The COVID-19 pandemic has served as a magnifying glass on existing structural challenges of the Romanian health system – for example the low level of financing, considerable shortage of health workers, including of family physicians, and outdated hospital infrastructure. In response to the COVID-19 pandemic, the Romanian Government has purchased critical medical products and covered COVID-19 related medical costs. Additionally, access procedures have been adapted to the new context including the possibility of family physicians prescribing therapies and use of technology for medical prescriptions or consultations. Nevertheless, several categories of patients faced challenges accessing therapies, and this should be a priority for the Romanian authorities in 2021.
There is a momentum for real and sustainable reform and major health policies to be revised and adopted including the Public Health Strategy and the Operational Programme for Health.
Through cross-sector collaboration (public & private entities included), Romania can rethink and transform its health policies in order to increase patients’ access to healthcare. Important structural changes are needed, including an increase in financing and investments in the healthcare system, development of preventive, screening and early diagnosis programmes, employment of more health workers, enhancement of technology as well as improvement of the infrastructure, coverage and accessibility of health services to existing patients and citizens, in general.
The COVID-19 pandemic has led to thousands of patients being hospitalised, triggered a significant contraction of GDP of over 4% and left hundreds of thousands of people without jobs. Meanwhile, Romania has an aging population and a constant increase in the burden of non-communicable diseases, likely negatively influenced by pandemic-related limitations in accessing primary, secondary and tertiary healthcare services. Each citizen who is unable to work or who dies prematurely as a result of non-communicable diseases represents a loss of workforce participation and has an indirect impact on GDP, while workforce participation continues to decrease due to immigration. Moreover, Romanians are among the biggest groups of EU citizens living in other EU Member States, at over 3 million , while the country is facing a shortage of skilled employees.
Investment in healthcare is an investment in the human capital of the country, for the current generation but also for forthcoming ones. Optimised allocations and prioritisation of resources through evidence-based public healthcare policy investments are proved to have a positive return by saving lives and improving the quality of life, while promoting economic growth and increased productivity, as seen in other European countries. The economic return could be $2 to $4 for each $1 invested in better health. In higher income countries, implementation costs are more than offset by productivity gains in healthcare delivery. For example, funding of cancer control with capital investments and funding of services ensure equitable financial and geographical access to high-quality cancer services. Investment in an essential package of cancer services and activities could avoid 7.3 million deaths globally from cancer between 2020 and 2030 with gains for the broader health system and economic benefits for governments, families and individuals, along with intangible benefits for citizens. The costs of inaction and the return on investment in healthcare have not been properly analysed and considered over the past few years. According to recent studies, poor health reduces global GDP by 15 percent. Meanwhile, better use of currently available interventions, with demonstrated cost-benefit value, could bring down the global disease burden by about 40 percent over the next two decades.
The costs of inaction and the return on investment in healthcare have not been properly analysed and considered over the past few years. According to recent studies, poor health reduces global GDP by 15 percent. Meanwhile, better use of currently available interventions, with demonstrated cost-benefit value, could bring down the global disease burden by about 40 percent over the next two decades.
Romania has a unique opportunity in 2021 to build a new healthcare strategy, rebuild its economy and boost competitiveness. The main pillars in the Government’s healthcare program focus on: strengthening the role of prevention - vaccination programs included - rethinking the claw-back tax, expanding patients’ access to new therapies and increasing the number of healthcare professionals.
While significant efforts have been made in the last few years by the Romanian authorities to raise the quality of care and increase efficiency in the healthcare system, Romania needs more investment to close the current healthcare financing gap with other European countries, and also needs to implement e-health solutions aimed at supporting more efficiency and more transparency in its current expenditure. The World Health Organisation (WHO) has estimated that removing wasteful and ineffective treatments can deliver a 20-40% efficiency saving in health spending across Europe. Thus, the countries affiliated to the Organisation for Economic Co-operation and Development (OECD) could gain approximately two years life expectancy by reducing inefficiencies across their healthcare systems. Interventions such as early diagnosis and screening can be considered efficient if they help reach populations at highest risk, and lead to improved health outcomes .
An adequate level of funding for the healthcare system should be ensured with a gradual increase in the share of GDP allocated to healthcare, with a clear aim of reaching the European average by 2025. This strategy should include an effective merging of public and private funding. In terms of its current health expenditure relative to GPD, Romania is in last places among EU Member States. Considering the strong economic growth Romania has enjoyed during the last three years, the FIC considers that this performance should also be reflected in healthcare funding.
Healthcare authorities should change perspective and realize that healthcare is an investment in the country’s future and prosperity given that “health affects economic growth directly through labour productivity and the economic burden of illnesses, and indirectly since aspects such as child health affect the future income of people through the impact health has on education ”. For the first time, Romania will have an Operational Program dedicated to Health over the programming period 2021-2027.
Moreover, the financing mechanism that ensures access for Romanian patients to innovative therapies should be improved. While we acknowledge the efforts made by the Romanian authorities to include new innovative therapies in the reimbursement system in the last few years, Romanian patients still face significant limitations in terms of access to innovative treatments. Implementation of and adequate financing for the “Innovation Fund” program is essential.
There should be a gradual increase in the percentage of GDP allocated to healthcare, in order to close the gap between Romania and other EU countries in terms of healthcare financing, especially since Romania has one of the fastest growing economies in the EU .
Healthcare contributions should be collected more efficiently, and the contribution base should be widened by eliminating exemptions. According to Law 95/2005 several categories are exempted from social contributions such as: construction workers, retired people, the unemployed, persons receiving social assistance, priests and pastors etc, independently of their level of income.
New alternative funding solutions for healthcare should be identified, with a focus on private contributions, EU funds in the next programming period as well as public private partnerships.
Until the reform of the exemptions from healthcare contributions, funds should be transferred from the state budget to cover the exempted or uninsured population and funds collected from pharmaceutical taxes (claw back) should be reallocated, exclusively, to the medicines budget.
Predictability of the allocation of funding at subnational level - at the level of local health insurance authorities (case de sanatate)- should be ensured in order to provide patients access to treatments without restrictions and prevent potentially life-threatening fluctuations in access to healthcare services of adequate quality.
Procedures should be developed to improve allocation of funds between central and local public authorities.
Efficiency should be improved across the entire care pathway by support for access to screening and early diagnosis programs.
Resources should be leveraged for investments to be made in health infrastructure from diverse sources (e.g. from European Structural and Investment Funds, IFIs, and the private sector, including via PPPs).
The debts of all companies (either public or private) to the healthcare fund should be recovered and a mechanism to monitor their contribution should be put in place.
Digital tools (including electronic registries), aimed at creating more efficiency, control and transparency over the way the healthcare budget is spent, should be introduced.
More specifically, in the 2021-2027 programming period, the funding of health care and public health from European Structural and Investment Funds should focus mainly on the following areas of action:
The Innovation Fund programme should be developed and implemented with sufficient resources to ensure its success and sustainability.
In the short and medium term, the public healthcare system should be supported by adjusting the legal framework so that public clinics and hospitals can carry out private practice for privately insured medical services. This would attract additional resources for the public hospitals and would enhance patient satisfaction. In the medium and long run, health system reform should entail resizing the basic health insurance package and the reintroduction of co-payment. These measures would protect the long-term financial sustainability of the healthcare system and help the development of the private health insurance industry.
Introduced as a temporary measure in 2009 during the economic crisis and amended several times, the claw back tax has become a tool through which the pharmaceutical industry has been forced to take full responsibility for covering the reimbursed medicines funding deficit, in the context of severe under-financing of the reimbursed medicines budget. The claw-back tax was and still is difficult to bear by the Marketing Authorization Holders (MAHs) by themselves, as the tax is not shared by the whole distribution chain. More than 12 years since its adoption, medicine manufacturers/MAHs are still covering the full difference between the reimbursed medicines budget set by the budget law and the real consumption on the market. Up to December 2018, the calculation basis for this tax was a budget frozen at the level of 2012 (RON 6 billion), while the real consumption on the market was RON 1.5 billion higher.
On 20 December 2019, the Government approved an Emergency Ordinance, which increased the quarterly approved budget (BAT) for medicines covered by the Single National Health Insurance Fund (FNUASS) and the Ministry of Health’s budget. Specifically, starting from the fourth quarter of 2018 and until 31 December 2019, by applying the inflation indices calculated for 2012-2017 by the National Institute of Statistics, the BAT rose to RON 1.595 billion.
In May 2020, the Government approved an Emergency Ordinance, which increased the quarterly approved budget (BAT) for medicines covered by the Single National Health Insurance Fund (FNUASS) and the Ministry of Health’s budget. Specifically, starting from the 4th quarter of 2019, the BAT was increased to RON 1.688 billion, compared to the previous value of RON 1.595 billion. In March 2020, the claw back tax was capped at 27,65% for the first three months of the year through GEO no. 31/2020. On 15 May 2020, Law no. 53/2020 was published in the Official Journal of Romania which introduces a differentiated claw back tax. The law makes significant and long expected amendments to GEO 77/2011 by introducing a differentiated claw-back tax.
Specifically, starting from the first quarter of 2020, the claw-back tax will be paid by considering three types of medicines:
These measures aim to improve the sustainability of the public health system through the efficient use of the allocated funds and also to encourage the introduction of new innovative medicines, together with the maintenance on the market of various innovative and generic medicines (for example, for generic medicines the lowest percentage is applied) which were at risk of being withdrawn from the market. According to the law, when medicines are manufactured in Romania, they should fall into Type II, regardless of whether they are generic or innovative medicines. In each case, the percentage will be applied to the centralised consumption of the relevant medicines communicated by the National Health Insurance authority (Casa Nationala de Sanatate).
The list of the three types of medicines should be published quarterly through an order issued by the Ministry of Health, and no later than 25th of the month following the end of a quarter. For the first quarter of 2020, the list was not published, and the National Health Insurance authority sent the notifications of the total consumption in accordance to the former provisions of the law, leaving the MAHs/legal representatives of the MAHs not knowing which percentage to apply.
Therefore, some of them applied the new differentiated claw-back tax while others applied the percentage according to the National Health Insurance authority’s notification. For the second three months of 2020, the list was published in July 2020 through an Order issued by the Ministry of Health, while for the third three months the list was published in November 2020. Over the years, before the introduction of the differentiated approach, the tax reached unprecedented levels, far more than in any other country in the EU which uses this type of taxation system.
Even in the context of the latest regulations, the FIC considers that this mechanism is unsustainable, and the tax is no longer justified considering the impact it generates on the availability of medicines on the Romanian market as well as the fiscal burden on manufacturing companies. The claw-back tax in its present form continues to have a disproportionate impact on the pharmaceuticals sector, with a corresponding negative effect on investment and the availability of medicine on the local market. Considering a long-term perspective, the next step which could be made in this sense could be the total elimination of the tax. This could bring major economic benefits for the Romanian health sector and significant improvements in the quality of care.
The FIC considers that the reimbursed medicines budget should be readjusted to cover the real needs of the Romanian healthcare system, considering that after more than 12 years, the drug industry continues to cover this deficit with the claw back tax. This tax has generated and continues to have negative effects on the availability of medicines on the market and adequate and sustainable funding of the medicines budget must be ensured to improve patients' access to the medicines they need.
Even though the legislators’ intentions for the claw back tax was to be introduced as a temporary measure (i.e. as a financial solution during the economic crisis), it has effectively been made permanent, as it has been applied for more than 12 years, and it has made it a challenge for patients to access medicines. Even though the FIC welcomes the new differentiated claw back tax as a step in the right direction, we believe that the claw back tax should be abolished entirely or at least replaced by a newly reformed claw-back mechanism and the lack of adequate budget funding for reimbursed medicines to be addressed through fair budgeting, in line with real market needs.
In the short term, the claw-back tax should be revised to make it more predictable, taking into consideration that currently there are many court disputes generated by the lack of transparency in its calculation. Hence, it should exclude pharmacy and wholesaler margins and should be applied to the producer’s price. Further improvements could include the elimination of the claw-back tax for essential cheap medicines, in order for the population to have better access to them, and also the adjustment of the quarterly budget by the annual registered inflation index.
Funds raised from the claw-back tax should be used exclusively for the reimbursed medicines budget and multi-annual budgeting should be introduced to increase predictability.
The budget allocated to medicines should be reconsidered to reflect the real consumption on the market while hospital consumption should be excluded from this tax.
Finally, in order to increase transparency, the healthcare authorities should allow an independent audit of the data on which the claw-back tax is calculated.
An immediate beneficial measure to ensure access for patients to innovative treatments would be the active encouragement of cost-volume / cost-volume-result agreements and the development of new facilitated access schemes. Such agreements have proven to be an efficient means of cooperation between state and private companies for the benefit of patients and should be encouraged more.
We recognise the progress made by the authorities on access of Romania patients to innovative treatments and medicines but there is still a considerable gap between Romania and Western European countries.
According to the European Federation of Pharmaceutical Industries and Associations (EFPIA) W.A.I.T. indicator study, only 21% of recently approved medicines are available to patients in Romania. In contrast, nearly 85% of all medicines newly authorised by the European Medicines Agency (EMA) are available to patients in Germany. Moreover, on average, it takes 812 days to achieve permanent reimbursement in Romania after the approval of the European Medicines Agency (EMA), almost 8 times longer than in Germany . Meanwhile, the main healthcare indicators continue to be much lower in Romania than in other European countries. In Romania, 5-year survival rate for breast cancer is around 50%, while in Finland, Iceland and Sweden it is 89% .
In the case of lung cancer, the 5-year survival rate is only 11%, while in Switzerland it is around 21%. Improvements in survival rates require additional investments in early diagnosis and fast access to innovative treatments. This difference is caused partially by the delays in the reimbursement process. In the past couple of years, the reimbursement list has been updated several times and, thus, some innovative medicines have become available for Romanian patients.
Nevertheless, the process continues to be slow, for several reasons: one problem is that in some cases, the updating of the reimbursement list is postponed in the absence of clear timelines in national legislation. Moreover, after some medicines are included in the reimbursement list, prescription protocols are often released very late (in some cases more than 4-5 months after the decision for inclusion on the list of reimbursed medicines).
New mechanisms for access to innovative medicines have been put in place and the budget for innovative medicines, financed through cost-volume and cost-volume-result contracts, has been increased. These mechanisms are increasing access to new therapies, covering areas like oncology, hematology, rare diseases and cardiovascular diseases, under conditions of efficiency, financial sustainability and predictability of costs in the health system. With the progress of medical technology, an increased number of state-of-the-art therapies have been approved by the EMA. The 57 medicines launched between 2014 and 2018 have now gained 89 indications across 23 different cancer types . In this respect, central and local authorities had faced new challenges in the absence of legislative changes.
However, at the level of hospitals there are barriers to treatment due to difficulties in getting the proper budgetary allocation from regional health authorities as well as different procedures and understanding of the public procurement procedures applicable for the medicines included in the cost-volume contracts.
Access for Romanian patients to innovative treatments should be a national priority, whatever government is in power.
The national health authority’s budget for medicines should be correlated with GDP growth and updated yearly.
The new HTA methodology should minimise the gap between treatment options available in Romania compared with other EU countries.
Approval timelines for clinical trials should be minimised in order to allow fast access to innovative therapies and reduce the gap between Romania and other EU countries.
New Managed Entry Agreements together with electronic registries should be put in place.
Value based healthcare principles and mechanisms should be adopted by healthcare authorities.
Multi-year-multi-indication (MYMI) agreements should be Implemented to expend access to innovative medicines and create predictability for the national health budget.
Legislation for home delivery of medicines should be introduced, especially considering the context of the Covid 19 pandemic and the issues it has generated around access to care but also as a solution to increase patient access and facilitate treatments in a faster and more efficient manner.
There should be better predictability of the funds allocated for the implementation of cost-volume contracts at regional level.
Guidelines on the procurement and financing of medicines included in cost-volume contracts should be issued by the National Health Insurance authority and the National Authority for Public Acquisitions.
Prevention and vaccination policies and campaigns should be promoted.
New legislation should be passed on Mental Health and a national strategy should be adopted in this area in order to respond to the current needs of patients and the population. A proper national infrastructure should be developed.
New legislation should be passed on Mental Health and a national strategy should be adopted in this area in order to respond to the current needs of patients and the population. A proper national infrastructure should be developed.
Molecular tumor boards (MTB) should be implemented as a way to work in oncology.
The testing program for more personalized treatments should be expanded, including testing capacity in more hospitals, increasing the capacity of hospitals for treatment and diagnosis in oncology, hematology, bone marrow transplantation center, etc.) but also ensuring adequate funding between these activities.
Screening programmes should be introduced for the early detection of serious diseases like cancer, tuberculosis, diabetes, and hepatitis, which represent a huge burden for the healthcare system.
New pricing methodology should be introduced avoiding minimum European prices, to help ensure the availability of medicines on Romanian market
The Romanian National Health Insurance authority has developed three major projects related to e-health. Two of them have been financed with European Union funds: the e-prescription (implemented in 2012) and the electronic health record (implemented in 2014). One is self-funded – the e-health card (introduced in May 2015). Currently, the electronic card is the only way to obtain prescription medicines. Moreover, all reimbursed medicines are available only through this card, which is the access key to the national health insurance system (except for emergency medical services). All these systems are integrated into the existing centralised sole integrated information system (SIUI). The Reporting and e-Invoice project started in 2013 as part of the extension of the SIUI system to Romania. It includes a web-based connection of health institutions for reporting purposes (including expense forms and invoices). Reporting of activity and subsequent invoicing is carried out based on xml and zip uploads (by type of activity) made by medical providers.
Despite the integrated systems, there are many complications which generate problems in data crosschecks and delays of several days in processing information.
1. The e-Prescription - SIPE (Sistemul Informatic de Prescriptie Electronica) project started in 2012 and became operational in 2014 under the regulation of the national health authority for the public and private medical sector (under contract from the national health authority). The objective of SIPE is to track patients’ medical records, report payments and prevent fraud. Currently the platform manages subsidised prescriptions. The system continues to malfunction frequently, affecting the activity of healthcare professionals and the way data is centralised; a platform registers all these setbacks (www.siui-monitor.ro).
2. The patients’ electronic health files project (DES), launched in 2014, aims to include information on medical treatment as well as on each patient according to the health e-Card stored data. The most important feature should have been the electronic medical registry of all the patients in the country. Even though a Government Decision has been issued that all doctors should upload the information about patients, only those doctors who are under a contract with the national health authority are doing it. The accuracy of data in the system should be improved by the extension of monitoring to the overall prescription process.
3. The e-Health cards began to be distributed from September 2014. However, the data registration on the card is limited or non-existent. The card is used for accessing medical services and authentication of the patient. Even though the use of e-Health cards is mandatory in Romania, there are still several medical units that do not have card readers.
Future developments envisaged by the Ministry of Health: a) The possibility for e-Prescriptions issued in Romania to be used anywhere across the EU to buy prescribed medicine; b) A single platform to be launched in the next few years (based on EU funding) with the aim of jointly organising patients’ electronic health files and the list of medical service providers available for the medical investigations required by patients as per the e-files. A list of over 100 e-files will be prepared and uploaded on to this platform in time for its introduction.
In 2020, during the COVID-19 pandemic, various measures were taken which aimed to ensure safe access to medical services for doctors and patients, by limiting travel and interaction with others. Thus, for the period of state of emergency and alert, the obligation to use the national health card was suspended so that patients could avoid an extra physical visit to the doctor in order to obtain, for example, a prescription. Consequently, in order to have a consultation with the doctor but avoid a physical meeting, the patient and his/her doctor have the option to have a medical conference / videoconference based on which the patient can obtain medical advice virtually and be given electronic prescriptions.
So, doctors have been able to send an e-prescription to the patient, based on his/her medical history, by e-mail, or even through various mobile applications, in situations in which the patient’s medical problems can be handled remotely. This can be considered significant progress, and is an important step towards the development of telemedicine in Romania. The COVID-19 situation accelerated the digitalisation of Romania’s healthcare system, helping patients and doctors to minimise physical contact. However, the legislation still needs updating to adapt Romania’s health system more closely to the new situation in which where online communication and digitalization has become vital.
The adoption of legislation on telemedicine which would make remote medical consultations part of the minimum and basic packages of medical services would be an important step forward.
The FIC recommends that the healthcare authorities should adopt a Healthcare Digital Strategy, following models from other European countries. The healthcare authorities should urgently implement a more efficient digital system considering the current state of the healthcare system in the context of the COVID-19 pandemic.
The current legislation still needs to be updated to ensure a legislative framework which would cover on-line communication at various levels in the healthcare system, covering each segment of activity or sub-activity.
Electronic registries should be developed and introduced as soon as possible to create more efficiency in the way financial resources in healthcare are spent, increase transparency and gather supporting data for better healthcare policy decision making.
The reporting requirement should be introduced as soon as possible, irrespective of whether or not the doctor has a contract with the national health authority. It is important that all medical records from all medical care providers should be available in the database.
Thus, further steps should be taken on the implementation of the patients’ electronic health files project (DES), launched in 2014 and currently in a permanently offline state. In addition, negative feedback has been received from healthcare professionals and also healthcare organisations with respect to DES. Specifically, the electronic health file collects insufficient information from few sources which do not hold the entire medical history of the patient.
With respect to the e-Prescription and e-Health cards, further issues relating to maintenance and dysfunctionalities of the digital infrastructure should be addressed, as the systems have not worked well. Disruptions have led to patients being unable to receive prescriptions and examinations not being registered in the system.
A 24/7 professional maintenance service is also a paramount requirement to ensure a functional system that would ease the operational burden on doctors.
Interoperability, common standards and data sharing to private health care payers of medical records (rights and health expenses) should be enabled and extended to facilitate payment for medical services and medication in addition to the basic package.
Thus, the adoption of patient registries should be included in the government healthcare strategy, integrated with the other e-Health tools already introduced and should be seen as an important milestone in creating data to support healthcare policy decisions while generating more efficiency and transparency in budget resource allocation.
More steps should be taken in the immediate future in implementing telemedicine in the national health system. Although, as mentioned above, a Government Emergency Ordinance was issued setting the framework for telemedicine in Romania, given the pandemic situation, in order to ensure more efficient implementation, the healthcare authorities should prioritise and develop a Centralised Digital Healthcare System which should facilitate access for healthcare professionals to patients’ medical history (i.e. prescriptions, diseases, hospitalisation, previous examinations etc.).
Romania faces a major crisis caused by a lack of healthcare professionals: in 2017 there were an average of 2.9 healthcare professionals per 1,000 inhabitants, compared to the EU average of 3.70. and an average of 6,7 medical assistants per inhabitants, compared to the EU average of 8,5. Moreover, there is a major imbalance in the distribution of medical staff between regions of Romania and within the same region between counties (for example, a significant number of counties have less than 2.6 doctors per 1,000 inhabitants, while some have less than 1 doctor per 1,000 inhabitants). In 2017, 55,600 healthcare professionals emigrated from Romania. In the last few years, there were more physicians leaving the country than new graduates, so the situation is likely to deteriorate further. The low level of access to healthcare professionals due to migration has a direct effect on the long-term health of Romanian citizens. Moreover, the lack of specialists in public health severely restricts the possibilities for reform of the healthcare system. Even though medical investments and total healthcare expenditure are very low in Romania compared to the EU28 , in 2018, the Romanian Government raised salaries, in order to increase the number of healthcare professionals and also to reduce migration.
However the increases were only given to medical doctors who work in public hospitals. Consequently, the FIC believes that it is still critical for the authorities to take steps to deal with this problem, bearing in mind that a healthy business environment depends on a healthy community.
Moreover, the COVID-19 situation has put a lot of pressure on medical systems worldwide, including in Romania. Consequently, in order to motivate the healthcare professionals involved in the fight against COVID-19, a series of salary increases of between 5 and 30% have been granted to healthcare professionals directly or indirectly involved in the transport, diagnosis and treatment of patients infected with COVID-19.
Performance related pay should be introduced in the healthcare sector. The number of available places in medical schools should be increased to bring training of medical professionals into line with the population’s real health needs.
The access of healthcare professionals to continuous professional development should be improved. The social importance of healthcare professionals should be acknowledged and the role of professional associations in reforming the system should be enhanced. The healthcare system can only be reformed by healthcare professionals.
FIC recommends better training, continuous medical education, higher performance indicators and standardised evaluation processes will lead to better performance of healthcare professionals, enabling them to gain a better image, respect and public recognition. Having in mind all of these elements and wanting to contribute to the reform of the Romanian healthcare system, FIC continued the projects dedicated to doctors, started in 2013 when it initiated in partnership with the Ministry of Health the development of several projects dedicated to medical staff in order to draw attention to the exodus of doctors, continuing with a series of courses dedicated to students and residents in the medical field, and in 2019 and 2021 organizing courses for hospital managers through the project "Leaders for Excellence in Healthcare".
However, a higher budget allocation for salaries is ultimately essential to ensure the retention of healthcare professionals.
The public health system should be decentralised, as this would also lead to more entrepreneurial management of each medical facility and higher staff retention rates. National academic evaluating committees should be set up to issue mandatory professional criteria and curricula per speciality and set up the basis for a more accurate and consistent professional evaluation process.
There is a need for national, regional and international cooperation in the development and implementation of the best policies in relation to evidence-based strategies for human resources in health. Currently, the Ministry of Health does not cooperate and communicate with the NGO sector. This should be changed. For years, several reputable NGOs have been developing training programmes for medical professionals, and innovative services for patients, as well as setting out standards and treatment guides. These NGOs have also been lobbying for better access to treatment and improved patient care. The Ministry of Health should become more open to the expertise developed by the NGO sector. It could allow for a percentage of its programmes (especially in prevention, health education, training and patient support) to be developed and implemented in partnership with civil society, according to national health strategies and plans and keeping in touch with the needs of local communities.
The Ministry of Health should become more open to the expertise developed by the NGO sector. It could allow for a percentage of its programmes (especially in prevention, health education, training and patient support) to be developed and implemented in partnership with civil society, according to national health strategies and plans and keeping in touch with the needs of local communities.
The National Healthcare Strategy provides for extensive measures designed to alleviate the impact of migration of doctors and ultimately to reverse the trend. These measures are set out in the second appendix of the strategy and should be implemented as soon as possible.
The information flow on health workers needs to be improved by adjusting the mechanism of collecting, processing, analysing and disseminating data on human resources in health so that the planning and distribution of the workforce is carried out correctly. Furthermore, we need to support human resources analysis and research activities to identify evidence-based policy options.
Since 2013, when FIC started developing several projects dedicated to the medical staff to draw attention to the doctor’s exodus, continuing with a series of courses dedicated to students and residents in the medical field, then focusing on hospital managers through the project "Leaders for Excellence in Healthcare”, FIC strongly believed that in order to improve the medical system, special attention needs to be paid to the development of health professionals.
Public Health in Romania could significantly benefit from a shift of the healthcare system towards prevention and health promotion, while developing the capacity of the Romanian healthcare system to decrease the burden of disease through prevention and early detection.
While health promotion and health education is the cornerstone for prevention, healthcare indicators show that mortality from preventable and treatable causes is very high in Romania as a result of chronic systemic focus on curative services. Access to preventive care was suboptimal, and undersized for several decades in Romania. According to the latest studies , the preventable mortality rate is the fourth highest in Europe. The main causes of preventable mortality are ischaemic heart disease, lung cancer, alcohol-related deaths and accidents. Currently, most resources are allocated to hospital care, but a proactive and robust Public Health System, prepared to address current as well as future health needs, should keep an appropriate balance between curative healthcare (whether inpatient or outpatient) and preventative care. With only 1.8 % of health expenditure allocated for prevention, Romania ranks last in the EU .
Prevention-oriented interventions mainly focus on supporting national vaccination policies, while those aimed at increasing the level of health education among the population of all ages in relation to risk factors, healthy behaviour, and about health promotion in general are poorly financed and implemented. While the complexity of treatments offered by the healthcare system increases year after year, health literacy among the general public is poorly and only sporadically supported, starting with the youngest ages. A low health literacy level, which it not necessarily related to socio-economic status, constitutes a barrier to the adoption and pursuit of healthy behaviours and even to accessing curative care services.
According to the WHO, “Health literacy implies the achievement of a level of knowledge, personal skills and confidence to take action to improve personal and community health by changing personal lifestyles and living conditions. Thus, health literacy means more than being able to read pamphlets and make appointments. By improving people’s access to health information, and their capacity to use it effectively, health literacy is critical to empowerment.”
The WHO has called upon governments to assume the leadership in “providing the foundation on which citizens are enabled to play an active role in improving their own health, engage successfully with community action for health, and push governments to meet their responsibilities in addressing health and health equity”.
The report “The power of European patients - options and implications”, published in Brussels, shows that Romanian patients are among the least informed in Europe, occupying only 30th place in a ranking of European populations. While countries such as Germany, Italy, Spain and Portugal pay more attention to the concepts of “health literacy”, “medical literacy” and “health knowledge”, in Romania they are seldom in circulation even among professionals. Moreover, the European Health Literacy Survey shows that 1 in 10 European citizens (12.4%) has inadequate health knowledge, with considerable differences both between EU Member States and within different regions at national level and between urban and rural. The same study shows that an inadequate level of medical knowledge exists mainly among people with poorer health, who use a higher number of health care services, have a low socio-economic status and who are older.
The highest prevalence of low health literacy was observed among people with “very bad” or “poor” self-perceived health status (78.1% and 71.8%, respectively), those with more than one long-term illness (61%) and those who report six or more visits to the doctor during the last 12 months (58.9%). In conclusion, poorer health and therefore higher demands for health services seem to be accompanied by lower levels of health education. Although Romania organised a national health strategy in 2014-20 with the aim of improving health education and promotion, access to these continued to be suboptimal in general and unequal, especially within vulnerable groups.
The Ministry of Health (MoH) has set up a Health Promotion Working Group including, besides its own experts, representatives of the Ministry of Education, the National Public Health Institute, the WHO, UNICEF and the FIC. The working group has finalised the detailed version of the National Programme for Health Promotion (PNPS) as well as a draft of a Government Decision for the approval of the plan and for the setting-up of a National Coordination Mechanism for Health Promotion.
The PNPS aimed to develop, for the first time in Romania, a unitary, multi-sectoral and integrated concept of health promotion at national level, aligned with the UN Sustainable Development Goals and with the key principles of the WHO. The plan aimed a strategic framework for:
The National Public Health Strategy 2021-2027 should aim to decrease the mortality rates from preventable and treatable causes while promoting health literacy and vaccination by use of evidence-based, cost-effective interventions.
Sustainable development of the prevention and health literacy-oriented pillar of the health sector should start with institutional and professional capacity building, especially of the Public Health Network, of the Education Network and of local public authorities as well as collaboration with the Ministry of Education and civil society organisations.
Health Literacy should be prioritised within public health policies as it has the potential to increase effectiveness across a multitude of other dimensions. A dedicated National Health Literacy Strategy should be developed to target age-groups by specific communication channels and with tailored health messages. It is time to progress from sporadic health education and health prevention interventions towards more systematic and holistic approaches, that are also adapted, as appropriate, to the high tech and digitalization era we are currently living in.
Enough human and financial resources should be allocated to increase the level of health literacy of the Romanian population – especially in rural areas and those underserved by medical professionals. A partnership with the Ministry of Education and introduction of dedicated school programmes, following models from various EU countries, could be an efficient solution, which would bring significant future benefits to society.
Local public authorities should be involved in and prioritise implementation of health literacy programmes targeting the high burden diseases, such as cardiovascular disease, diabetes and cancer. Health Literacy activities should adjust to the dynamics of the prevalence of preventable diseases and cover those with the highest burden. Besides cardiovascular disease, cancer and musculoskeletal disease, depression has become one of the top reasons for disability in EU countries. Romania is no exception and should step up its efforts to bring the mental healthcare system up to date. Moreover, Romania should focus on reducing the burden of tuberculosis, with a focus on the multimedicine resistant (MDR-TB) type.
The development of strategic documents such as the Multiannual Plan for Health Promotion should support the subsequent optimisation of financing for health promotion and disease prevention and health promotion programmes. Funding should not be limited to the Ministry of Health’s budget, but should also include EU funds, local authorities’ budgets and contributions by other governmental authorities or private organisations.
Large education projects funded by the EU could be an important measure for preventing chronic diseases by stimulating a healthy lifestyle. Partnership with civil society organisations and scientific societies could bring benefits. Education about a healthy lifestyle could be the first measure to prevent chronic diseases, for example: specific school curricula for a healthy lifestyle, with the support of the Ministry of Education.
Vaccination is one of the most effective public health tools. It has made a major contribution to the control of infectious diseases. A life course approach to vaccination recognises that for optimal public health and societal impact, vaccine coverage needs to reach beyond childhood. For example, seasonal influenza has a major impact on sick leave. Vaccines in development against common healthcare-associated infections may reduce mortality and shorten hospital stays among people of all ages, but particularly the elderly, by preventing these serious infections.
The World Health Organisation (WHO) advocates a life course approach to vaccination for the benefit of all individuals and healthcare systems. Preventing disease in children, adults, and seniors reduces its transmission, improves quality of life, reduces absenteeism, and contributes to economic growth.
In the context of increasing pressure on healthcare budgets and an ageing population, vaccination contributes to the sustainability of healthcare systems by reducing the burden of infectious diseases and avoiding unnecessary use of financial and human resources, making them available for other medical interventions.
Priorities for vaccination: