Romania Health Profile 2012

The government represents the highest authority within the Romanian health system, performing its stewardship role through the Ministry of Public Health. The National Health Insurance Fund (NHIF) represents the main financial source as the third party payer of the system and receives the funds collected by the agencies of the Ministry of Finance. Through the Yearly Framework Contract, agreed by the NHIF with the Ministry of Public Health and the CoPh, the health care services to be contracted by the District Health Insurance Funds (DHIFs) from both public and private health care providers (hospitals, ambulatory care, primary care and so on) are established.
At the national level, cross-sector approaches in health policy are ensured through collaboration between the Ministry of Public Health, the Ministry of Labour, Social Solidarity and Family, the Ministry of Interior and Administrative Reform, the Ministry of Education and Research, Ministry of Finance, the CoPh, the College of Pharmacists and the NHIF. At district level, cross-sector interventions are ensured through the district public health authorities (DPHAs), DHIFs, district councils, district public finance departments and district departments of the Ministry of Labour, Social Solidarity and Family, district school inspectorates, and district local government prefects.

Organizational overview
Since Romania adopted a mandatory social health insurance system in 1998, the roles of the main participants in the health system have changed, the relationships between different organizations have become more complex and the number of participants involved has increased. The system is organized at two main levels: national/central and district (judet). The national level is responsible for attaining general objectives and ensuring the fundamental principles of the government health policy. The district level is responsible for ensuring service provision according to the rules set by the central units The central level The main central institutions are the Ministry of Public Health (formerly named the Ministry of Public Health and Family) and the NHIF.

Ministry of Public Health
The Ministry of Public Health is the state’s institution responsible for ensuring the health of the nation. It does so through the definition of policies and strategies, and planning, coordinating and evaluating outcomes. Since 1 January 1999, the Ministry of Public Health ceased to have direct control over the financing of a large part of its network of service providers. Responsibilities consist of:

• Stewardship role in engaging main stakeholders in different types and different stages of health policies and strategies formulation, implementation and evaluation;
• Defining and improving the legal environment in the context of wide public circulation that includes views of stakeholders and of patients;
• Ensuring increased transparency in managing the state’s budgetary allocation for health. The Ministry of Public Health retains responsibility for financing and managing the national public health programmes, selected specialty services and investments in buildings and high-technology medical equipment.
• Regulating both the public and the private health sectors, and their interface.
• Ensuring leadership in conducting research and developing policy and planning in relation to developing reform policies and monitoring their impact; monitoring the impact of financing reforms; monitoring the need to upgrade buildings, major repairs and high-technology medical equipment; and monitoring the emergence of the private health sector;
• Defining and improving the legal and regulatory framework for the health care system. This includes regulation of the pharmaceutical sector as well as public health policies and services, the sanitary inspection and the framework contract.
• Developing a coherent human resources policy and for building capacity for policy analysis and management of the health care system.

National Health Insurance Fund
The NHIF is an autonomous public institution that administrates and regulates  the social health insurance system. Between 2002 and 2005, the NHIF was under the coordination of the Ministry of Public Health. In 2005, the NHIF regained its independent status and is currently mainly responsible for:

• developing the strategy of the social health insurance system;
• coordinating and supervising the activity of the DHIFs;
• elaborating the framework contract, which together with the accompanying norms sets up the benefit package to which the insured are entitled, and the provider payment mechanisms;
• deciding on the resource allocation to the DHIFs;
• deciding on the resources allotted between types of care. The NHIF has the authority to issue implementing regulations mandatory to all DHIFs in order to insure coherence of the health insurance system. According to the initial Health Insurance Law, the leadership of the NHIF was meant to be established through national election. However, a 2002 government ordinance decided that the Council of Administration of the NHIF should be appointed differently. At present, according to the Health Reform Law (95/2006), the Council of Administration consists of 17 members with the following composition:
• five representatives of the government: one each appointed by the Minister of Public Health, the Minister of Labour, Social Solidarity and Family, the Minister of Public Finances, the Minister of Justice and the Romanian President;
• five representatives of trade unions;
• five representatives of employers’ associations;
• two members appointed by the prime minister upon consultation with the National Council of the Elderly.
The president of the NHIF is appointed by the prime minister. The Council of Administration has two vice-presidents, elected by Council members.

The Romanian health care system is currently in the process of rapid transformation. Probably one of the main problems with the Romanian health care system is the lack of a clear vision of its future and the lack of a coherent project for its health system, which is shared and accepted by the main stakeholders. The increased turnover of decision-makers within the health system has resulted in a number of health projects and strategies, often developed with international support, that are then abandoned by a new political team from the Ministry of Public Health, which started the development of its own “health policy”. For these reasons, many health policy areas are still not touched by serious reforms, for example human resources training in health  care or hospital organization, which is very similar to that before 1989.
One of the main problems arising during the first years of reforms after 1989 was inadequate authority for, and coordination of, the whole process of change. It can be said that, after the 1989 revolution, instead of one health care system functioning inappropriately, there were several health systems with inadequate performance. The primary health care system has almost no functional links with the hospital system, which is also not integrated with the outpatient care (ambulatory system).
The major difference is in the increased budget for the health care system, especially after 2005, and in the increased transparency of the system, which led to constant media coverage of the dissatisfaction of patients, health providers, managers and politicians. Added to this, is the persistent perception among the population that the health care system is one of the most corrupt parts of Romanian society (Transparency International, 2006), which can only increase general discontent.
Some new organizations, such as health insurance funds, with important roles in the health system, were able to adapt to the reforms, while others, such as DPHAs, are still unclear about their roles. The Ministry of Public Health is struggling to strengthen its stewardship role. In this context, coordination and establishment of clear roles for the main participants is one of the major challenges for the Romanian health system. Health legislation is very complex and changes frequently. While the Health Insurance Law was amended several times, other regulations known as “secondary legislation” were changed even more often. Constant change complicates a coherent decision-making process and sound management of the system, both at macro and micro levels. For instance, the new legislation enacted in 2006, which was supposed to providea holistic and coherent framework for the health care reform process, has been amended several times already, with what seems to be, in some parts, radical change, becoming another new version of the old legislation; this is occurring in a situation where hospital organization had not been challenged at all in the previous two decades.
The introduction of social insurance was seen as a solution to overcome the prior limited health care budget. Apparently it succeeded in mobilizing financial resources but it did not contribute to an acceptable balance between deliberately increasing expenditure and controlling unnecessary spending through its chosen forms of reimbursement. The challenge remains to find the appropriate mix between capitation, fee for service and activity-dependent budgets. Hospital reform in terms of hospital reorganization is still regarded as a possible tool to improve control of expenditure. The increase in the size of the pharmaceutical market was also stimulated by the significant increase in spending in this sector. Despite the lessons learned from neighbouring countries such as Hungary, the Czech Republic and Poland, the Romanian NHIF, along with the Ministry of Public Health, were not well prepared to face the anticipated increasing cost pressure from pharmaceuticals, and no clear strategy for this sector is in place Both the hospital and pharmaceutical sectors are perceived by the population as unresponsive to their expectations. Finally, it is important to highlight that expectations, real or induced, have to be considered in the context of the socioeconomic development level of the country and of transformation of the
health system.
The last developments showed that health has finally gained a better place on the government’s priority list, mainly in terms of budgets allotted to health, as the public funds available for health have doubled in the last three years. It seems that the Romanian Government has finally understood both its stewardship role for the health system and its responsibility for increasing access of Romanian citizens to health services and, therefore, is devoting more resources to the health sector. Furthermore, owing to the EU accession process, Romania has succeeded in harmonizing legislation with EU requirements. However, there is still a gap between the legal developments and the actual implementation on the ground, mainly because of poor administrative capacity, lack of accountability mechanisms at the local level, inadequate communication between public institutions, insufficient management skills among elected local officials and administrative personnel, and lack of a clear vision of health system reform. And, as Lewis Carroll said, “when you don’t know were you are going, any road will get you there”. However, the doubling of public funds available for health in just two years, coupled with the declared intention to further improve the legislative and administrative framework, are to be regarded as positive developments, showing greater commitment at the political level towards the health of the population.