ROMANIAN HEALTH SYSTEM S REORGANIZATION UNDER THE GLOBAL ECONOMIC CRISIS. ANALYSIS AT EUROPEAN, NATIONAL AND REGIONAL LEVEL

Transcription

1 International Research Journal of Applied and Basic Sciences. Vol., 2 (7), , 2011 Available online at ISSN X 2011 ROMANIAN HEALTH SYSTEM S REORGANIZATION UNDER THE GLOBAL ECONOMIC CRISIS. ANALYSIS AT EUROPEAN, NATIONAL AND REGIONAL LEVEL ROXANA CRISTINA RADU 1, MARIUS CRISTIAN NEAMŢU 2 AND OANA MARIA NEAMŢU 3 1- Faculty of Law and Administrative Sciences, University of Craiova, Romania. 2- University of Medicine and Pharmacy, Craiova. 3- Faculty of Physical Education and Sport, University of Craiova. *Corresponding author: rocxaine@yahoo.com Abstract: In the context of global economic crisis, Romanian health system is undergoing a reorganization process that presents controversial issues, both positive, and especially negative. According international statistics, Romania is not placed on enviable positions in terms of health system s performance indicators: the share of health expenditure of GDP, the level of medical spending per capita, number of hospital beds and medical staff reported to the population, distribution of types of hospitals and other health care facilities in urban and rural area, access to medical services, infant mortality rate, natural growth, etc. By analyzing these indicators at European, national and regional level, the authors intended to measure Romanian health system s performance and determine the causes of non-performance, in order to identify new methods to improve the medical act and increase population s access to medical services. Key words: Assistance, Health, Insurance, Medical, Service. INTRODUCTION After the Revolution of 1989, health reform has advanced more difficult in Romania, unlike other countries of Central and Eastern Europe (Avram et al., 2007; Preda, 2002; Mărginean, 2006; Popescu, 2004). Health system in Romania is lagging behind in terms of its reform and health reform initiated by the Ministry of Health, had many failures, due to lack of coherence and budgetary funds, aggravated by global economic crisis (Bompa and Porojan, 2010; Radu and Avram, 2011). For these reasons, the health system has not contributed to the increasing of quality health care, the widening of access to care, increasing life expectancy and lowering mortality and morbidity indicators. Much of the population is virtually excluded from effective access to health services because of financial and transportation difficulties (Zamfir et al., 2010). A number of specific health and demographic indicators still place us on last positions in European ranking. Budgetary allocations for health and total expenditure on health for each inhabitant puts us in the last position among EU countries during 2006-present, while in period Romania held the penultimate position, ahead of Estonia (Bompa and Porojan, 2010). MATERIALS AND METHODS Our research focuses to fulfill the following desiderata: identifying the difficulties faced by the Romanian health system before and after the global economic crisis; defining the main objectives of the reorganization of hospitals, medical structure and stuff. The final objective, after studying the statistics, legislation and the official sites of the Romanian Ministry of Public Health and the Romanian Government, is to discover the steps to make Romanian health system to be modern, efficient and competitive. Last but not least, the intention of this paper is to stimulate debate on a subject

2 closely related to the well-being of citizens and social development of Romania and is motivated by the fact that there are no previous works in this field. RESULTS AND DISCUSSION Romanian Constitution provides to every person, regardless of the employer status, the right to health care by placing certain firm obligations to the responsibility of state, who must take measures to ensure hygiene and public health (Article 33). In recent years, it seems that the Romanian government could not discharge that obligation in a satisfactory manner, especially during the economic crisis. Against the background of chronic underfunding, health system performance and medical services are of poor quality, with negative effects on the efficiency with which people s contributions to the social security system are spent. According to statistics of international organizations, Romania is not placed on enviable position in terms of health system s performance indicators. Thus, the share of health spending has exceeded 10% of gross domestic product (GDP) in Germany and France (2007), the amount being almost twice the rate registered in Romania (under 6% of GDP). Disparity is even greater in terms of level medical expenses per capita, which reached a value of 635 in Romania, compared with 4280 in Luxembourg. Although differences in organization systems and healthcare financing from EU Member States are extremely high, these data suggest that Romanian citizens spend less on goods and health care than individuals who live in those Member States with a higher level of average income per capita. Although differences in the organization and financing of healthcare systems in EU Member States are extremely high, these data suggest that Romanian citizens spend less on health care goods and services than individuals who live in those Member States with higher average income per capita ( Bompa and Porojan, 2010; Radu and Avram, 2011). In terms of financing health care systems in EU Member States, the share of public and private funds to finance health care costs also reflect large disparities. In 2008, public financing of health sector dominated in most EU Member States, ranging from 56% in Bulgaria to more than 80% in Romania, Netherlands, Czech Republic, Sweden, Luxembourg and Denmark. The costs of healthcare operational models show that in 2008, curative and rehabilitative services accounted for more than 50% of current health costs in most EU Member States, exceptions are Romania (47.5%), Slovakia ( 44.7%) and Hungary (48, 9%). Sharing the costs of medical care depending on provider shows that hospitals generally have the highest part of the expenses, ranging from 27% in Slovakia to 39.1% in Romania and more than 46% in Denmark, Estonia and Sweden. With regard to providers of ambulatory care services, the share of expenditures varies from over than 16% of total health expenditures in Romania (16.3%) and Bulgaria (16.7%), to more than 30% of total Germany, Finland, Cyprus and Portugal. The cost of procurement of medical supplies from various retail establishments and other providers of medical goods varied widely, from 11% in Luxembourg to 13% in Denmark, to 26.6% in Romania, to 30% or more of the total provision of healthcare in Lithuania, Hungary, Bulgaria and Slovakia. Another relevant indicator of health system s development in different countries is the number of hospital beds. In 2008, the number of hospital beds per 100,000 inhabitants ranged between European states, the general trend being the continuous decrease of the number of beds available. In Romania, during the decade , the number of curative care beds per 100,000 inhabitants decreased from 525 to 451, and the number of the psychiatric care beds from 88 to 80 (Table no. 1). Reducing the number of hospital beds may reflect, among other things, economic difficulties, increasing efficiency through the use of new technical resources, a shift to outpatient care for stationary operations, and shorter periods of hospitalization. Romanian health system continues to rely on hospital care as the main method of health care, Romania recording one of the highest rates of hospitalization in the EU: hospitalizations per 1,000 inhabitants in In 2008, in Romania there were 457 hospitals (units with inpatient options) of which 427 were majority state-owned hospitals, 897 outpatient facilities, specialized medical centers, high performance medical centers, including 9038 specialized medical cabinets. Also, there were 2555 medical imaging laboratories and facilities (including the ones from hospitals), 11,279 family medical clinics and other 1033 offices of general medicine that provided mainly 240

3 occupational health services, 11,025 dental surgeries and 6127 pharmacies. An analysis at regional level of key health units with majority state and majority private ownership in the period , is particularly relevant, reflecting disparities between counties analyzed: Vâlcea, Gorj, Dolj, Olt, Mehedinţi, Teleorman. As we can observe, there are large discrepancies between counties regarding the distribution of types of hospitals and other health units (Table 2. And Table. 3) and the number of beds and health workers, reported to the population (Table no. 4). Table no. 1 - Number of hospital beds ( ) Curative care beds in hospitals Psychiatric care beds in hospitals Year EU Belgium Bulgaria Czech Republic Denmark Germany Estonia Ireland Greece Spain France Italy Cyprus Latvia Lithuania Luxembourg Hungary Malta Netherlands Austria Poland Portugal Romania Slovenia Slovakia Finland Sweden Great Britain Norway Switzerland Croatia Macedonia Turkey The global economic crisis had a drastic impact on the Romanian health care system, leading to a comprehensive reorganization and restructuring action of the hospital network. From February to August 2010 took place a campaign for assessing hospital on their activity, sanitary conditions, quality of health services delivered to population, after which the Ministry of Health took the necessary steps to minimize excess hospitalization capacity of Romanian hospitals, reducing a number of approximately 9200 beds at national level, and the measures to reduce management staff (finally reaching a total number of approx. 500 management positions reduced). Other measures concern the merging of hospitals, including merging with another hospital (out of 111 hospitals proposed for merging at national level, five are in the county of Dolj, two in Vâlcea County, one in Gorj 241

4 County, one in Olt County, two in Teleorman County) and redesign hospitals into units for social assistance and homes for the elderly care (from the total of 71 hospitals proposed for readjustment at national level, two are in Vâlcea County, one in Dolj County, two in Gorj County, one in Olt County and two in Mehedinţi County). It is true that the transfer of social cases assistance and elderly assistance to care units and medical and social units, is expected to release hospital beds that are currently occupied by these types of patients, not only in hospitals for chronic diseases, but also in hospitals for acute diseases, because of the acute lack of alternatives for adequate care, but the closure of these hospitals for reorganization produced many negative effects. Another measure implemented by Government Decision no. 145/2011 approving the 2011 Report of the Committee of Selecting hospitals with beds that can not conclude contracts with health insurance houses, was the selection of medical units with beds that can not contract with health insurance houses (out of 6 7 hospitals selected at national level, two were in Mehedinţi County, one in Olt, three in Teleorman, one in Gorj, one in Vâlcea County). Table no. 2 - The main health units with majority state ownership County Hospitals Polyclinics Dispensaries Health Nurseries Pharmacies Years (total) Centers Vâlcea Gorj Dolj Olt County Years Table no. 3 - The main health units with majority private ownership Hospitals Polyclinics Family General Specialized medical medicine medical clinics cabinets offices Mehedinţi Gorj Dolj Stomatological cabinets 242

5 Teleorman County Years Hospital beds (including beds in health centers) Table no. 4 - Beds in hospitals and healthcare professionals Doctors (public and private sector) Dentists Pharmacists Average Trained Health Staff Vâlcea Gorj Dolj Olt Another important aspect of decentralization in health care system is the adoption of Government Emergency Ordinance no. 48/2010 for amending and supplementing certain laws on health field for decentralization process through establishing the transfer of a significant number of hospitals (370 out of 435) from the administration of the Ministry of Health in the administration of local and county councils. Government Emergency Ordinance no. 48/2010 states that the unit manager will conclude the management contract with local government leadership and not with the minister of health, as in the past. Also, according to the same ordinance, the proportion of wages costs in the total hospital costs should not exceed 70%. Government Emergency Ordinance no. 48/2010 has also changed the leadership of the hospital by the appearance of management boards, bodies that have the powers of approval of the revenue and expenses budget and financial statements of the hospital, organizing the contest for the position of manager, approval for business development measures according to population needs for medical services, approval of annual procurement program, analyzing the fulfillment of obligations by Members of the Steering Committee and business manager and even the proposed removal of the manager and other members of the Steering Committee, in case of incompatibility, gross negligence or breaking the performance indicators. Thus, for hospitals whose management was decentralized, two of the five board members are appointed by county or local council and a representative will be appointed by the mayor or chairman of the county council, as appropriate. 243

6 Another measure to reform the health system in recent years is changing the classification of hospitals. According to World Bank recommendations, hospitals will be classified in five categories: - Category V Hospitals: limited competence level - hospitals that provide, as appropriate, the following medical services: medical services for the chronically ill care, medical services in one specialty or palliative care services; - Category IV Hospitals: the basic level of competence - hospitals serving a population for diseases with low degree of complexity, in a limited administrative-territorial jurisdiction; - Category III Hospitals: average level of competence - hospitals serving the county population for diseases with average degree of complexity in territorial-administrative area in which they are located and only by exception, from adjacent counties; - Category II Hospitals: high competence level - hospitals serving the county s population of their administrative and territorial area and the adjacent counties, with high level of equipment and employment of human resources, ensuring delivery of health services with high complexity; - Category I Hospitals: very high level of competence - hospitals that provide care at regional level, serving the county s population of their administrative and territorial area and other counties, with the highest level of equipment and employment of human resources, ensuring delivery of health services with very high complexity. To correct differences in regional, county and local level, National Master Plan for hospitals and hospital accreditation, according to the classification, proposed various medical specialties to be implemented for each of the three levels of organization of hospital care (local, county and regional). Thus, at county level, there will be basic medical and surgical specialties, including emergency, intensive care and urgent medical transportation. At regional level, this plan will establish medical and surgical specialties based on powerful technology, including the ones concerning patients burned, heart surgery and transplants, which have to be introduced or developed based on epidemiological studies showing real care needs of the population. Health care needs may differ from region to region, as well as health care network available to each region, meaning there may be differences in the number or extent of medical services to be implemented. With regard to quality assurance in healthcare, crisis years have brought a hospital accreditation procedure. Thus, in 2009 was established the National Commission of Hospitals Accreditation which includes representatives of the Presidency, the Romanian Government, Romanian Academy, Romanian College of Physicians, and of Romanian Order of Nurses. In principle, accreditation requires uniform quality standards that hospitals should meet - quite independent of the level of assistance they provide - and internal and external processes in order to ensure current performance checking compared with those standards and their improvement. During 2010, the Ministry of Health, at the proposal of the National Commission of Hospitals Accreditation approved the procedures, standards and methodology for accreditation of hospitals through the Order of the Minister of Health no. 972/ Government Emergency Ordinance no. 48/2010 introduced also the mandatory provisions concerning the time within which hospitals must request accreditation: If within one year from the approval of procedures, standards and accreditation methodology, hospitals do not require accreditation under the law, they lose the right to be financed from public funds. Similarly, if accredited hospitals do not require re-accreditation under the law, at least six months prior to termination of accreditation, they lose the right to be financed from public funds. And in terms of human resources in health sector, a worrying phenomenon is that the level of ensuring the Romanian population with doctors and nurses is lower than the average European level. Besides the uneven territorial distribution of medical staff (Table no. 4) is also recorded an insufficiency of professional staff, especially for preventive sectors, medical, social, public health and health care management fields, inadequate staff share, concentration of medical staff in urban areas and hospitals. The cause of such deficiencies lies in the lack of incentives for medical career choice and supporting young professionals, low wages and lack of connection between health performance and official income, facts which encourages corruption. Another cause can be identified in healthcare education model that has a low performance, as well as the Romanian education system as a whole, none of the Romanian medical institutions not being in the top 500 in any of the existing world rankings. Hospital medical staff in Romania represents one of the lowest percentages 244

7 compared with the EU level; one of the negative effects of Romania s joining the EU being the brain drain experienced, in healthcare system, especially by young doctors emigration. Emigration of health professionals produced other serious imbalances in the distribution of medical personnel, especially doctors and specialized nurses; is frequently the case when, in some hospitals, there is a single specialist on section, which in principle should ensure continuity of care for all patients admitted for 24 hours, 7 days a week. Lack of medical staff was determined by a series of system failures such as unattractive wage system, non-stimulation of staff performance. Overtime are not paid or compensated by free time, according to the law, and numerous irregularities were found in providing heavy duty allowance. The Report of the Presidential Commission for analyzing and setting up public health policy in Romania, entitled A healthcare system focused on citizen needs points out that in the density of doctors in European countries members of the World Health Organization, Romania is ranked 31 of 33 countries, with a density of 1.9 doctors per 1,000 inhabitants, only Albania and Bosnia-Herzegovina recording densities lower than our country. Romania ranks last in terms of the number of nurses (3.89 nurses per 1000 inhabitants), dentists (0.22 dentists per 1000 inhabitants) and pharmacists (0.06 pharmacists per 1,000 people), our country with a number at least one third lower than the European average in terms of mortality and morbidity higher than the EU average, and at certain medical specialties personal deficit is even greater. Note that these phenomena have been aggravated during the last four decades, health human resources being always much lower in Romania than the European average. Meanwhile, outside the small number of medical personnel at the national level, there are important regional and local imbalances (Table no. 4). Human resources are concentrated in urban areas at the expense of rural and poor areas and those inhabited by specific groups that are most vulnerable (ethnic minorities, poor, etc..) are avoided by medical professionals. Thus the system can not respond adequately to the needs of those groups or regions, which are excluded from access to health services, increasing the risk of morbidity and mortality at birth. Although the EU-27 population increased during 2010, the trend of population growth has been uneven across Member States. Of 27 EU member states, 20 states reported an increase in population in recent years while the number of inhabitants has decreased in Germany, Latvia, Lithuania, Hungary, Portugal, Romania and Bulgaria. Increasing life expectancy is achieved by reducing the mortality rate at birth, factor influenced mainly by the quality of health care in hospitals. One of the most important changes in the decade was a reduction in infant mortality in the EU-27 by half. Reduce child mortality was more significant among Member States in Eastern Europe that have previously registered a higher level of infant mortality. In 2008, the lowest infant mortality rate in the EU-27 was registered in Luxembourg (1.8 deaths per 1,000 live births), and the highest levels of infant mortality were in Bulgaria (8.6 ) and Romania (11.0!). It can be seen that there is a very big difference even between the penultimate place occupied by Bulgaria, and the last place on which stands Romania. Natural increase of population in Romania has dropped to negative values, from 3.0 inhabitants in 1990 to -2.5 in 2003, to in 2004 and 2005, to -1.8 in 2006, to -1.7 in 2007, to -1.5 in 2008 and -1.6 in Analyzing data on the natural movement of population in three counties of Oltenia (V âlcea, Gorj, Dolj), we noticed worrying trends: population growth is negative (Table no. 5), except in Vâlcea County (urban), reflecting the fact that depopulation of these counties has increased, a phenomenon now, in fact, nationwide. Table no. 5 - Natural movement of population County Vâlcea (2009) Gorj (2009) Dolj (2010) ABSOLUTE DATA Total Urban Rural Total Urban Rural Total Urban Rural (number) Live new-born Deaths Natural increase Marriages Divorces Dead new-born Deaths at under 1 year age

8 Rate (per 1000 inhabitants) Live new-born 8,6 9,4 7,9 8,5 8,6 8,4 8,8 9,4 8,2 Deaths 11,4 8,1 14,2 11,0 7,4 14,2 14,3 9,9 19,4 Natural increase -2,8 +1,3-6,3-2,5 1,2-5,8-5,5-0,5-11,2 Marriages 5,5 7,2 4,1 6,1 7,1 5,1 5,0 6,2 3,5 Divorces 0,98 1,4 0,62 1,63 2,03 1,27 0,49 0,51 0,46 Deaths at under 1 year age (per 1000 live new-born) 7,1 6,3 7,9 14,5 14,1 14,9 5,3 4,8 6,1 Medical treatment costs are another indicator that highlights inequalities in access to health care by class of income, within the different European countries. Less than 1% of the social category with the highest income is declared as being unable to perform a medical exam or receive appropriate treatment when they need it. In general, the income level decreases, the greater proportion of the people which consider the cost of medical services as an obstacle to the possibility to receive healthcare. The number of those who consider the cost of medical services a barrier is negligible in Denmark, Slovenia and the UK, quite high in Latvia and Portugal, the highest in Romania. Another important issue is related to certain types of treatment that are available in legal limits, healthcare providers being required to select patients who will benefit from them. In these situations, patient rights law no. 46/2003 stipulates that the selection is solely based on medical criteria developed by the Ministry of Health. Introducing the National Health Card, and electronic patient records, known as electronic medical records, and electronic prescription, which will lead to a detailed record of health services provided for settlement, revealing at level of detail information about costs and quality of care, will be achieved in the second half of Implementation of these new measures is likely to help to improve quality and safety of healthcare, including by facilitating continuity in patient care. Costs of healthcare were traditionally low in post-revolutionary Romania compared to the average of European countries and even compared to former socialist countries. In recent years, the amounts allocated to the health system grew in European countries, from about 90 Euro / capita at 200 Euro / capita. A completely different situation is registered in Romania, which continues, for more than 20 years, being situated on one of the last places in the EU in terms of resources allocated to health, if not the last. Table no. 6 - Resources allocated to health - Euro / capita (Eurostat) Year Belgium Bulgaria Czech Republic 589, Denmark Germany (including ex-gdr from 1991) Estonia Spain France Lithuania ,83 Hungary Netherlands Austria Poland Portugal Romania Slovenia Finland Sweden Iceland Norway Switzerland

9 CONCLUSIONS The multitude of laws and unstable legal framework, lack of national and regional long term plans concerning care services generally, including the hospital care, but also the effective use of funds and increasing quality of care and training of health professionals are other issues that worse Romanian health care system s crisis. Monetary and non-monetary statistics can be very helpful to assess how the health system in a country responds to health care needs of the population, by measuring the financial resources, human and technical resources in the health sector and by allocating these resources between health care activities (e.g. preventive and curative care), between categories of healthcare providers (e.g. hospitals and outpatient centers) or between health professionals (e.g. medical and paramedical staff). Combining these data with information on technical and managerial options that are made in the provision of care (e.g. hospital or ambulatory care or hospital average length of stays), it is possible to evaluate and measure the performance of healthcare system, determine the factors of pressure and causes of nonperformance in order to identify measures and methods to improve medical care and increase public access to medical goods and services. REFERENCES Avram C et al. (2007) România şi exigenţele integrării europene, Editura Alma, Craiova. Bompa TO, Porojan D (2010) România acum ori niciodată! Un model de guvernare care salvează România, Editura Irecson, Bucureşti. Mărginean I (2006) Calitatea Vieţii în România , Institutul de Cercetare a Calităţii Vieţii, Bucureşti. Popescu L (2004) Politicile sociale est-europene între paternalism de stat şi responsabilitate individuală, Presa Universitară Clujeană, Cluj-Napoca. Preda M (2002) Politica socială românească între sărăcie şi globalizare, Editura Polirom, Bucureşti. Radu R, Avram C (2011) Politica socială românească între tranziţie, reformă şi criză, Editura Aius, Craiova. Zamfir C et al. (2010) După 20 de ani: opţiuni pentru România, Academia Română, Institutul Naţional de Cercetări Economice, Institutul de Cercetare a Calităţii Vieţii, Bucureşti. Government Decision no. 145/2011 approving the 2011 Report of the Committee of Selection of hospitals with beds that can not contract with health insurance houses and the list of these health units. Government Emergency Ordinance no. 162/2008 on the transfer of all the functions and powers exercised by the Ministry of Health to local authorities. Government Decision no. 562/2009 for approving the strategy of decentralization in the health system. Government Decision no. 56/2009 for the approval of the Methodological Norms for applying Government Emergency Ordinance no. 162/2008 on the transfer of all the functions and powers exercised by the Ministry of Health to local authorities. Government Decision no. 144/2010 on the organization and functioning of the Ministry of Health, as amended and supplemented. Government Decision no. 139/2008 on approving the Methodological Norms for applying Law no. 195/2006 on decentralization. Law no. 95/2006 on healthcare reform. Ministry of Health, National Strategy for Rationalization of Hospitals (Strategia Naţională de Raţionalizare a spitalelor), approved by Government Decision no. 303/2011. Romanian Government, Ministry of Health, Activity report for 2011 (Raportul de activitate pentru anul 2011). ned/index.php/healthcare_statistics. ageid= eid= PpUnitSanitareProprStat.ro.do. id= r&pageid= eid= PpUnitSanitProprPriv_ ro.do. 247

10 r&pageid= ageid= eid= PaturiSpitalePersSanitar.ro.do. id= comasate_8806_6768.doc. 20reprofilate_8806_6767.doc. ned/index.php/sustainable_development_ -_Public_health. ned/index.php/mortality_and_life_expect ancy_statistics Ministry of Health, National Strategy for Rationalization of Hospitals (Strategia Naţională de Raţionalizare a spitalelor), p ageid= eid= _MiscNatPop.ro.do. ned/index.php/sustainable_development_ -_Public_health 248