Romania is a country in the southern part of Central Europe, bordering Eastern Europe and the Balkan Peninsula, in the northern hemisphere of the globe ^[1]. Romania is bordered by Ukraine, Moldova, Bulgaria, Serbia, and Hungary.

Since 1 January 2007, Romania has been a member state of the European Union. With a surface area of 238,397 km², Romania constitutes 4.8% of Europe and 5.4% of the European Union ^[1]. The estimated population of Romania as of 1 January 2022, is 21,980,534.

Romania is an upper-middle-income country with an economy that is the 13th largest in the European Union and the 49th largest in the world ^[2]. The Romanian economy has undergone significant changes in the past few decades, transitioning from a centrally planned economy to a market-oriented one. Romania has a mixed economy that is dominated by the service sector, which accounts for approximately 60% of the country’s GDP ^[2]. The industrial sector is the second-largest contributor to the economy, accounting for around 20% of GDP, while agriculture contributes approximately 4.2% of GDP ^[3].

2. Healthcare Infrastructure in Romania

The latest report of the Romanian National Institute of Statistics shows that there are more than 65,000 health units operating in the country, with 53,000 in urban areas and 12,000 in rural areas ^[4]. The number of hospitals in the country is 543 (488 in urban areas and 55 in rural areas), but there are also 160 other hospital-like establishments, such as medical centres, diagnostic centres, health centres, and other hospital-like medical establishments providing day hospital services only (not inpatient continuous admission) ^[5]. Of the total number of hospitals and hospital-like establishments, 49.8% were large establishments with more than 100 beds for continuous or day hospitalisation, and 38.7% were small establishments with less than 50 beds ^[5]. The total number of continuous inpatient beds available in hospitals is 135,085. According to the specialty for which hospital beds were allocated; psychiatry (12.0%); surgery (10.4%); internal medicine (8.9%); obstetrics, gynaecology, and rehabilitation; physical medicine; and balneology (6.3% each); and pneumology (6.2%) received the most hospital beds ^[5]. Following that are paediatrics (5.4%), infectious diseases (4.5%), cardiology and ATI (4.3% each), neurology (4.0%), neonatology (3.4%), orthopaedics and traumatology (3.2%), and oncology (3.1%). Romania faces unequal access to healthcare between settings. In urban areas, there are 90.9% of the total number of hospitals and hospital-like establishments, 92.3% of the total number of specialist outpatient clinics and hospital-integrated outpatient clinics, 97.3% of the total number of medical dispensaries, 97.8% of the total number of dialysis centres, 98.5% of the total number of specialist medical centres, as well as nine out of eleven spa sanatoriums, all mental health centres, blood transfusion centres, and TB sanatoria. There are 366,821 health professionals working in Romania’s healthcare system. Of these, 36.9% are highly qualified health professionals (e.g., doctors, dentists, pharmacists, etc.), 42.4% are medium-qualified health professionals, and 20.7% are auxiliary health staff. It also shows once again the inequitable distribution of medical staff between rural and urban areas ^[5]. In 2001, urban healthcare units had 92.1% of all doctors, 89.0% of all dentists, 83.4% of all pharmacists, and 89.4% of all average healthcare staff ^[5]. In 2021, the healthcare network provided continuous inpatient care for 2,651,230 patients in hospitals, 1458 patients in health centres with hospital beds, 2282 patients in TB sanatoriums, 1037 patients in neuropsychiatric or neuropsychiatric sanatoriums, and 19,713 people in spa sanatoriums ^[5].

3. Health Expenditure in Romania

The public sector dominates healthcare in Romania, owning the majority of hospitals and providing national health insurance to nearly all Romanian citizens ^[6]. The financing of the health system in Romania always depended on the economic and political transformation the country was going through. In 1946, the budget allocated by the State was 6.42% of the country’s budget, increasing afterwards at quite a steady pace. In the 1950s, the annual growth rate of the total expenditure for health was 22.78%; between 1967 and 1977, the average annual rate of growth of expenditures for healthcare was 7.25%. In the 1980s and until the Romanian revolution in 1989, the variations in the resources allocated for health were considerable, leading to problems in the medical system ^[7]. After 1989, to reduce expenditure and improve the efficiency of the system, Romania carried out a series of reforms to optimise the hospital infrastructure. In most cases, reform mainly meant closing hospitals or at least reducing their capacity as performance thresholds were introduced and the existing healthcare units were unable to meet them. For Romania, evaluations considered not only the number of readmissions and transfers but also the number of cases that could be avoided, and certain hospitals were considered to underperform, leading to the closure or transformation of 67 hospitals into units of care for elder people. Additionally, hospital networks were put in place for a better allocation of resources and to coordinate the services offered. The network of services provided for a reduction of costs was also achieved in Estonia, Lithuania, and Latvia. Other Eastern Europe countries went through similar processes but with small differences: Hungary preferred to just reduce the number of beds or close sections in certain hospitals, while the Czech Republic centralised specialised care services in different centres and care facilities, increasing the quality by offering specialised treatment just in those places ^[8]. Still, despite the good intentions of increasing the efficiency of the use of public resources, the long tradition of getting medical care directly from specialists in hospitals created a huge resistance to the idea of reducing the number of people that would get to hospitals for health services by introducing family medicine. It was a needed reform, as the budgets allocated for the health sector were extremely limited ^[8]. In the 1990s, family medicine started to work, and universities offered new lines of training in the field, generating specialists in family medicine and giving this reform a chance to finally be accepted by the end beneficiaries. At the beginning, the new system was implemented only in a few regions to check its efficiency and allow necessary laws to be passed. Still, there were problems that needed care, such as the lack of control over the quality of services provided as well as over the billing of these services, which seemed to get out of hand. The experience of Romania led to some conclusions regarding the steps to be taken and their order: for the system to work, first the doctors must be trained for their new role in order to quickly gain the trust of future beneficiaries of their services; then, regulations for control and monitoring should be put in place for protection against the misuse of public funds; next come measures regarding the incentives in the payment system and the establishment of private, independent practices for the family doctors, with clear ways of accreditation and ownership over certain primary care facilities that previously belonged to the government ^[8]. The health reforms in the 1990s dealt with funding sources as well. A special fund for health was created in 1992, and the government provided partial compensation for specific medicines. Contributors to this fund were all employed persons, through a tax on salary, as well as the producers and sellers of alcohol and tobacco, through additional taxation on these types of products. These sources remained the main sources of financing for the next 5 years. After that, besides the compulsory contribution to the health system, private health insurance became an option for the employees ^[8]. In 1990, the health expenditure was 2.7% of the GDP; in 1998, it was 3.2%; and in 2005, it reached 5.4%. Afterwards, the system financing became more fluctuant, reaching the lowest percentage of GDP in 2015, when the allocation was 4.5% of the GDP, a step back to the value of 2002. In 2017, it went above 5% again, and in 2020, healthcare spending was estimated to be 6.3% of GDP, well below the 10.9% of GDP average for most European Union (EU) countries ^[9]. The level of current healthcare expenditure was valued at EUR 13.7 billion in 2020. It has grown by 118% in the last decade, reaching EUR 6.2 billion in 2012 ^[9]. In relation to population size and in EUR, current expenditure on healthcare in 2020 was EUR 713 per capita ^[9].

4. Health Status in Romania

In Romania, one in four people aged 2 and over suffers from at least one chronic disease or long-term health condition ^[10]. However, in 2021, 72.8% of the Romanian population reported that their health was good or very good; this proportion is close to the average of the European Union countries, with a level of good or very good health of 69.0% ^[11]. At the other end of the scale, 7.4% rated their health as bad or very bad, and 19.8% rated their health as satisfactory ^[11]. Perceptions of a bad or very bad health status were more prevalent among the elderly, especially older women. Life expectancy at birth is 75.0 years, up from 71.2 years in 2000 but still among the lowest in the EU ^[12]. In 2021, 19.9% of people in Romania aged over 16 years suffered from a chronic disease or long-term health issue, below the EU countries’ average of 35.2% ^[11]. The infant mortality rate in Romania is 5.26 deaths per 1000 live births [13,14]^[13][14]. This is a significant improvement over the previous years, as the infant mortality rate in Romania has been constantly decreasing over the last decades, being 24.35/1000 live births in 1990, 18.13/1000 live births in 2000, and 10.55/1000 live births in 2010 ^[13]. The neonatal mortality rate is reported at 3 per 1000 births ^[15]. Moreover, the under-5 mortality rate is estimated at 6.42 per 1000 live births, with 1281 deaths reported in 2021 ^[15]. This indicator has also shown remarkable improvements in recent decades, with under-5 mortality being 31.11/1000 live births in 1990, 21.45/1000 live births in 2000, and 12.39/1000 live births in 2010 ^[15]. The rate of young people suffering from at least one chronic disease is 3.3% in the 0–14 age group, 1.1% in the 15–24 age group, and 4.5% in the 25–34 age group. The older a person is, the more likely they are to suffer from chronic diseases, so the proportion of people aged 55–64 suffering from at least one chronic disease is 43.4%, and the proportion of people aged 65–74 suffering from chronic diseases is 69.1% ^[10]. The most common chronic diseases in the population aged 15 and over are: hypertension (159 per 1000), low back disease (78 per 1000), diabetes mellitus (50 per 1000), and cervical disease (36 per 1000) ^[10]. In 2018, ischemic heart disease was the leading cause of death in Romania, accounting for more than 19% of all deaths, followed by stroke (16% of all deaths), and lung cancer (3.9% of all deaths), the latter being the most common cause of death from cancer, with mortality rates increasing by nearly 11% since 2000 ^[12]. Adult smoking prevalence is currently slightly lower than the EU average. However, while in 2014, 19.8% of adults smoked tobacco every day, today the prevalence of smoking among adults is over 20%, still lower than the EU average ^[12]. Despite predictions that Romania would have a lower incidence of cancer than the EU average, Romania’s overall cancer mortality was estimated to be slightly higher than the EU average, with 283 deaths per 100,000 people ^[12].

5. Healthcare System in Romania

The healthcare system in Romania is a social health insurance system that has remained highly centralised despite recent efforts to decentralise some regulatory functions. It provides a comprehensive benefits package to 85% of the population, with the remaining population having access to a minimum package of benefits ^[16]. The healthcare systems comprise all organisations, institutions, and resources that are dedicated to health actions ^[17]. In the European Union, there are three models of operation and organisation of the public health system: the Bismarck model, the Beveridge model, and the mixed system ^[18]. Initially, Romania adopted the Semashko model, which happened at the end of 1989, and in the course of time, this model endured several corrections. The reasons why this system did not work for Romania were the conditions under which funding was not optimally administered and the funds that were supposed to flow into the system were almost nonexistent. As a result of these problems, Romania decided to adopt another model, the Bismarck model, adopted in 1997 by Law No. 145, with compulsory health insurance based on the principle of solidarity and operating within a decentralised system. This model, adopted by Romania, implies that:

• Financial resources are characterised by compulsory contributions that are paid by employees and employers;
• Emergency medical services other than those directly financed by the Ministry of Health;
  Resources from state, local, or national budget subsidies;
• Non-profit institutions;
• Insurance funds, which are managed and administered at the national level through the social directorates.

The current healthcare system in Romania operates on the basis of Law No. 95/2006, drafted and adopted by parliament, which was subsequently amended in 2012 ^[19]. Additionally, the primary healthcare law (Act No. 95/2006 on Healthcare Reform) was modified in 2020 to provide the foundation for the advancement and application of telemedicine ^[20]. The main challenges for the Romanian healthcare system are cost and quality issues. As far as cost issues are concerned, these are related to insufficient funds and inefficiency in the way they are used. In addition, there are also problems related to informal payments, such as money people give to doctors and nurses to get services faster—money that distorts fair access to health services. The Ministry of Health is in charge of overall social health insurance system governance, while the National Health Insurance House administers and regulates the Single National Health Insurance Fund social health insurance system. The Ministry of Health is primarily responsible for healthcare in Romania. It is responsible both for the regulatory framework and policies and for the management of the health system in general ^[21]. The National Health Insurance House (NHIH) administers and regulates the health system. The activity of the National Health Insurance House requires the fulfilment of certain functions. These involve the administration of collected funds and the financing of medical services needed by the insured ^[22]. The National Health Insurance House is a public, autonomous institution of national interest with legal personality whose main object of activity is to ensure the unified and coordinated functioning of the social health insurance system in Romania. The NHIH operates on the basis of its own Statute and has the following obligations ^[23]:

• To ensure the logistics of the unified and coordinated functioning of the social health insurance system;
• To monitor the collection and efficient use of the fund;
• To use appropriate media to represent, inform, and support the interests of the insured persons it represents;
• To meet the health service needs of individuals within the limits of the funds available.

Both the Ministry of Health and the National Health Insurance House have representation at the local level through district public health authorities (DPHAs) and district health insurance houses (DHIHs).

6. Social Health Insurance in Romania

Social health insurance in Romania can be seen as a whole as an insurance programme through which Romanians can insure their health and at the same time finance their medical needs. Medical services are divided into two categories: those that are paid for by the Health Insurance House and those that are not paid for by the Health Insurance House. Medical services that are paid for by the Health Insurance Fund ^[19]:

• Medical services provided to the sick person up to the diagnosis of the condition: medical history, clinical examination, and paraclinical investigations;

The services that are not paid from the fund are:

• Medical services in the event of occupational diseases, accidents at work, and sports accidents, medical care at work, medical care for sportsmen, and sportswomen;
• Certain high-performance medical services;
• Medical and surgical treatment and certain rehabilitation procedures;
• Certain dental care services;
  The prescription of the treatment necessary for improvement or cure, including indications concerning living and working conditions, hygiene, and diet.

Insured persons benefit from medicines, with or without personal contribution, on prescription for medicines included in the list of medicines drawn up by the Ministry of Health and NHIH. Insured persons are entitled to receive some home healthcare services, including palliative care at home, and are entitled to medical transport necessary for the performance of a medical service.

• Hotel services with a high degree of comfort;
• Cosmetic corrections carried out on persons over 18 years of age, with the exception of breast reconstruction by endoprosthesis in the case of oncological surgery;
• In vitro fertilisation;
• Medical assistance on request;
• The cost of certain materials necessary for the correction of sight and hearing;
• Personal contribution towards the price of medicines, certain medical services, and medical devices;
• Medical services requested by the insured person;
• Certain rehabilitation services and procedures;
• Family planning services provided by the family doctor in the hospital planning offices.