European Observatory on Health Systems and Policies


Health Systems in Transition (HiT) profile of Romania

3.4 Out of pocket payments

OOP payments in Romania include: direct payments for goods or services that are not included in the statutory health insurance benefits package or covered by the national health programmes; direct payments by uninsured patients; direct payments for (uncontracted) private providers; user charges for some health care services and pharmaceuticals; and informal payments.

The exact share of private expenditure on health has always been difficult to estimate because of informal payments and the underreporting of incomes by private providers. As shown in Table3.1, OOP expenditure as a share of total health spending in Romania decreased from 26% in 1995 to 19% in 2014.

3.4.1 Cost-sharing (user charges)

The introduction of user charges in 2002 aimed to reduce the inappropriate demand for health care services, to contain costs and to raise revenue. A list of services for which user charges were to be applied was to be established by a commission comprising representatives of the Ministry of Health and NHIH, agreed by the College of Physicians, and made statutory by the relevant Framework Contract and its implementing norms (see section 2.8.1). However, apart from inpatient care, no such lists have so far been developed and the co-payment for hospital admission, which is charged at the point of discharge (less than €2.5), although included in the legislation since 2002, was only implemented in 2013 (see section 6.1). Vulnerable population groups were exempted from this co-payment, as were certain hospital services (Table3.3). Private providers contracted by the DHIHs can charge extra for services they provide (extra billing) and this is generally not regulated. In 2013, extra billing for superior hospital accommodation was capped at 300 lei per day (less than €70) with no explicit justification.

A reference price system is applied for pharmaceuticals. The reference prices are based on the lowest-priced product within a cluster of medicines. In addition, patients have to pay 10% or 50% of the reference price (i.e. of the lowest-priced product in the cluster). If the patient prefers a more expensive product, they will also have to pay the difference between the price of the lowest-priced product and the price of the desired drug (see section 2.8.4).

Co-insurance is applied for balneary treatment and rehabilitation services. The patient contributes 30–35% of the daily tariff and pays the full tariff for lengths of stay over 14–21 days and for admissions without referral (see section 3.7).

Institutions that provide both social and medical care are mainly financed from OOP payments and funds from the state, the NHIF and local budgets. The level of OOP payments made by the clients of these institutions is set by the local authorities that own them.

3.4.2 Direct payments

Services that are not covered by statutory health insurance and that require payment of the full fee include: treatment of occupational diseases, treatment of work and sports accidents, services that require certain medical equipment, some dental services, plastic surgery for aesthetic purposes for persons over 18 years (except for breast reconstruction after mastectomy), some medical supplies and forms of transport (that are not specified within the law), issuing of medical documents, IVF, the cost of certain devices used to correct eyesight and hearing, and some rehabilitation treatments (Law 95/2006). Patients who visit a specialist without a referral from the family medicine physician must pay the full fee. The amount varies depending on the service required and the type of specialist. Fees charged by non-contracted providers are not regulated.

3.4.3 Informal payments

Informal payments are firmly rooted in Romanian culture, with the practice growing in intensity during the communist period. There have been several surveys on informal payments in Romania, attempting to measure their magnitude, frequency, geographic variation and the rationale behind them over the years, but since these were elaborated by different institutions that used different methodologies, their results are not comparable.

A study conducted in 2010 in the north-east of Romania, which focused on corruption in the health care system, revealed that 75.5% of those admitted to hospital in the previous year had offered so-called gratitude payments to medical staff and 3.6% of patients had offered gratitude payments but the medical staff had refused to accept them (2.1% of the respondents did not provide an answer). Over 60% of the respondents considered the main reason for medical staff accepting gratitude payments to be the very low level of their earnings (Asociatia Sf. Damian, 2010).

Another study on corruption in the health care system conducted across the whole country in 2014 by the Association for the Implementation of Democracy found that 37% of those who had been admitted to hospital in the previous year had offered so-called gratitude payments to physicians, 34% to nurses, 25% to housekeeping staff and 14% to other auxiliary staff (laboratory technicians, porters, stretcher-bearers, etc.); 60% of those who offered gratitude payments said that this was their own choice, while 10% said that the medical staff had requested the informal payments (MS&AID Romania, 2014).