization regime and an under-utilization of the services at a national level, as well as the needs of change primary and community assistance. There is an allocation in the medical field. The investigation explored aspects

406 Romanian Journal of Legal Medicine Vol. XXVII, No 4(2019) of the legislation regulating the activity of the medical models practice. The interview time ranged from 22:04 service providers, the problems faced by the medical minutes to 1:15 minutes. The answers were audio service providers, as well as the possibilities of developing recorded with the consent of the study participants and the medical services at the level of the medical service then they were transcribed in electronic format. provider and at a local level. Documentation of the study The focus groups, in number 12, each three focus was done by studying the specialized literature, reports, groups organized in each of the aforementioned regions, studies, previous research in the field, legislation, models brought to the participants' discussion three main topics: of international practice. the legislation regulating the activity of the healthcare The quantitative research was carried out providers, problems facing the healthcare providers that between September 2018 - February 2019 and was they can be solved by public policies, proposals for the based on a questionnaire, which was sent by e-mail to development of medical services at the level of the medical all medical service providers based on the data obtained service provider and at local level. The duration of the from the Directorates of Public Health and the General focus groups ranged from 1:35 minutes to 2:37 minutes, Directorates of Social Assistance and Protection Child the discussions being recorded audio and in writing in Romania. The questionnaire included a number of (flipchart sheets), with the participants' agreement, 28 questions regarding the type of medical unit, the subsequently being electronically transcribed. legislation that regulates the activity carried out and the The inclusion of the participants in the study standards respected, categories of beneficiaries, types was done on a voluntary basis, following the written, of services offered, staff, sources of financing, problems informed and freely expressed consent. The study arising in the medical activity, good practices. complied with the ethical norms of scientific research, In the second part of the study, the approach constantly respecting the principles of anonymity and chosen was qualitative, as it aims to analyze in-depth confidentiality, the subjects being able to withdraw at any the subject addressed so that the data collected will be time from the study. The research had the agreement of relevant to the study. The qualitative research was carried the Ethics Commission with no. 772 / 29.10.2018 issued out in four relevant regions (Bucharest-Ilfov, South-West by the Faculty of Sociology and Social Work, University Oltenia, North-West and North-East), from November of Bucharest. 2018 to July 2019 and consisted of document analysis This study presents some limitations: the (studies, research, statistics, laws, orders, Government qualitative study was not carried out with the participation decisions, enforcement rules, standards in force in the of all the representatives of the medical services providers field of health) as well as the application of 68 semi- in Romania. Focus groups were organized and interviews structured interviews and the organization of 12 focus were applied to specialists from the Bucharest-Ilfov, groups. The participants in the interviews and focus South-West Oltenia, North-West and North-East groups were specialists from hospitals, health centers, regions. The interviewed specialists and participants in medical-social units, residential units for persons focus groups were both female and male. with disabilities, tuberculosis sanatoriums, preventive hospitals, psychiatric sanatoriums, spas sanatoriums, RESULTS medical dispensaries, school medical offices, medical offices. students, independent offices of general medicine, The analysis and interpretation of the data were independent offices of family medicine, civil medical focused on two directions, namely: problems identified societies, polyclinics, diagnostic and treatment centers, at the level of the legislation and the problems faced by specialized medical centers, specialized ambulatories, the providers of medical and socio-medical services. integrated outpatient hospitals, dental offices, health The problems identified in the legislation by the centers, transfusion centers blood, medical laboratories, interviewed persons, the participants in focus groups and dental technology laboratories, mental health centers, the respondents to the questionnaires were of the opinion ambulance units transporting patients and SMURD, that there are normative acts "too loaded", as well as a residential units for the elderly providing medical care lack of legislative coherence and integrated legislation. within the unit, as well as public health specialists. Also, "there are normative acts that are not correlated In-depth interviews were applied, face-to-face with each other, do not add value, do not work together". in each region (Bucharest-Ilfov, South-West Oltenia, The updating of the normative acts is not always North-West and North-East), with the participation of followed by the repeal of the old ones, which makes a batch of 68 specialists. The semi-structured interview different provisions in normative acts that regulate guide included 22 open questions regarding categories the same theme, which can lead to difficulty in their of beneficiaries, types of services offered, legislation corroboration to the interpretation. On the other hand, regulating the activity of the institution, the standards part of the legislation governing health services in respected, the staff from medical and medical-social Romania is not updated and requires changes. One of institutions, existing difficulties in the activity, good the interviewees considered that "the law regulating the

407 Alexandru M. et al. An analysis of the current state of health services in Romania minimum equipment of the cabinets requires updates small number of screening actions carried out in the and modifications since it has not been modified for 10 rural area, to facilitate access to this type of investigations; years." reduced involvement of the environment family members Also, some of the respondents stated that the in facilitating local screening activities. procurement legislation hinders the hospital's activity, Early detection of cancer diseases increases the meaning that the purchases are long-lasting and there chances of survival of the patients and consequently are many challenges. “The reform of the health system increases the quality of life. On the other hand, the in Romania should start with the reform of the health presence of the doctor only in emergency cases greatly insurance system. The payer, respectively the Health increases the risk of the disease (cancer) being detected Insurance House (C.A.S.) should reconsider the packages in an advanced stage (III and IV), and the costs from the that are defined in the law, otherwise not very clear, state budget for the treatment of cancer patients is very and which do not necessarily find a correspondence in high. practice. There should be a basic package, which each 2. Low rate of blood donors in Romania. The one has to pay and a private insurance supplement to the specialists in the medical field feel the need in each basic package included in the public insurance. " county to intensify the Blood Donation Campaign so The access of patients (disadvantaged people) that the number of donors and the blood quantity are in to health services is unequal, due to the lack of adequate correlation with the needs of the patients; at present this legislation to solve the health insurance problems for area is deficient. disadvantaged groups (elderly, street people, Roma In rural and disadvantaged areas, it is found that citizens, etc.) and other exposed categories. More efficient the level of information of the population regarding the cross-sectoral collaboration is needed, especially at the importance of blood donation is low. At the same time, it level of vulnerable groups. is highlighted the difficulty with which the people from In the field of palliative care, it is necessary the disadvantaged / isolated areas reach the transfusion to supplement the legislation regarding the length of centers. Poor infrastructure, long distances and lack of hospitalization that is correlated with the real needs specialized personnel make donor mobility difficult for of patients' care, as well as the completion of the list of donation services. At the same time, the Program for diagnoses that can benefit from palliative care services. the donation of territorial transfusion centers does not Currently, legislation is required to provide for the include the weekend, which determines the low blood introduction of the palliative care discipline for all the donation rate of the potential donors. specialists involved in this field (doctors, psychologists, 3. The difficult access to the population from the psychiatrists, social workers, physiotherapists, and rural area to specialized healthcare. Due to the large priests) at the post-secondary, university and post- distances from the medical units, it is found, especially university level, as well as facilitating access to education in rural areas, low access of the population to specialized programs for palliative care specialists in each county. medical services. This situation is amplified by the Regarding the problems faced by the medical small number of specialists in rural communities or service providers and the accessibility of the population disadvantaged areas. According to the National Institute to quality medical services, the following relevant of Statistics on 31.07.2019, the number of family doctors problematic/critical issues were identified: in the rural area was 4205, decreasing compared to 2018 1. Low access to medical screening services in when their number was 4441. The number of insured Romania, especially in the case of medically or socially persons in the rural area decreased from 6,974,080 (75 , vulnerable persons, with a focus on the population from 82% of the rural population) in 2014 to 6,310,947 (65.64% rural areas and vulnerable groups. Although there are of the rural population) in 2016 and to 6,196,895 (68.64%) national screening programs of the Ministry of Health on 31.07.2019. The number of uninsured persons in the (through which free access is ensured to all potential rural area as of 31.07.2019 was 1,645,834, increasing by insured / uninsured beneficiaries, according to Order 182,415 persons as compared to 2016. In the Romanian MS 977/2018 and 978/2017, among the reasons why the villages, one in three inhabitants is not registered with the population ignores the regular presence at the specialized family doctor and there are also 7 times less doctors only consultation, we mention: the lack of a uniform practice in the city [12]. Almost half of Romania's population lives regarding the media coverage of the screening programs in the village, which is why a very small percentage of (either they are publicized for a limited period or they people have access to specialized medical services, such are mediated through low impact media channels); as cardiology, radiology, ophthalmology, oncology, etc. It insufficient resources for the media/promotion actions; is felt the need to increase the access of the population low degree of awareness among citizens, regarding the from the rural area to the specialized medical services by mortality rate caused by cancer; the reduced number identifying practical and viable solutions [13]. of counseling and information programs for citizens 4. Insufficient interinstitutional collaboration wishing to benefit from specialized consultations; the at the local level, between the public and private sectors,

408 Romanian Journal of Legal Medicine Vol. XXVII, No 4(2019) in order to facilitate the access of the population to kinetotherapist, the clinical pharmacist and the priest). the medical-social services. In the field of health, the 10. Insufficient palliative care services, which are collaboration between the public and the private sector needed in each county. Based on the needs identified is deficient, there are problems such as lack of qualified in the community, it is necessary to set up pediatric personnel, insufficient resources necessary to provide palliative care services for adults, outpatient palliative the medical service, legislation too burdensome, lack of a care, at home, day centers and mobile hospital teams. coherent computer system, etc., all of which considerably Due to insufficient settlement of palliative services at hinder the development of public strategies. Even if the home, service providers focus on providing these services private sector (non-profit and/or for-profit) has been in large cities, where distances are smaller. One solution able on several occasions to cover some needs regarding would also be to create a Call center for patients in need the provision of medical-social services or the access of of palliative care. people to these services, however, such actions are quite limited at present. COMMENTS AND PROPOSAL Identifying solutions to encourage viable partnerships/collaborations between the public and Although the legislation in the health field is private sectors, in order to improve the population's access rich, it still requires some updates and correlations with to medical services, especially in rural communities and/ the legislation in the other sectors of activity. It would or disadvantaged areas, is a problem that needs to be be desirable to centralize all information regarding a solved. particular subject in a single normative act, in parallel 5. Poor development of the telemedicine system with the repeal of old normative acts. The lack of proper at a national level. There is an urgent need to develop legislation leads to inequality in terms of access for the telemedicine system (consultations, basic imaging disadvantaged people to health services. Cross-sectoral investigations, etc.) at the level of the medical services collaboration is especially needed at the level of vulnerable providers in each county, addressed especially to the rural groups. communities and / or to the disadvantaged areas. In the There was a great need for the training of case of telemedicine, interaction is more frequent with specialists on health legislation and the quality standards patients, without the need for "face-to-face" consultations: of medical services. The use of a legislative program for monitoring of vital parameters (such as blood pressure, healthcare providers would facilitate access to information heart rate, EKG, blood sugar, weight) and adjusting the in a timely manner, eliminating problems arising from its real-time therapy, early detection of predisposition to lack of knowledge. different conditions, etc. Regarding the problems related to the lack of 6. The medical services provided under day legislative coherence, the solution of centralizing the hospitalization at the national level are reduced, which information for a certain subject in a single normative means that medical assistance is mainly provided in act was identified, in parallel with the repeal of the the hospital regime. The development of day hospital old, inapplicable normative acts. It is also desirable to medical services would make the costs more efficient and corroborate the information when issuing normative significantly contribute to improving the quality of the acts. services offered to patients, but also to the fluidization of It is also necessary to develop a legislative the services in the continuous hospitalization. framework to help and improve medical prevention 7. The financing of medical and medical-social services in all sectors and for all patient groups. It is also services is deficient at the national level. This fact affects necessary to invest more in National Health Programs and the number of medical services, their quality and has a to intensify the application of educational programs with negative effect on the health status of the population. prophylactic/curative purposes at the community level, 8. Radiotherapy, radiology and medical imaging especially at the level of disadvantaged communities. services are not correlated with a large number of patients, It has been found that in rural areas, at each and settlement at C.N.A.S is done for a limited number of county level, there is a need to develop activities that patients / monthly. One study participant stated that “in respond to the needs of the community, because it has Romania, approximately 40-45 radiotherapy units would been identified that in the rural area there are a small be needed, almost one in each county. Due to the lack/ number of health care providers that respond to the needs insufficiency of these services, patients who need such of the population. There is a need for the development services wait a long time until they can start treatment ”. of community health care, which will ensure equitable 9. The system faces an insufficient number access to health services of all persons in each community, of specialized personnel (doctors, nurses), auxiliary regardless of whether they live in rural or urban areas. staff, but also the absence of specialists within the The aim is to increase the access of vulnerable groups to multidisciplinary team to provide holistic care (eg social health services, especially to those focused on prevention. worker, psychologist/psychotherapist, psychiatrist, Although community health care is regulated according

409 Alexandru M. et al. An analysis of the current state of health services in Romania to O.U.G. 18/2017, it is still under development, within care services; elaboration of a management plan for the limits of the allocated funds. the provision of screening services, blood donation, In order for rural area patients to access health specialized consultations through telemedicine services, services, it is necessary to make the community service case management in the case of people who have suffered system more efficient by developing Multifunctional certain conditions, offering palliative services (including Integrated Community Centers that provide integrated telemedicine). community services and use mobile medical technologies In conclusion, the realization of these services (screening, telemedicine, mobile blood donation centers). as "closer" to the beneficiaries reduces the costs of Community medico-social assistance can become an population travel, determines the detection of diseases in important component both for the health system and for real-time, the prevention of the population's illness, the the sustainable development of collaborative relationships faster access to treatment, the reduction of costs with the between the public and the private sector. Integrated treatment of the patients, etc. Community Centers (KICs) are an important opportunity To streamline socio-medical activities and to bring essential medical services such as telemedicine, services, the Integrated Community Centers (KICs) can screening and blood donation to the community, closer establish partnership relations with both state institutions to the residents of disadvantaged areas. (local public authorities, hospital units, decision-making Integrated community centers can be forums, etc.), as well as with various NGOs, health care developed firstly at the micro-regional level, but with units. cult or other legal entities from the private sector. interdisciplinary teams for each locality. The role of these Integrated Community Centers (KICs) is to: Conflict of interest. The authors declare that identify existing needs in communities - mapping there is no conflict of interest. needs, establishing intervention measures according to Contribution of authors. The authors have existing needs; offering integrated community services equal contributions as the first author. - medical, social and educational; monitoring of chronic Acknowledgment. This research benefited from patients (HTA, diabetes, cancer); monitoring of pregnant funding through the Operational Program Administrative women and newborns; informing communities about: Capacity 2014-2020, the project "Alternative public need for vaccination, disease prevention, healthy policies in the field of health", SIPOCA 245 / MySMIS eating, screening, blood donation, etc.; providing home 111413.

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