State of Health in the EU Romania RO Country Health Profile 2019 The Country Health Profile series Contents
The State of Health in the EU’s Country Health Profiles 1. HIGHLIGHTS 3 provide a concise and policy-relevant overview of 2. HEALTH IN ROMANIA 4 health and health systems in the EU/European Economic 3. RISK FACTORS 7 Area. They emphasise the particular characteristics and challenges in each country against a backdrop of cross- 4. THE HEALTH SYSTEM 9 country comparisons. The aim is to support policymakers 5. PERFORMANCE OF THE HEALTH SYSTEM 13 and influencers with a means for mutual learning and 5.1. Effectiveness 13 voluntary exchange. 5.2. Accessibility 16 The profiles are the joint work of the OECD and the 5.3. Resilience 19 European Observatory on Health Systems and Policies, 6. KEY FINDINGS 22 in cooperation with the European Commission. The team is grateful for the valuable comments and suggestions provided by the Health Systems and Policy Monitor network, the OECD Health Committee and the EU Expert Group on Health Information.
Data and information sources The calculated EU averages are weighted averages of the 28 Member States unless otherwise noted. These EU The data and information in the Country Health Profiles averages do not include Iceland and Norway. are based mainly on national official statistics provided to Eurostat and the OECD, which were validated to This profile was completed in August 2019, based on ensure the highest standards of data comparability. data available in July 2019. The sources and methods underlying these data are To download the Excel spreadsheet matching all the available in the Eurostat Database and the OECD health tables and graphs in this profile, just type the following database. Some additional data also come from the URL into your Internet browser: http://www.oecd.org/ Institute for Health Metrics and Evaluation (IHME), the health/Country-Health-Profiles-2019-Romania.xls European Centre for Disease Prevention and Control (ECDC), the Health Behaviour in School-Aged Children (HBSC) surveys and the World Health Organization (WHO), as well as other national sources.
Demographic and socioeconomic context in Romania, 2017
Demographic factors Romania EU Population size (mid-year estimates) 19 587 000 511 876 000 Share of population over age 65 (%) 1 7.8 19.4 Fertility rate¹ 1.7 1.6 Socioeconomic factors GDP per capita (EUR PPP²) 18 800 30 000 Relative poverty rate³ (%) 23.6 16.9 Unemployment rate (%) 4.9 7.6
1. Number of children born per woman aged 15-49. 2. Purchasing power parity (PPP) is defined as the rate of currency conversion that equalises the purchasing power of different currencies by eliminating the differences in price levels between countries. 3. Percentage of persons living with less than 60 % of median equivalised disposable income. Source: Eurostat Database.
Disclaimer: The opinions expressed and arguments employed herein are solely those of the authors and do not necessarily reflect the official views of the OECD or of its member countries, or of the European Observatory on Health Systems and Policies or any of its Partners. The views expressed herein can in no way be taken to reflect the official opinion of the European Union.
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© OECD and World Health Organization (acting as the host organisation for, and secretariat of, the European Observatory on Health Systems and Policies) 2019
2 State of Health in the EU · Romania · Country Health Profile 2019 76 81 71 EUR 3000 EUR 2000 Life expectancy at birth,years EUR 1000 % of adults premature mortality. could substantially reduce and improved accessto services, enhanced role for primary care prevention policies, andan effective public healthand the highestinEU. More and treatable causesare among The deathrates from preventable Effectiveness Per capita spending(EURPPP) imbalance between primary care andhospitalcare, andtackling the growing shortages ofhealth professionals. uninsured andis entitledtoonly aminimalbasket ofservices. Key challenges forthehealthsysteminclude fixing the Health Insurance system provides acomprehensive benefit package –however, about11%ofthe population remains behaviours, butalsosocioeconomicinequalitiesas well assubstantialdeficienciesinhealthservicedelivery. The Social Although ithasincreased, Romaniahasamong thelowest lifeexpectancy intheEU. This reflects unhealthy 1 per 100000population, 2016 Age-standardised mortality rate Prevent ble Obest Bne drnn Smon RO RO RO RO 712 773 mort lt mort lt Tre t ble Highlights EUR 0 2000 Bne drnn 2005 EU EU EU Smon 17 Obest 21 22 93 2011 157 RO RO 10% 208 15 2017 19 20 20 % EU 753 809 310 2017 35 % % reporting unmet medical needs, 2017 EU RO sectors islow andthehealth systemissignificantly underfunded. are bothsubstantialand widespread. Inabsoluteterms, spending inall are generally low, except foroutpatientmedicines, informal payments line with theEUaverage (79.3%), and out-of-pocketwhile payments EU 9.8%). The share of publicly financedhealthspending (79.5%)isin basis (EUR1 029, EUaverage EUR2884)andasa proportion ofGDP(5%, Health spending inRomaniaisthelowest intheEU, bothon a per capita Health system (35 %)farexceeding theEUaverage of20%. Inmen, thisrate isover 50%. consumption isamajor public healththreat, with thebinge drinking rate in children have increased over thelastdecadetoreach 15%. Alcohol are among thelowest intheEU(10%), butoverweight andobesityrates higher rate among men(32%)than women (8%). Adult obesityrates risk factors. Oneinfive Romanianadultsare daily smokers, witha much Around deathsinRomaniaare halfofall tobehavioural attributable Risk factors tuberculosis casesintheEU. challenges incontrolling someinfectiousdiseases, with thehighestrate of of death, althoughcancermortalityisontherise. Romaniaalsofaces than themosteducated. Ischaemic heartdiseaseremains themaincause for men:theleasteducatedmencanexpecttolive about10 years less disparities inlifeexpectancy by gender andeducationlevel, particularly since 2000(from 71.2 years to75.3 years in2017). However, there are large Life expectancy atbirthinRomaniahasincreased by more thanfour years Health status Accessibility all face greater barriers to care.to face greaterbarriers all and lower socioeconomic groups, from marginalised communities, access. People inrural areas, those and income-related disparitiesin are significant regional, ethnic for medicalcare; moreover, there population reports unmetneeds A substantial proportion ofthe %01 0% Hh ncome Countr EU EU Countr State of Healthin the EU ·Romania ·Country HealthProfile 2019 %01 EU Countr 3% All Low ncome 6% 9% improvements. making itdifficulttosteer is not generally undertaken, assessment ofthehealthsystem primary care. Performance reallocate resources towards but there are attempts to under-resourced andunderused, system. Primarycare isboth inefficient health toan contributes inpatient care over-reliance on The long-standing Resilience 3
ROMANIA 2 Health in Romania ROMANIA Life expectancy has increased, but lags women living on average seven years longer than men almost six years behind the EU average (71.7 years compared to 79.1).
While life expectancy at birth in Romania increased Romania has one of the highest rates of infant by more than four years between 2000 and 2017 (from mortality in the EU – 6.7 per 1 000 live births 71.2 years to 75.3 years), it remains among the lowest compared to the EU average of 3.6 in 2017. Insufficient in the EU and almost six years below the EU average medical equipment and the shortage of doctors may (Figure 1). There is also a marked gender gap, with help to explain this figure (see Section 5.3).
Figure 1. Life expectancy in Romania is among the lowest in the EU
Yers 2017 2000 90 –
Gender gap: Romania: 7.4 years 85 – 834
831 EU: 5.2 years 827 827 826 825 824 822 822 821 818 817 817 816 816 814 813 812 811 811 809
80 – 791 784 78 7 78 773 76 758
753 749 748 75 –
70 –
65 – EU Sp n Itl Frnce MltCprusIrelnd Greece Polnd Ltv NorwIcelndSweden Austr F nlndBel um Czech Eston Crot Bul r Portu l Sloven GermnDenmr Slov Hun rL thun Romn Luxembour Netherlnds Un ted n dom Source: Eurostat Database.
There are stark inequalities in life Figure 2. Men with low education die 10 years earlier expectancy by educational level than those who are tertiary educated
Differences in life expectancy across educational levels are substantial, particularly for men. As shown in Figure 2, men with low levels of educational attainment at age 30 live on average 10 years less 516 than those with high education, considerably higher 478 ers 469 ers than the EU average of 7.6 years. The gap among ers 37 2 women is much less pronounced — about four years, ers which is around the same as across the EU (Figure 2). Lower Higher Lower Higher educated educated educated educated women women men men
Education gap in life expectancy at age 30:
Romania: 3.8 years Romania: 9.7 years EU21: 4.1 years EU21: 7.6 years
Note: Data refer to life expectancy at age 30. High education is defined as people who have completed a tertiary education (ISCED 5–8) whereas low education is defined as people who have not completed their secondary education (ISCED 0–2). Source: Eurostat Database (data refer to 2016).
4 State of Health in the EU · Romania · Country Health Profile 2019 -100 1: ‘Healthy life years’ measuresthenumberof years atdifferentages. thatpeoplecanexpecttolivefreeofdisability access tocare (Section5.2). in Romania, althoughthere are known tobeissuesin of theRoma population, orofany otherethnic group As aresult, nodataare available onthehealthstatus and dataare reported forthe general population only. ofstatisticsbycollection ethnic group is prohibited gaps inself-reported healthby ethnicityasthe over intheEUasa whole. Itisnot toquantify possible of 45-to64-year-olds and41.4%ofthoseaged 65and average, from 87.5%forthoseaged 16to44, to66.8% aged 65andover. This decline issteeper thantheEU 44, to69%of45-64-year-olds and23%ofthose sharply with age: from 94%ofRomaniansaged 16to of individuals reporting being good healthdeclines the EUaverage. As inothercountries, the proportion being in good health(71%in2017), slightly more than care (Section5.2), three quarters ofRomaniansreport Despite thehighlevels ofunmetneedsformedical age more than in the EUasa whole health, but the proportion declines with Most Romaniansreport being in good Source: Eurostat Database. Note: Thesize of thebubbles isproportional to themortality rates in2016. Figure 3. Cardiovascular disease takes thelargest toll butcancer onmortality deaths are increasing whole. Despiteamarked reduction since2000, stroke three timeshigher inRomaniathantheEUasa The deathrate from ischaemic heartdiseaseisalmost 550 deaths per 100000 population in2016(Figure 3). causes ofdeath, togetheraccounting formore than Ischaemic heart diseaseandstroke are theleading cause ofdeath cardiovascular diseasesare the leading Deaths due to cancerhave increased, while 100 % c -50 50 0 hn Stomch cncer Brest cncer dne dsese e 2000-16(orner Chronc obstructvepulmonr dsese Colorectl cncer 50 Pneumon est Lver dsese
Lun cncer er) 100
State of Healthin the EU ·Romania ·Country HealthProfile 2019 150 and breast cancers (Section5.1). increased inrecent years, particularly forcolorectal rates. Mortalityrates forothercancertypeshave also nearly 14%since 2000, duemainly tohighsmoking deaths, with amortalityrate thathasincreased by Lung canceristhe mostfrequent causeofcancer EU average of80. deaths per 100000 population in2016, well above the remains thesecond leading causeofdeathat256 EU average. Regarding healthy life years years lessthan women), the gap isinline with the (with Romanianmenliving about three andahalf gap inlifeexpectancy atage 65remains substantial above theEUaverage (Figure 4). the While gender 65 are spent with somechronic diseaseordisability, from 2000. However, several years oflifeafterage 16.7 years in2017, anincrease ofalmosttwo years Romanians aged 65could expect tolive anadditional 65 affect women more than men Chronic diseaseordisability afterage above theEUaverage. living (ADL)such asdressing andeating, which is well report somelimitationsintheiractivities ofdaily into old age. However, 31%ofRomaniansover 65 EU), mostare abletocontinue tolive independently one ormore chronic disease(compared to54%inthe onlyWhile 46%ofRomanians over 65report having 2017). men (5.1 years formencompared to5.9 per women in women live only slightly longer in good healththan 200 Ae-stndrdsed mortlt rteper100000populton,2016 Str o e
Isc 300 hemc hertdsese 1 , onaverage, 350 5
ROMANIA Figure 4. Just under half of those aged 65 or over have a chronic condition
Lfe expectnc t e 65
ROMANIA Romn EU
5.5 167 199 10 9 9 ers ers 11.2
Yers wthout Yers wth dsblt dsblt
% of people ed 65+ reportn chronc dseses % of people ed 65+ reportn lmttons n ctvtes of dl lvn (ADL) Romn EU25 Romn EU25
16% 20% 18% 31% 46% 53% 30% 34% 69% 82%
No chronc One chronc At lest two No lmtton At lest one dsese dsese chronc dseses n ADL lmtton n ADL
Notes: 1. Chronic diseases include heart attacks, high blood pressure, high blood cholesterol, strokes, diabetes, Parkinson disease, Alzheimer’s disease, rheumatoid arthritis and osteoarthritis. 2. Basic activities of daily living include dressing, walking across a room, bathing or showering, eating, getting in or out of bed and using the toilet. Sources: Eurostat Database for life expectancy and healthy life years (data refer to 2017); SHARE survey for other indicators (data refer to 2017).
Tuberculosis remains an important in 2017). The notification rates for all TB cases are public health issue in Romania also falling but remain well above the EU/EEA average (66.2 compared to 10.7 per 100 000 in 2017) (Figure 5). The control of certain infectious diseases, such Measles is also a persistent public health issue in as tuberculosis (TB) and measles, continues to be Romania, with one of the highest notification rates an important public health issue in Romania. The in the EU (102.1 per million in 2018, compared with number of TB cases has declined over the past decade, 26.2 in the EU as a whole). This trend is linked to low but is still the highest in the EU (around 13 000 cases immunisation coverage (Section 5.1).
Figure 5. Although improving, the number of TB cases in Romania is still the highest in the EU
Not f ct on rte for 100 000 popult on Romn Ltv Bulr L thun EU28 160
120
80
40
0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Source: ECDC Surveillance Data, Tuberculosis.
6 State of Health in the EU · Romania · Country Health Profile 2019 adolescents being overweight orobesein2013-14. prevalent inchildren, however, with oneinsix Being overweight orobeseisbecoming increasingly obese in2017 theEUaveragewhile was 15%). is thelowest intheEU(only oneintenadults was physical activity, theadultobesityrate inRomania Despite the prevalence ofunhealthy dietsandlow physical activity every week isthelowest intheEU. adults reporting engaging inatleastmoderate countries (Figure 7). At 38%, thenumber ofRomanian These figures are much higherthaninmostEU despite recent healthy eating campaigns (Section5.1). and asimilar proportion donotconsume vegetables, that they donoteatatleastone piece offruitdaily, Nearly three fifthsofRomanianadults(59%) report not seem to have obesity animpactonadult Unhealthy dietandlow physical activity do Source: IHME(2018), GlobalHealth Data Exchange (estimates refer to 2017). beverage andsaltconsumption. can beattributed to more thanonefactor. Dietary risksinclude14components, suchaslow fruitandvegetable consumption andhighsugar-sweetened Note: Theoverall numberof deaths related to these riskfactors (135 000) islower thanthesumof each taken individually(165 000) because thesamedeath Figure 6. Behavioural riskfactors are implicated inasignificantnumberof deaths average (44%)(Figure 6). Dietaryrisks(27%)include and low physical activity (62%), well above theEU including poor diet, tobaccouse, alcoholconsumption, toaselectionofbehaviouralattributed riskfactors, More deathsinRomaniacanbe thanhalf of all more deathsthan halfofall Behavioural riskfactorsaccount for 3 EU 18% Romn 27% Detr rss Riskfactors State of Healthin the EU ·Romania ·Country HealthProfile 2019 EU 17% Romn 17% Tobcco of deathsare related tolow levels of physical activity. the proportion seenacross theEU(6%). A further4% toalcoholconsumption,attributed more thandouble deaths,an estimated17%ofall 14%canbe while direct andsecond-hand smoking) isresponsible for consumption of sugarandsalt. Tobacco use(including insufficient fruitand vegetable intake, andexcessive (see Section5.1)are yet tobeseen. of the2016Law onPrevention andControl of Tobacco in 2015, among thehighestrates intheEU. The effects reporting having smoked during the preceding month concern, with nearly onethird of15-and16-year-olds consumption inadolescentsisalsoamatterof higher thanamong women (8%). Regulartobacco with smoking rates among men(32%)fourtimes (Figure 7). There isalarge gender gap insmoking, smoked daily in2014, inline with theEUaverage in smoking rates since2008, oneinfive adultsstill challenge inRomania. Despiteaslightreduction Tobacco consumption isamajor public health smokes onadaily basis One infive Romanianadults Low phsclctvt Romn 4% EU 6% Romn 14% Alcohol EU 3% 7
ROMANIA Excessive alcohol consumption is a major Obesity, unlike many other risk behaviours, problem, particularly among Romanian men is strongly linked to education
ROMANIA On average, more than one third of adults in People with lower education or income generally are Romania reported engaging in episodic heavy alcohol more likely to have behavioural risk factors; however, consumption (binge drinking)2 at least once a month, only obesity shows striking inequalities in Romania. the second highest rate in the EU (35 % compared For example, nearly 11 % of people with a lower level to 20 % on average in the EU). Moreover, this figure of education were obese in 2017, compared to 7.5 % belies a strong gender difference, with more than 50 % among those with higher education. For smoking the of men reporting having engaged in heavy drinking. results are reversed, with nearly 13.5 % of people in Two in every five 15- and 16-year-old adolescents the lower education groups being regular smokers in Romania reported at least one episode of heavy compared to nearly 21 % in the highest education drinking during the preceding month in 2015. This groups. However, the smoking rate was similar for is also above the EU average, and is of particular both high- and low-income groups (18-20 %). concern given the association between heavy alcohol consumption and accidental injuries, particularly in adolescents.
Figure 7. All behavioural risk factors, apart from obesity, are highly prevalent
Smon (chldren)
Veetble consumpton (dults) 6 Smon (dults)
Frut consumpton (dults) Bne drnn (chldren)
Phscl ctvt (dults) Bne drnn (dults)
Phscl ctvt (chldren) Overweht nd obest (chldren)
Obest (dults)
Note: The closer the dot is to the centre, the better the country performs compared to other EU countries. No country is in the white ‘target area’ as there is room for progress in all countries in all areas. Source: OECD calculations based on ESPAD survey 2015 and HBSC survey 2013-14 for children indicators; and EU-SILC 2017, EHIS 2014 and OECD Health Statistics 2019 for adults’ indicators.
Select dots + Effect > Trnsform scle 130%
2: Binge drinking is defined as consuming six or more alcoholic drinks on a single occasion for adults, and five or more alcoholic drinks for children.
8 State of Health in the EU · Romania · Country Health Profile 2019 Source: OECD Health Statistics 2019 (data refer to 2017). Figure 8. Healthspendingislower inRomania thaninany other EU country operating inthesystem. For some vulnerable groups are alsoanumber ofexemptions from contributions the amountemployers were expectedtocover. There and atthesametime, salariesincreased toinclude became responsible for paying thefull premium, to pay. Following new legislation, employees therefore of employees –however, employers consistently failed their share totheNHIHonbehalf ofSHIcontributions scheme inRomania. 2017, Until employers transferred Employers donotdirectly totheSHI contribute Health undernationalProgrammes. health care providers mightbe paid by theMinistryof home care providers, etc.) atlocallevel; moreover, (GPs), specialist practices, laboratories, hospitals, from healthcare providers (general practitioners with centrally determinedrules. DHIHsbuyservices delivered in41districts(judet)andBucharest inline insurance houses (DHIHs). Healthcare servicesare public healthauthorities(DPHAs)anddistrict have locallevel representation, through district the system. BoththeMinistryofHealthandNHIH Insurance House (NHIH)administersandregulates for overall governance, theNationalHealth while presence. The MinistryofHealthisresponsible Insurance (SHI) model, with thestatehaving alarge Romania’s healthsystemisbasedonaSocialHealth Social HealthInsurance system Romania hasahighly centralised 4 4 000 EUR PPPpercpt 2 000 5 000 3 000 1 000 Government &compulsor nsurnce 0 The health system Thehealthsystem Norw
Germn
Austr
Sweden Netherlnds
Denmr
LuxembourFrnce
Belum
Irelnd Voluntr schemes &household out-of-pocet pments
Icelnd Unted ndom Fnlnd State of Healthin the EU ·Romania ·Country HealthProfile 2019
EU Mlt
Itl (Section 5.3). results inchronic underfunding ofthehealthsystem Overall, thelow number of people contributing toSHI from ofthe theSHIcontributions working population. andchronicallydisabilities ill patients) are financed and studentsunder26, pregnant women, people with health servicesusedby other groups (such aschildren behalf to guarantee theirhealthservicecoverage. The budget pays totheNHIHontheir aSHIcontribution pensions and people on socialbenefits)thestate (such astheunemployed, retired people onlow value Spn unknown. thought tobesubstantial, extentis althoughtheirfull spending in2017(Section5.2). Informal payments are (OOP) payments, which accountedfor20.5%ofhealth The secondlargest source ofrevenue isout-of-pocket (79.5 %in2017), inline with the EUaverage of79.3%. three quartersofhealthspending is publicly funded (compared totheEUaverage of9.8%). More than EU average ofEUR2884(Figure 8), or5%ofGDP differences in purchasing power), lessthanhalf the EUR 1 029 per person onhealth(adjustedfor increased inrecent years, in2017Romaniaspent GDP. Although, healthexpenditure hassystematically country, bothin per capita termsandasashare of Romania spendslessonhealththanany otherEU but overall expenditureis very low Most healthspending isfrom sources public
Czech
Sloven
Portul
Cprus
Greece
Slov
Lthun
Eston
Polnd
Hunr
Bulr
Crot
Ltv Shre of GDP Romn % of GDP 00 25 50 5 7 100 125 9
ROMANIA Spending on hospitals dominates while policy and Slovakia. Again, however, the absolute value of efforts seek to strengthen primary care per capita spending on pharmaceuticals (EUR 280) remains relatively low, with Romania spending only a
ROMANIA The shift to outpatient care is at an early stage, with little over half the EU average (EUR 522) (Figure 9). more than 42 % of health spending still directed to inpatient care (compared to the EU average Notwithstanding efforts to strengthen primary and of 29 %), although the overall amount per capita community care, underpinned by the National Health remains low in absolute terms, totalling around Strategy 2014-2020, the proportion of health spending half of what is spent across the EU as a whole devoted to primary and ambulatory care remains (European Commission, 2019a). Another 27 % is the second lowest in the EU (18 %, compared to the spent on pharmaceuticals and medical goods. This is 30 % EU average). Romania also spends very little on particularly high compared to other countries, and prevention, only EUR 18 per person in 2017, or 1.7 % the third highest proportion in the EU after Bulgaria of total health spending, compared to 3.1 % across the EU.
Figure 9. Health care financing is skewed towards inpatient care
EUR PPP per cp t Romn EU
1 000
800 835 858
600 42% of totl spend n 522 471 400 432 27% of totl spend n 18% of totl 280 spend n 200 6% 188 of totl 2% spend n of totl spend n 89 0 6565 18 18 Inpt ent0 cre Phrmceut cls0 Outpt ent0 cre Lon -term0 cre Prevent on0 nd med cl dev ces
Notes: Administration costs are not included. 1. Includes curative-rehabilitative care in hospital and other settings; 2. Includes only the outpatient market; 3. Includes home care; 4. Includes only the health component. Sources: OECD Health Statistics 2019; Eurostat Database (data refer to 2017).
The benefits package is broad, but from user charges for hospital care, including children universal coverage is yet to be achieved under 18 and young people up to 26 years of age if they are enrolled in any form of education; patients SHI enables insured individuals to access a covered by the national health programmes; pregnant comprehensive benefit package, while the uninsured women without income; and all pensioners (since are entitled to only a minimum set of services. 2018). In practice, only around 89 % of the Romanian population was covered by SHI in 2017. There are Romania has fewer doctors and nurses coverage gaps for workers in the informal economy, per capita than most EU countries the unregistered unemployed and Roma people without identity cards who are not registered and do Despite increases in the size of the health workforce not pay SHI contributions (Section 5.2). over the course of the last decade, the Romanian health system is still suffering from shortages of While there are no co-payments for ambulatory care doctors and nurses. In 2017, there were 2.9 practising and relatively low payments for hospital admission, doctors per 1 000 population, the third lowest more significant co-payments are applied to figure in the EU (EU average 3.6), and 6.7 nurses outpatient prescription medicines, particularly where per 1 000 population (EU average 8.5). Migration these are branded or above a certain price threshold. outflows of medical staff seeking better career and Furthermore, 60 % of the population are exempted remuneration prospects abroad have contributed to
10 State of Health in the EU · Romania · Country Health Profile 2019 infrastructure withinfacilities (Section 5.3). been taken towards investment inimproving constraints, thoughsome preliminary steps have substantial challenge, given thetightbudgetary improving other aspectsof working life isa raises scheduled over thenext three years. However, to medicalstaff in2018, withmore modest pay government awarded substantial salaryincreases numerous protests andstrikes. Inresponse, the conditions. Inrecent years there have also been sector because of poorremuneration andworking substantial numbers have left thepublichealth sinceparticularly EU accession in2007, and outward-migration of healthprofessionals, For some time, Romania hasseen significant workforce shortages Box 1.Recent reforms have targeted chronic health sector more attractive (Box 1). retention andmake employment inthehealthcare the government hastaken measures totryimprove (seeSection5.2).accessibility Inresponse tothisissue, professionals, with negative consequencesoncare the development ofadomesticshortage ofhealth (Section 5.3). in improving infrastructure withinfacilities steps have beentaken towards investment budgetary constraints, thoughsome preliminary life isasubstantial challenge, given thetight However, improving other aspects of working pay raises scheduled over thenext three years. to medicalstaff in2018, withmore modest government awarded substantial salaryincreases numerous protests andstrikes. Inresponse, the conditions. Inrecent years there have also been sector because of poorremuneration andworking substantial numbers have left thepublichealth particularly since EU accession in2007, and outward-migration of healthprofessionals, For some time, Romania hasseen significant health workforce shortages Box 1.Recent reforms have targeted chronic State of Healthin the EU ·Romania ·Country HealthProfile 2019 social andeconomicintegration. individuals outof poverty and promote their wider education, employment, andhousing servicestolift wider population needs andcombinessocial, health, institutions. The Protocol embedshealthcare within for implementing integrated community care across in July 2017approved aCollaboration Protocol, atool poor continuity ofcare for patients. Legislation passed public health, primary andhospitalcare. This leadsto lack ofintegration between different sectors, namely Another characteristic ofthehealthsystemis assistance, including non-urgent care. hospital emergency departments ifthey needmedical EU average of7.5consultations. Patients oftenrely on (ambulatory) doctoronly five times, compared tothe Romanian consulteda primary care orspecialist rates (Figure 10andSection5.3). In2016, theaverage demonstrated by the very highhospitaldischarge there isover-utilisation ofhospitalservices, as Primary care continues tobeunder-used, while ongoing effortstostrengthen therole of primary care. 2010. The decreasing trend poses real challenges for is inline with theEUaverage butdown from 29%in up only 22%of the doctor workforce in2016, which conditions canaccessspecialistsdirectly. GPsmade gatekeeping role, although patients with specific practices contracted by theDHIHs. They have a GPs provide primary care mainly in(private) solo numbers andoveruse ofhospitals is hampered by low general practitioner A shift towards integrated community care 11
ROMANIA Figure 10. Outpatient care remains under-utilised in Romania
Number of doctor consulttons per ndvdul
ROMANIA 14 Low nptent use Hh nptent use Hh outptent use Hh outptent use
12 S CZ HU 10 DE MT LT NL EL 8 ES EU PL EU vere 75
IT BE LU SI AT EE BG 6 IS LV IE HR NO FR RO D 4 PT FI SE 2 CY
Low nptent use Hh nptent use Low outptent use EU vere 172 Low outptent use 0 50 100 150 200 250 300 350 Dschres per 1 000 populton
Note: Data for doctor consultations are estimated for Greece and Malta. Source: Eurostat Database; OECD Health Statistics (data refer to 2016 or the nearest year).
12 State of Health in the EU · Romania · Country Health Profile 2019 Source: Eurostat Database (data refer to 2016). indicators refer to premature mortality (under age75). Thedata are based ontherevised OECD/Eurostat lists. treatable (or amenable)causes isdefined asdeath that can bemainlyavoided through health care interventions, includingscreening andtreatment. Both Note: Preventable mortality isdefined asdeath that can bemainlyavoided through publichealth andprimaryprevention interventions. Mortality from Figure 11.Avoidable deaths that are preventable ortreatable are amongthehighest intheEU and prevention interventions. The maincausesof 2016, highlighting theneedforeffective public health rate was thefourthhighestinEurope (Figure 11)in is very highinRomania. The preventable mortality Mortality from both preventable andtreatable causes better prevention and treatment Many deaths could be averted with 5.1. 5 Unted ndom Alcohol-relted dseses Lun cncer Ischemc dseses hert Performance of thehealthsystem Luxembour Netherlnds Effectiveness Lthun Germn Denmr Romn Hunr Ae-stndrdsed rtes mortlt per100000populton Portul Sloven Slov Bulr Belum Norw Sweden Czech Eston Fnlnd Crot Icelnd Austr Polnd Cprus Irelnd Greece Frnce Ltv Mlt Spn Itl Preventble cusesofmortlt EU 0 50 100 Others Accdents (trnsport ndothers) Stroe 100 110 115 118 121 129 150 133 134 138 139 140 140 141 154 155 158 161 161 161 166 200 184 195 218 250 232 232 244 262 300 State of Healthin the EU ·Romania ·Country HealthProfile 2019 310 325 350 332 336 timely treatment. the healthsystemfacesin providing appropriate and cancer. This result reflects theconsiderable challenges and treatable), stroke, pneumonia andcolorectal disease (which isconsidered tobeboth preventable in theEUand was alsodriven by ischaemic heart for mortalityfrom treatable causes was thehighest cancer, alcohol-related deathsandaccidents. The rate preventable mortalityare ischaemic heartdisease, lung Unted ndom Hpertensve dseses Stroe Ischemc dseses hert Luxembour Netherlnds Lthun Germn Denmr Romn Hunr Ae-stndrdsed rtes mortlt per100000populton Portul Sloven Slov Bulr Belum Norw Sweden Czech Eston Fnlnd Crot Icelnd Austr Polnd Cprus Irelnd Greece Frnce Ltv Mlt Spn Itl EU Tretble cusesofmortlt 0 50 62 62 63 67 67 68 69 71 71 71 76 77 78 80 80 100 87 87 89 90 93 Others Colorectl cncer Pneumon 95 128 130 150 140 143 168 176 200 194 203 206 208 250 13
ROMANIA Efforts to improve prevention Box 2. Vaccination rates have declined dramatically have had limited success Box 2. Vaccination rates have declined Romaniadramatically has a recommended vaccination schedule
ROMANIA The main risk factors affecting the health of for children, but immunisation is not compulsory, and Romanians are unhealthy dietary habits, smoking, vaccinationRomania has rates a recommendedare below both vaccination European scheduleaverages alcohol consumption and low levels of physical andfor WHO children, recommended but immunisation targets isof not 95 compulsory,% (Figure 12). activity (Section 3). Despite recent efforts aimed at Lowand immunisation vaccination rates coverage are below has given both riseEuropean to several modifying diet through healthy eating campaigns, measlesaverages outbreaks and WHO since recommended 2016 (UNICEF, targets 2019) of with, there is no evidence of a decrease in the already high for95 example, % (Figure 3 07112). Lowcases immunisation of measles reported coverage in has the levels of consumption of animal fats and calorie- six-monthgiven rise period to several between measles September outbreaks 2016 since and 2016 dense foods with excessive sugar and salt content. February(UNICEF, 2017. 2019) New with, national for example, measures 3 071 have cases been of approvedmeasles to reported respond in to the these six-month outbreaks period and between to In 2015, the government established a National growingSeptember vaccine 2016 hesitancy, and February including 2017. Newlowering national the age Council to coordinate policies and actions to tackle formeasures administering have beenthe first approved vaccine to responddose from to 12 to 9 excessive alcohol consumption. However, no concrete monthsthese andoutbreaks recommending and to growing that all vaccine children hesitancy, up to measures have been adopted to date to address this 9 yearsincluding of age lowering now be the vaccinated age for administering (Rechel, Richardson major public health challenge. Some efforts to reduce & McKee,the first 2018). vaccine dose from 12 to 9 months and tobacco smoking have been made, with a revised recommending that all children up to 9 years of version of the Law on Prevention and Control of Followingage now the be seriousvaccinated measles (Rechel, outbreak Richardson in early & 2017, Tobacco Use in 2016, which banned smoking in all RomaniaMcKee, opted2018). to temporarily suspend exports of public indoor spaces, except in designated places with vaccines in order to ensure adequate supplies and appropriate ventilation. increaseFollowing the thevaccination serious measles rate. Pharmaceuticals outbreak in early in Romania2017, Romania tend to opted be less to expensive temporarily than suspend in other In 2018, the Ministry of Health announced a new EUexports countries of vaccines(except forin ordersome to new ensure medicines), adequate programme to screen for cardiovascular disease- whichsupplies encourages and increase parallel the exportvaccination and increases rate. related risk factors, with an allocation of EUR 25 thePharmaceuticals likelihood of domestic in Romania shortages. tend to3 beIn 2018,less the million over five years. The programme will be Europeanexpensive Commission than in other accepted EU countries the measure (except andfor implemented by GPs, who will receive additional endedsome infringement new medicines), procedures which encourages against Romania. parallel At payments, in collaboration with cardiologists. theexport same andtime increases Romania the agreed likelihood to seek of domesticother ways to increaseshortages. vaccination3 In 2018, rates,the European including Commission through training Measures are being taken to improve relatively andaccepted increasing the awareness,measure and which ended are infringement supported by EU low and declining immunisation rates funding.procedures against Romania. At the same time Romania agreed to seek other ways to increase As testified by the fact that Romania experienced Thevaccination influenza rates, vaccination including rate through among training older andpeople is several measles outbreaks in recent years, children’s alsoincreasing low (Figure awareness, 12) and whichhas decreased are supported markedly by EU from immunisation rates are among the lowest in the EU 54 funding.% in 2007 to 8 % in 2017 (the WHO target is 75 %). (Box 2 and Figure 12). A draft vaccination law was Reasons include vaccine supplies not reaching mobile presented for public debate in 2017 to regulate the communitiesThe influenza such vaccination as the Roma, rate amongand insufficient older people organisation and financing of immunisation (although informationis also low on(Figure entitlement 12) and hasto free decreased vaccination markedly it has not yet been passed). It foresees a variety of reachingfrom 54 the % olderin 2007 population. to 8 % in 2017 (the WHO target measures to increase vaccination rates, including is 75 %). Reasons include insufficient information strategies to raise public awareness and clarify the on entitlement to free vaccination reaching the responsibilities of all actors involved in immunisation. older population, and vaccine supplies not reaching The legislation also foreshadows the establishment mobile communities such as the Roma. of a Technical Group for the Coordination of Immunisation Activities, to advise the Ministry of Health.
3: Parallel trade in medicinal products is permitted within the EU Single Market, but in certain cases Member States may restrict it, as long as the measures protect a legitimate public interest and are justified, reasonable and proportionate.
14 State of Health in the EU · Romania · Country Health Profile 2019 mediator programme). place (seeSection5.2andBox 3ontheRomahealth more broadly) forexcluded communities are now in preventive interventions (andindeed tohealthcare barriers. Somenew measures toimprove accessto and thehomeless, experiencing significantaccess the most vulnerable groups, such astheRoma health promotion andeducationresources, with population doesnothave equitableaccessto is predominantly oncurative care. Moreover, the or maternalandchild health, islow andthefocus policy programmes, e.g. thoseaddressing cancer prevention component inmostnationalhealth least on prevention intheEUafterSlovakia. The on prevention perperson,the spent Romania average is3.2%). When measuring expenditure 1.8 %ofhealthexpenditure inRomania(theEU In 2017, spending on prevention represented only to prevention servicesispatchy Spending onprevention islow andaccess year). Database for people aged 65 andover (data refer to 2017 orthenearest children (data refer to 2018); OECD Health Statistics 2019 andEurostat Source: WHO/UNICEF GlobalHealth Observatory Data Repository for hepatitis B, andthefirst dose for measles. Note: Data refer to thethird dose for diphtheria, tetanus, pertussis and average Figure 12.Vaccination rates are well below theEU Amon chldrened2 Mesles Amon chldrened2 Amon peopleed65ndover Influenz Amon chldrened2 Heptts B Dphther, tetnus,pertusss 90 86 93 8 % % % % Romn EU State of Healthin the EU ·Romania ·Country HealthProfile 2019 44 % 93 % 94 % 94 % the EUStructural Fundsandthe World Bank. colorectal cancers were introduced with supportfrom screening programmes forbreast, cervicaland cancer (EUaverage: 47%). In2018-19, nationwide of thoseaged 50-74hadbeenscreened forcolorectal over thesame period (EUaverage: 60%), andonly 5% aged 50-69reported accessing breast cancerscreening EU average of66%). Only 6%ofRomanian women cancer over the preceding two years (compared tothe 20-69 reported having beenscreened forcervical practices. In2014, only onequarterof women aged participation, andsub-optimalqualityofscreening There isalsoalack ofsystematicscreening, low common cancers. to improve thediagnosis andtreatment ofthemost Multiannual PlanforCancerControl, inanattempt is implementing the2016-20NationalIntegrated of treatment. Recognising this, the government a needtoincrease the timelinessandeffectiveness liver (13%)cancers. These poor outcomessuggest risk factors, thatis, lung (11%), stomach (3%)and cancers thatare preventable through minimising EU averages (Figure 13), and particularly sofor such asbreast, prostate andcervicalare well below Five-year survival rates from treatable cancers screening, diagnostics and treatment but new initiatives seek to improve Cancer outcomesremainrelatively poor, or deemedtoounreliable fordecision-making. underdevelopment,still with data eitherunavailable largely becausequalityassurance inhealthcare is hospital admissionsforacute conditions. This is avoidable hospitalisations, ormortalityfollowing data onqualityindicatorsforhospitalcare, such as and there isalack ofinternationally comparable are notroutinely by collected healthcare providers, Romania appears tobe poor. Patient safetyindicators In general, informationonthequalityofcare in regarding qualityofcare There isapaucityofdata available Medicine. Source: CONCORD programme, London Schoolof HygieneandTropical Note: Data refer to people diagnosed between 2010 and2014. lag behindthose intheEU Figure 13. Five-year cancer survival rates inRomania EU26 87% Prostte cncer Romn 77 % EU26 15% Romn Lun cncer EU26 83% Brest cncer Romn 11 75 % % 15
ROMANIA Antimicrobial resistance has been Urgent reorganisation of the recognised as a major concern blood service is needed
ROMANIA Levels of antimicrobial resistance (AMR) remain high Safe blood supplies are essential for the organisation in Romania. In 2017, 22.5 % of Klebsiella pneumoniae of surgery, emergency care, intensive care and isolates tested resistant to carbapenems, a potent cancer care. However, a 2017 audit identified many last-line class of antibiotics. This is the third highest shortcomings that put the safety and quality of percentage in the EU, though it has decreased Romania’s blood supply at risk. Issues cover a variety since 2016 (31.4 %) (ECDC, 2018). Since November of aspects including organisation, ICT, investment, 2018, steps have been taken on AMR, including training, as well as political and legal mandates. establishing the Multisectoral National Committee The Romanian authorities are therefore bringing for Limiting Antimicrobial Resistance to monitor together key decision makers, as well as international the implementation of a national strategy to fight experts from other EU Member States with similar it. AMR was also selected as one of the priorities of experiences to develop, within the next 2-3 years, a the Romanian Presidency of the EU Council in the concrete and endorsed plan of action to reorganise first half of 2019. This culminated in the adoption of the blood service. Conclusions on the Next Steps towards Making the EU a Best Practice Region at the Employment, Social Policy, Health and Consumer Affairs Council (EPSCO) in June 2019.
5.2. Accessibility
The number of Romanians without The benefit package is comprehensive, coverage is significant although dental care is not covered by default
The Romanian SHI system aims to provide universal Every insured person in Romania is given access to health insurance coverage, and participation in SHI a comprehensive benefit package, which includes is mandatory for those not covered by exemptions. In prevention, outpatient primary and specialist care, practice, SHI covered only 89 % of the population in as well as hospital care. The key coverage gap is 2017, with coverage gaps for workers in the informal dental care: only certain groups, such as children or economy, people without an identity card and those with chronic conditions, are entitled to public several other groups who are not registered and do coverage, and even for them, coverage is only for a not pay SHI contributions (Section 4). The number of selection of procedures (European Commission, 2018). Romanians without coverage is, however, difficult to As a result, Romanians report experiencing the fifth quantify (Box 3) because of the significant numbers highest level of unmet needs for dental care in the of Romanians working abroad who are still counted EU (5.4 % in 2017), twice the EU average (2.7 %) (see as residents (around 3 - 4 million) and thus appear Figure 15). in the statistics as having no insurance. Romanians not covered by SHI have access to a minimum benefit package only, which is restricted to emergency care, communicable diseases treatment and ante-natal care.
Box 3. Vulnerable groups experience barriers to access
Individuals without an identity document, mostly and therefore experience significant barriers to Roma and homeless people, are excluded from access for many services. These barriers have long statutory coverage, as they cannot register in been recognised. In 2002, a Roma health mediator the system. Other groups, mainly people without programme was instituted to facilitate access to formal income who do not contribute to SHI, are health care and prevention services. Health mediators also not covered. This includes people working in provide information and act as liaisons between small-scale agriculture, those employed ‘unofficially’ health care professionals and Roma communities, in the private sector, and the unemployed, who especially to promote access to public health are not registered (or cannot register) for benefits interventions.
16 State of Health in the EU · Romania · Country Health Profile 2019 private providers under-report income. In2014penaltiesforproviders acceptingmoney ‘underthetable’wereexpandedandmay havereducedthepractice. 4: However, toassessaccurately thereal magnitudeofOOPspendingisdifficult becauseofwidespreadinformalpayments (mainly inhospitalcare)andbecause Sources: OECD Health Statistics 2019 (data refer to 2017). Figure 14. Most formal out-of-pocket spendingisonpharmaceuticals 2017 compared to15.8%intheEU;Figure 14) current Romanian healthexpenditure (20.5%in OOP spending accounts foraboutonefifthof medicines, poseachallenge to access Out-of-pocket payments, mostly foroutpatient technical capacity. process somewhat hasstalled duetoalack of institutionalisation ofHTA inthedecision-making technology assessment (HTA) unit. However, the generates a positive list with input from itshealth National Agency forMedicinesandMedicalDevices actors informdecisionmaking. For medicines, the established exante, butconsultations with different criteria fortheselectionof goods andservicesare included inthe statutory benefit package. No clear-cut for agreeing onthedefinitionofservicesand goods The MinistryofHealthandNHIHshare responsibility Co-payments fortheseoutpatientmedicinesrange to pay formedicines purchased outside hospitals. this share ofOOPspending, over two thirds are used Romn EU Overll shreof helth spendn Overll shreof helth spendn 205% 158% OOP OOP 4 . Of State of Healthin the EU ·Romania ·Country HealthProfile 2019 Dstrbuton ofOOPspendn Dstrbuton ofOOPspendn b tpeofctvtes some oftheseshortages (see Box 2). introduced by the government in2017aimtotackle vaccines constitute anotheraccessbarrier. Measures and theresulting shortages ofmedicinesand providers hasalsobeenincreased. Parallel exports 2016 to13000in2018)andthenumber ofcontracted extended since2016(from about6000 patients in to direct-acting antivirals forhepatitis Chasbeen access toexpensive medicines. For example, access Romania hasmadesome progress inimproving obstruct accesstoneededmedicines. However, as 80%fornovel prescription medicinesandmay from 10%ofthe retail price for generics toasmuch b tpeofctvtes Others 33% Dentl cre 25% Phrmceutcls 55% Outptent medclcr Inptent 14% Others 21% Dentl cre 32% Phrmceutcls 132% Outptent medclcr Inptent 02% e e 31% 18% 17
ROMANIA Unmet needs for care have decreased Access imbalances disproportionately affect over time but not disappeared certain disadvantaged socioeconomic groups - the unregistered5, pensioners, agricultural workers, and
ROMANIA In 2017, 4.7 % of Romanians reported unmet needs for the Roma population (Council of the European Union, medical care because of cost, distance or waiting time, 2019). As is the case in most EU countries, those with compared to an average of 1.7 % in the EU (Figure 15). the lowest incomes report the greatest unmet needs. There is also anecdotal evidence that medical staff In 2017 around 6.5 % of Romanians from low-income commonly request informal payments which would households said that they had foregone medical care create additional barriers. While still higher than for financial reasons, compared to 2.3 % in the EU. the EU average, reported levels of unmet needs for However, this was a better than the 14.5 % reported in medical care in Romania have improved dramatically 2010. over the last six years, having decreased by 7.5 percentage points since 2011.
Figure 15. Unmet needs are much higher and more unevenly distributed than EU averages
Unmet needs for medcl cre Unmet needs for dentl cre
H h ncome Totl populton Low ncome H h ncome Totl populton Low ncome
Eston Ltv Greece Portu l Ltv Greece Romn Icelnd Fnlnd Eston Sloven Romn Polnd Fnlnd Unted n dom Norw Icelnd Denmr Irelnd Spn Slov Republc Lthun Portu l Sloven Bel um Bel um Bul r Cprus Itl Irelnd EU Frnce Crot Unted n dom Cprus EU Lthun Bul r Sweden Itl Norw Polnd Denmr Slov Hun r Sweden Frnce Hun r Czech Republc Crot Luxembour Czech Republc Austr Austr Germn Germn Mlt Luxembour Spn Mlt Netherlnds Netherlnds 0 5 10 15 20 0 5 10 15 20 25 30 % reportn unmet medcl needs % reportn unmet dentl needs
Note: Data refer to unmet needs due to costs, distance to travel or waiting times. Caution is required in comparing the data across countries as there are some variations in the survey instrument used. Source: Eurostat Database, based on EU-SILC (data refer to 2017).
The availability of services is unequal across the poor transport infrastructure. The government sees country. The skewed distribution of health care mobile health units as a tool for increasing access to facilities means that access to both primary and services in rural and remote areas, and in 2018, eight specialist services is poorer in rural areas. This pattern mobile cervical cancer screening units were provided is repeated in the uneven distribution of doctors as part of a project financed by the World Bank. (Figure 16), with access challenges exacerbated by
5: People without income who are not registered for social benefits, which would grant them SHI cover.
18 State of Health in the EU · Romania · Country Health Profile 2019 200 250 Tretble per100000populton mortlt 100 6: Resilience refers6: Resilience tohealthsystems’capacityadapteffectively tochanging environments, suddenshocks orcrises. Source: Eurostat Database; OECD Health Statistics 2019. Figure 17. Low healthexpenditure isassociated withavoidable deaths from treatable causes reduce mortalityfrom treatable causes(Figure 17). to timely andeffective care, which could inturn spending, ifusedefficiently, could improve access country intheEU(Section4). Increasing health Romania spendslessonhealththanany other health systemsustainability demographic challenges jeopardise Lack offinancialresources and 5.3. Source: Eurostat Database. Figure 16. Theuneven distribution of doctors exacerbates access issues 150 50 0 500 Resilience West RO 37 Reon 1 000 South LV HR North-West West 6 BG PL Olten 298 HU 27 Reon 1 500 CY LT Reon EE EL Centrl S SI South MuntenReon CZ 296 Reon PT State of Healthin the EU ·Romania ·Country HealthProfile 2019 Bucurest-Ilfov 2 000 ES 152 553 EU North-Est MT IT 221 in meansthatthesystemischronically underfunded. the populationpaying proportionof persistentlysmall of exemptions andincrease rates, contribution butthe have beentaken over the years toreduce thenumber base andstrengthen thesystem. Various measures 2019b). Addressing this would increase thefinancing totheschemecontribute (European Commission, a quarterofthetotaleligible population actually but a vast range ofexemptions meansthanonly areSHI contributions themainsource offinancing, U Helth expendture (lon-term cre excluded), EUR PPP percpt Reon IS 2 500 FI South-Est IE BE D NL 201 SE Reon LU 3 000 FR per 1000populton Number ofph scns NO > 3 27 -3 < 27 AT 3 500 DE 4 000
19
ROMANIA Other trends jeopardise the long-term sustainability working conditions, as well as to prevailing negative of the system, including the ageing of the population attitudes within the medical profession towards (which increases health care demand and shrinks the the role of GPs. Measures have mainly been taken
ROMANIA resource base) and outward migration of people of to increase the number of health professionals in working-age (which reduces contributions and further public (hospital) facilities, countering emigration and shrinks the resource base). Outward migration is improving retention rates. The government began forecast to be very high in the coming years (Iftimoaei with modest salary increases in 2015 and 2016, & Baciu, 2018). These two structural changes both and pledged further incremental improvements in tend to further restrict the already limited resources working conditions by 2022. Pressure from strikes in available to the health system. The total economic 2017 accelerated doctor salary increases to the level dependency ratio, i.e. the relationship between the originally planned for 2022. Thus, in March 2018, total inactive population and employment, has the net salary for a junior doctor increased by some increased to 180 % in 2017 compared to 130 % in 160 % (from some EUR 344 to EUR 902 per month) and 2016, and is the highest in the EU. At the same time, the net salary of a senior doctor rose by 130 % (from public expenditure on health is expected to increase EUR 913 to EUR 2112). However, salary increases only from 4.3 % of GDP in 2016 to 5.2 % in 2070, in line benefited doctors employed in public hospitals while with increases in the EU average (6.8 % to 7.7 %). GPs, whose incomes are determined by contracts In addition, public spending on long-term care is with the DHIHs and patient charges, were excluded. expected to increase from only 0.3 % of GDP in 2016 to Other measures to improve working conditions, such 0.6 % in 2070, which is low by the EU standards, where as expanding access to modern equipment, are being it is forecast to grow from 1.6 % to 2.7 % (European implemented with support from European Structural Commission-EPC, 2018). and Investment Funds.
In 2017, the newly elected government increased the Shifting care away from hospitals will help health budget by a hefty 23.5 % (although it is not yet to improve efficiency and sustainability visible in public statistics). This is intended to address existing health system challenges, including boosting The very high hospital discharge rate and low retention rates for health workers (see below), fully numbers of doctor consultations outside hospitals are fund national health programmes, and provide better evidence of over-utilisation of specialised inpatient access to medicines (see Section 5.2). These objectives care and under-use of primary and community care are also aligned with the National Health Strategy (Figure 10 and Section 4). Patients in Romania often 2014-20 goals of increasing the volume of services bypass the primary care setting and present directly provided in outpatient (ambulatory) and community to hospital emergency departments or hospital care settings, rationalising the use of hospital services, specialists, even for minor health problems. Initiatives and supporting the long-term sustainability of the to bolster primary care, combined with hospital system. bed closures, should help to tackle this source of inefficiency. Although the number of acute care beds In response to the shortage of health has decreased by 10 % over the last two decades, professionals salaries are increasing their number is still high, at 6.9 per 1 000 population in 2017 – well above the EU average of 5 per 1 000 Romania is facing a shortage of health professionals population (Figure 18). (Section 4). Among doctors, shortages are especially severe for GPs – a phenomenon linked to poor pay and
Figure 18. Hospital bed numbers have been falling but remain among the highest in the EU
Romn Beds ALOS EU Beds ALOS Beds per 1 000 populton ALOS (ds) 8 10
7 8
6 6
5 4 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Source: Eurostat Database.
20 State of Health in the EU · Romania · Country Health Profile 2019 % of d sur eres 100 Source: OECD Health Statistics 2018; Eurostat Database (data refer to 2006 and2016, ornearest year). Note: 1.Nodata available for Romania for 2006. Figure 19. Day surgery isnot common inRomania legislation was passed in2017. the implementation ofthese plans, andtherelevant health care provision has provided animpetus for Linking EUStructural Fundstothereorganisation of health, education, employment, andhousing services). integrated service packages (incorporating social, population needsassessmenttocreate appropriate 2017) isenvisaged asatoolthat usesystematic will institutional Collaboration Protocol (approved July integrated community healthcentres. The inter- seeks toaddress someoftheseissuesby developing other services. The NationalHealthStrategy 2014-20 integration extendsto thelinksbetween healthand multimorbidity orchronic conditions. The lack of delivered thatare insiloes totreating ill-suited efficiency, withmostspecialisedhealthcare services Poor integration isalsorecognised ashampering has become apolicyfocus Increasing the integration ofservices EU (Figure 19). setting in2016, oneofthelowest percentages inthe cataract surgeries were performed inanoutpatient Romania isthesameasEUaverage, only 32%of share oftonsillectomies performed inday surgery in greater forsome utilisation procedures: the while is alsobeing expanded. However, there isscopefor use ofday surgery forselected procedures inRomania To increase theefficiency ofthehealthsystem, the 80 60 90 40 20 50 30 70 10 0 Romn Ctrct EU State of Healthin the EU ·Romania ·Country HealthProfile 2019 Romn In unl hern dimensions. assessment, yet only forsomespecific performance International surveys thenserve asa proxy for or the provision offeedback todecision makers. nor dothey supporttherapid evaluation ofneeds allow health priorities tobeidentified ortracked, evaluated. Current informationsystemsdonot the healthsystem’s performance isnot generally government objectives are being metbecause It is particularly difficulttoassess whether and leading tofragmentation andreform paralysis. 10 presidents oftheNHIH, undermining continuity since 2009, there have been15ministersofhealthand in Stability governance hasalsobeenachallenge: issues, attheexpenseoflong-term performance. having focusedexcessively onaddressing financial stakeholders have seen policies implemented as as fragmented and poorly coordinated. In particular, perceived by patients andhealthcare professionals stepped upinrecent years, the process hasbeen While plans forreforming healthcare have been major challenges for the reformprocess Stability andcoordination have been EU Romn Tonsllectom 2006 EU 2016 21
ROMANIA 6 Key findings ROMANIA • Life expectancy in Romania is among • Most health spending is publicly funded the lowest in the EU and, although it has (79 %), but the share of out-of-pocket increased since 2000, it remains almost six expenditure (around 20 %) can be years below the EU average. High preventable substantial, particularly for vulnerable mortality and avoidable deaths from treatable people. Most out-of-pocket spending is on causes indicate scope for improvement in pharmaceuticals. Besides cost, the unequal tackling risk factors and in the effectiveness of distribution of health facilities and health health care services. Life expectancy at birth workers poses barriers to accessing care, varies substantially by gender and education. especially for those living in rural areas. In particular, men with the highest level of Current gaps in population coverage for education live ten years longer than those social health insurance also leave certain with the lowest education. groups exposed, such as people without an identity card (affecting the Roma population • Behavioural risk factors are widespread and disproportionally), people without income constitute a serious threat to population who are not registered for social benefits, or health. Poor nutrition and lack of physical those in the informal economy who do not activity are major concerns. Although adult declare their incomes. obesity rates are among the lowest in the EU, overweight and obesity levels among • Health workforce shortages remain critical, children have increased significantly in recent with the number of doctors and nurses among years. Over 30 % of men smoke (but only the lowest in Europe. In 2018, the government 8 % of women), and regular smoking among addressed this under an Emergency teenagers is also high. Alcohol consumption Ordinance with substantial and rapid is heavy, with 50 % of men engaging in binge increases in pay, which more than doubled drinking regularly. There have been no recent junior doctors’ salaries in public hospitals. initiatives on alcohol and it remains to be This was a response to protests and it is hoped seen if the new tobacco regulation introduced that improved pay will help to retain medical in 2016 will be effective. personnel and reduce emigration.
• Health spending is historically low and less • Romania’s health system is also challenged than in any other EU country, both in per by governance issues. There is no systematic capita terms and as a proportion of GDP performance assessment, and transparency (5.2 % of GDP in 2017 compared with an EU is generally lacking. There have been frequent average of 9.8 %). The underfinancing of the changes in leadership, with more than a system undermines Romania’s ability to meet dozen health ministers over the last decade, current population needs, which will become as well as frequent changes in the leadership increasingly challenging as the population of the National Health Insurance House. This ages and the resource base shrinks. undermines stability, coordination and the progress of reforms. • The limited spending is skewed towards hospital and inpatient care. This helps to explain why primary and community care
remain underdeveloped. Health service inefficiencies, including the oversupply of hospital beds, underdevelopment of day surgery and poor care integration exacerbate the situation. The National Health Strategy 2014-20 and financial incentives from the EU support the delivery of services in the most cost-effective settings and aim to improve links across health care, as well as to other sectors.
22 State of Health in the EU · Romania · Country Health Profile 2019 Key Sources
Vlãdescu C et al. (2016), Romania: Health System Review. OECD/EU (2018), Health at a Glance: Europe 2018 – Health Systems in Transition, 18(4): 1–170. State of Health in the EU Cycle, OECD Publishing, Paris, https://www.oecd.org/health/health-at-a-glance- europe-23056088.htm
References
Council of the European Union (2019), Council European Commission (2019b), Joint report on health Recommendation on the 2019 National Reform care and long-term care systems and fiscal sustainability Programme of Romania, http://data.consilium.europa.eu/ – Country documents 2019 update. Institutional Paper doc/document/ST-10176-2019-INIT/en/pdf 105. Brussels, https://ec.europa.eu/info/sites/info/files/ economy-finance/ip105_en.pdf ECDC (2018), Surveillance of antimicrobial resistance in Europe, Annual Report of the European Antimicrobial European Commission (DG ECFIN)-EPC (AWG) (2018), Resistance Surveillance Network (EARS-Net) 2017. The 2018 Ageing Report – Economic and budgetary Stockholm, https://ecdc.europa.eu/en/publications-data/ projections for the EU Member States (2016–2070), surveillance-antimicrobial-resistance-europe-2017 Institutional Paper 079. May 2018. Brussels.
European Commission (2018), The ESPN Report Iftimoaei C, Baciu I C (2018), Statistical analysis of ‘Inequalities in access to health care’ Synthesis Report. external migration after Romania’s accession to the Brussels, https://ec.europa.eu/social/main.jsp?pager. European Union. Romanian Statistics Review, 12/2018, offset=25&advSearchKey=ESPNhc_2018&mode=adva National Institute of Statistics, Bucharest. ncedSubmit&catId=22&policyArea=0&policyArea Sub=0&country=0&year=0 Rechel B, Richardson E, McKee M, eds. (2018), The organization and delivery of vaccination services in European Commission (2019a), Country Report Romania the European Union. European Observatory on Health 2019. 2019 European Semester. Brussels, https:// Systems and Policies and European Commission, ec.europa.eu/info/sites/info/files/file_import/2019- Brussels, http://www.euro.who.int/__data/assets/pdf_ european-semester-country-report-romania_en.pdf file/0008/386684/vaccination-report-eng.pdf?ua=1
Country abbreviations
Austria AT Denmark DK Hungary HU Luxembourg LU Romania RO Belgium BE Estonia EE Iceland IS Malta MT Slovakia SK Bulgaria BG Finland FI Ireland IE Netherlands NL Slovenia SI Croatia HR France FR Italy IT Norway NO Spain ES Cyprus CY Germany DE Latvia LV Poland PL Sweden SE Czechia CZ Greece EL Lithuania LT Portugal PT United Kingdom UK
State of Health in the EU · Romania · Country Health Profile 2019 23 State of Health in the EU Country Health Profile 2019
The Country Health Profiles are an important step in Each country profile provides a short synthesis of: the European Commission’s ongoing State of Health in the EU cycle of knowledge brokering, produced with the ·· health status in the country financial assistance of the European Union. The profiles ·· the determinants of health, focussing on behavioural are the result of joint work between the Organisation risk factors for Economic Co-operation and Development (OECD) and the European Observatory on Health Systems and ·· the organisation of the health system Policies, in cooperation with the European Commission. ·· the effectiveness, accessibility and resilience of the The concise, policy-relevant profiles are based on health system a transparent, consistent methodology, using both quantitative and qualitative data, yet flexibly adapted The Commission is complementing the key findings of to the context of each EU/EEA country. The aim is these country profiles with a Companion Report. to create a means for mutual learning and voluntary For more information see: ec.europa.eu/health/state exchange that can be used by policymakers and policy influencers alike.
Please cite this publication as: OECD/European Observatory on Health Systems and Policies (2019), Romania: Country Health Profile 2019, State of Health in the EU, OECD Publishing, Paris/European Observatory on Health Systems and Policies, Brussels.
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