5. Provision of services
he provision of public health care services in Romania is coordinated by the Ministry of Health and mainly overseen by the NIPH and delivered by the DPHAs, and other specialized institutions, plus some carried out as part of health care services provision (mainly by family medicine physicians). Some identified weaknesses in the provision of public health care services include: environmental risk monitoring, such as gaps in the monitoring of drinking water and bathing basins; communicable disease surveillance, such as underreporting of nosocomial infections in hospitals; and health promotion and disease prevention, with prevention weak in most national health programmes on specific conditions or issues, such as cancer or mother and child health.
Primary care is provided by family medicine physicians, mainly in solo practices, under contracts with the DHIHs. Family medicine physicians have a gatekeeping role, although direct access to a specialist is possible for certain specific conditions. Family medicine physicians are not required to assure provision of primary care out of hours, at weekends or during public holidays, but they do on-duty calls in continuity care centres. Patients often rely on ambulance services and/or hospital emergency departments if they need medical assistance, including non-urgent care and within regular office hours. Although strengthening of primary care has been on the policy agenda since 1990, primary health care services remain underused and there is overutilization of hospital services. There are inequities in access to primary care, with access poorer in rural areas. A number of specific measures have been implemented in recent years to increase access to primary care services in rural areas, but there is no evidence of their effectiveness.
Specialized ambulatory care is provided through a network of hospital outpatient departments and polyclinics, specialized medical centres, centres for diagnosis and treatment, and individual specialist physician offices under contract with the DHIHs. Specialized physicians who work in ambulatory care generally divide their time between the public and private sectors.
Inpatient care is provided by a large hospital network, with hospitals varying in terms of size, competences and catchment areas. Similar to primary care, the accessibility of ambulatory specialized care and inpatient care is poorer in rural areas compared to urban areas. Day care is provided in hospitals and health care centres under contract with the DHIHs. The most frequent health care services provided on a day care basis in Romania include hypertension and diabetes monitoring, radiotherapy, monitoring of HIV/AIDS patients and endoscopy. Day care services expanded considerably in 2014, following an amendment of legislation that enabled a wider range of services to be provided as day care and a change in the payment for day surgery and day care, although there remains scope for further increasing the provision of day care in Romania.
At the hospital level, emergency care is provided by hospital emergency units. These units can be accessed directly through self-referral or by ambulance. A high percentage of ambulance call-outs are resolved at the patient’s home and do not require admission to hospital, indicating overuse of ambulance services and shortcomings in primary care.
While it has increased over the years, pharmaceutical consumption in Romania remains low compared to the levels observed in other EU Member States. There is concern about the underuse of generics in Romania, which has been attributed to the claw-back mechanism, price-setting procedures and lack of incentives to encourage the use of generics. There are also concerns that the lower prices of some medicines in Romania compared to other EU Member States may lead to parallel exports and consequent shortages in Romania.
Rehabilitation care is provided in ambulatory and inpatient settings, but access to such care is not adequate and there are long waiting lists. Access to LTC and palliative care is also poor, and Romania has one of the lowest residential LTC coverage rates in Europe, with only 7.9% of the needs for palliative care covered in 2014. Mental health care is still largely provided in institutional settings and a shift to community settings has yet to be achieved.
5.1 Public health
Public health is defined by Law 95/2006 as “the organized effort of the society towards the protection and promotion of population health” (Title I, Chapter I, Art. 2(1)). Public health services include health promotion, disease prevention and improving quality of life, and comprise the following activities: immunization; control and surveillance of diseases and risk factors; monitoring population health and health determinants; measuring efficiency and effectiveness of health care; assessment of population needs; health promotion and health education campaigns; occupational health; and environmental health, among others. The main strategic document in the area of public health is the National Health Strategy 2014–2020, which includes public health as one of the three main priority areas (see section 2.5 for the general objectives in the field of public health).
The provision of public health services is coordinated by the Ministry of Health, which is also responsible for the strategic planning and organization of public health services. The NIPH provides technical assistance, including the provision of data, expertise and training, on public health and related matters to the Ministry of Health and other ministries, such as the Ministry of Labour, Family, Social Protection and Elderly, Ministry of Environment, Waters and Forests, and ministries with their own health networks, such as the Ministry of Internal Affairs, Ministry of National Defence (Fig2.1) and other institutions with responsibilities in public health. It comprises four national specialized centres: the National Centre for Environmental Monitoring of Risks in the Community, the National Centre for Communicable Diseases Surveillance and Control (NCCDSC), the National Centre for Methodological Coordination and Information on Occupational Diseases and the National Centre for Health Status Evaluation and Health Promotion, as well as six regional public health centres, which are located in Bucharest, Cluj, Iași, Sibiu, Târgu Mureș and Timișoara, and function as the regional branches of the NIPH. The regional centres have mainly methodological and technical roles.
The 42 DPHAs, which represent the Ministry of Health at the local level (see section 2.3), are responsible for the provision of public health services locally, which include: monitoring the health of the population and health determinants; identification of public health needs of communities; performing controls of health institutions; coordinating the implementation of national public health programmes at the local level; carrying out sanitary inspection and health promotion activities, and so on.
Public health activities are also performed as part of medical care services contracted by the DHIHs. They are mainly carried out by family medicine physicians and include: early detection of diseases through check-ups; family planning; antenatal and postnatal care; health education and preventive activities. Family medicine physicians also perform special services under the national public health programmes (e.g. immunizations), which are contracted by the DPHAs. For example, family medicine physicians participate in the screening programme for cervical cancer.
Environmental risks monitoring
The National Centre for Environmental Monitoring of Risks in the Community under the NIPH is responsible for the supervision and monitoring of environmental health. The Centre is divided into specialized departments that are in charge of supervision and monitoring in their respective areas of competence: food and nutrition, occupational health and radiation hygiene. The Centre also coordinates the National Programme of Monitoring Environmental and Occupational Health Determinants implemented by the DPHAs. The NIPH publishes yearly reports on the environmental community risk monitoring.
There are some concerns about the effectiveness of environmental health surveillance and monitoring; for example, in 2014, only about half (48%) of the 50 monitored natural bathing basins were found to be in compliance with the legislative provisions and only 40% of drinking water distribution systems had complied with EC norms; about 5% of drinking water distribution systems were not monitored (NIPH, 2014). There is a comparatively high incidence of diseases that can be attributed to contaminated water in public fountains; for example, in 2010, the incidence of hepatitis A was 16.3 cases per 100 000 population, compared to 2.7 in the EU (WHO Regional Office for Europe, 2016). This can be viewed as a reflection of the low level of preventive measures taken by the DPHAs and family medicine physicians, especially in rural areas, where most communities do not have a sewerage system and people obtain drinking water from public fountains (NIPH, 2014).
Communicable disease surveillance, control and notification
The NCCDSC under the NIPH coordinates surveillance of communicable diseases in the country and is the coordinating competent body that interacts with the ECDC. The legislation on communicable diseases has been harmonized with EU standards. The reporting system covers over 110 communicable diseases, separated into three categories: diseases requiring immediate nominal notification by phone; diseases with nominal notification within five days after detection; and diseases with numerical periodic reporting (weekly, monthly, quarterly and annual). Any doctor who diagnoses a patient with a communicable disease included in the reporting system must report it. In addition, there are networks for the surveillance and control of certain diseases, coordinated by institutions, such as the Institute for Infectious Diseases “Matei Balș” for HIV/AIDS and the Institute of Pneumology “Marius Nasta” for TB, but data collected are also sent to the NCCDSC.
Overall, surveillance of communicable diseases is considered to be well organized and regulated. An assessment by WHO/Europe in 2001 highlighted a number of shortcomings in the epidemiological surveillance system for communicable diseases, identifying a lack of procedures and of microbiology laboratory capacity, as well as some overlapping responsibilities. This was improved in 2003 and 2004 as part of the PHARE programme of financial assistance pre-EU accession, which included enhancing technical capacity, conducting specialized training of epidemiologists and microbiologists, and establishing a coordinating body for the epidemiological surveillance network (Stevens, 2004).
However, there remain challenges in the surveillance of nosocomial infections, which are underreported by hospitals. This is mainly because, in the past, nosocomial infections were included in the individual performance indicators of hospital managers and the latter therefore did not report all cases to avoid being penalized. While the penalties have been abolished, the rate of hospital infections remains included among the indicators against which the performance of hospital managers is evaluated, thus there is an incentive to underreport infection. Efforts are being made to increase awareness of the importance of reporting nosocomial infections, monitoring antimicrobial resistance and reducing their impact. At the time of writing, the Strategic Plan for Prevention and Fighting of Nosocomial Infections 2016–2018 planned that the following measures would be taken in the 2016–2018 period: excluding hospital infection rates from the list of performance indicators; reducing the false reporting of microbiological diagnosis indicators; employing epidemiologists and infectious diseases specialists in all hospitals for antibiotic stewardship; and training hospital managers on the importance of surveillance and reporting.
Occupational health services
Occupational health is regulated mainly by the Law 319/2006 on Occupational Health and Safety. The Ministry of Labour, Family, Social Protection and Elderly, in collaboration with the Ministry of Health, is responsible for elaborating the national policy and strategy on occupational health and safety. The Ministry of Health is responsible for coordinating occupational health services at the national level, surveillance of occupational health through the DPHAs, provision of training and continuing education in occupational health, coordinating research activities, the notification and reporting of occupational diseases, issuing authorizations for occupational health offices and controlling the quality of occupational health services.
According to the legislation, each employer should assure occupational health services such as periodic medical check-ups and prophylactic health care services for their employees, although the extent to which this is being implemented is not regularly monitored. To that end, employers enter into contracts with private occupational health offices or employ an in-house occupational health specialist. The list of prophylactic health care services that employers have to assure for their employees is established by a government decision. If occupational health is perceived to be a public health problem in a given district, occupational health and professional diseases wards must be established within the district hospitals. This is done at the initiative of the DPHAs.
The DPHAs are notified about the incidence of occupational diseases and report on this monthly to the NIPH’s National Centre for Methodological Coordination and Information on Occupational Diseases. The NIPH also provides technical assistance on occupational health to ministries, DPHAs, employers and so on, and carries out research and assessment surveys on occupational risks.
The National Institute for Research and Development in Occupational Health “Alexandru Darabont” conducts scientific research and methodological activities in the area of occupational health and safety. It is also in charge of training and retraining of specialists in health and safety at work and provides technical assistance and consultancy to companies, for example on meeting the provisions of the legislation in force.
Surveillance of population health and well-being
The National Centre for Health Status Evaluation and Health Promotion under the NIPH is responsible for the surveillance of population health and well-being. Population health is evaluated mainly on the basis of general public health statistics published yearly and statistical bulletins on specific aspects of population health published periodically by the National Centre of Public Health Statistics and Informatics. Some aspects of population health are assessed using special surveys, such as surveys of self-perceived population health and health determinants undertaken by the National Institute of Statistics or special projects and initiatives. Examples include the 2012 National Report on Oral Health in Children and Young People and the 2013 Evaluation of the Nutrition Status in 6–9-Year-Old Children within the European Childhood Obesity Surveillance Initiative. Specific organizations, such as the Institute for Infectious Diseases “Matei Balș” for HIV/AIDS and Institute of Pneumology “Marius Nasta” for TB, also undertake assessments. Since 2007, information on cancer patients has been recorded in eight regional registers, coordinated by a National Committee. Through this initiative, the Ministry of Health intended to align Romanian cancer databases with international (WHO, International Agency for Research on Cancer) and European Network of Cancer Registries (ENCR) standards and recommendations.
Health promotion and education and disease prevention
The NIPH is responsible for health promotion and education. Education and information campaigns are also conducted by NGOs as part of specific projects, for example by the Romanian Association for Health Promotion, the Alliance for Fighting Alcoholism and Addictions, the Romanian Association for Education in Diabetes, the Anti AIDS Romanian Association and the Romanian Alliance for Suicide Prevention. There is recognition that the performance of preventive services is “suboptimal” (Ministry of Health, 2014, p. 28) and, in response, the National Health Strategy 2014–2020 (see section 2.5) proposes measures aimed at improving health education for certain vulnerable population groups and particular areas, such as maternal and child health, reproductive health, communicable diseases and healthy lifestyles.
The NIPH also coordinates the development, implementation, monitoring and evaluation of most of the national health programmes financed by the Ministry of Health. The following national health programmes, all renewed on an annual basis, were in place for the 2015–2016 period:
- National Programme for Immunization
- National Programme for Surveillance and Control of Communicable Diseases
- National Programme for Prevention, Surveillance and Control of HIV
- National Programme for Prevention, Surveillance and Control of Tuberculosis
- National Programme for Surveillance and Control of Nosocomial Infections and Monitoring of Antibiotics Use and Antibiotics Resistance
- National Programme of Monitoring Environmental and Occupational Health Determinants
- National Programme for Transfusion Safety
- National Programme for Cancer Screening
- National Programme for Mental Health and Prophylaxis of Psychiatry Pathology
- National Programme for Early Detection of Endocrine Disorders
- National Programme for Mother and Child Health
- National Programme for Health Status Evaluation, Health Promotion and Health Education
- National Programme for Management of National Registries of Chronic Patients
- National Programme for Dietetic Treatment of Rare Diseases
- National Programme for Transplants.
The preventive component of many of these programmes is, however, seen to be weak; for example, the National Programme for Health Status Evaluation, Health Promotion and Health Education includes a subprogramme on the prevention and control of tobacco consumption but it does not include any measures aimed at preventing smoking, instead focusing on the treatment of smoking addictions and supporting smokers who wish to give up smoking.
Some of the national health programmes were specifically established to include screening activities, such as screening for cardiovascular diseases risk factors; cancer (cervical cancer, breast cancer, colorectal cancer, prostate cancer); osteoporosis in women after the menopause; and phenylketonuria, congenital hypothyroidism and hearing screening in newborns. However, there are no publicly available data on the impact of these activities on morbidity and mortality rates (see section 1.4).
Certain preventive services, such as preventive checks-up provided in primary care for people at certain ages, are financed by the NHIF. These check-ups include laboratory tests for the early detection and risk assessment for different diseases (see above).
Access to health promotion and education as well as to disease prevention interventions is considered to be inequitable, with certain vulnerable groups having poorer access, (for example, Roma populations or homeless people) because they are more difficult to reach. The Roma health mediator programme is an example of a measure introduced in order to improve access to health care workers for Roma communities (see section 5.14).
The reported annual rates of nosocomial or healthcare-associated infections (HAI) in Romania between 1995 and 2015 varied between 0.3% and 0.7% of patients (CNSCBT, 2015). However, a point prevalence multi-country survey conducted by the ECDC in 2012 which included ten hospitals in Romania reported a much higher rate: 2.8% of patients with at least one HAI on a given day, and over 5% for the re-validated data in five hospitals. This is more in line with the EU average rate of 5.7% and indicates that the nationally reported figures are likely to underestimate the actual rates (ECDC, 2017). The following factors may suggest that this is indeed true: the very low number of epidemiologists and hygiene nurses in hospitals; lack of compliance with hygiene and other HAI prevention norms of medical staff; old hospital infrastructure with no advanced isolation units; and high bed occupancy rates in some hospitals. However, the main reason for underreporting is the fact that the rate of nosocomial infections has been included among the indicators against which the performance of hospital managers is evaluated.
Impetus for the reform
The government that acceded to power in November 2015 listed HAI prevention as one of the internal processes to be improved in order to attain its health policy objectives (Government of Romania, 2016). This may have been partly motivated by public pressure following a nightclub fire in Bucharest earlier in October (that also precipitated the change of government). The media revealed that many of the fire’s burn patients died or had to be transferred to clinics outside of Romania due to multi-drug-resistant nosocomial infections.
Consequently, in April 2016, a Strategic Plan for Prevention and Fighting of Nosocomial Infections 2016–2018 was launched. This plan was developed based on findings of site cross-checking evaluation of a sample of 112 hospitals.
Content of the reform
The main objectives of the HAI prevention policy are: (1) Increasing capacity for diagnosis, prevention and control of HAI; (2) Development of an effective reporting system; (3) Improving surveillance and reducing antibacterial resistance in the hospitals; and (4) Reducing the overuse of antibiotics. The measures to be implemented during 2016–2018 include: development of the legislative framework, development of an investment plan in order to improve the endowment of the microbiology laboratories and HAI control and prevention structures of the hospitals, and training the staff involved in the prevention, surveillance, diagnosis and control of HAI (Ministry of Health, 2016a).
The implementation of this policy will be evaluated based on indicators set out in the National Programme for Surveillance and Reduction of HAI. They include a prevalence study of the HAI and sentinel surveillance in the high risk departments. The targets set for 2018 for the 108 hospitals included in the Programme are: an increase in HAI reporting to 2% of patients, and of HAI incidence to 5% in the sentinel surveillance medical units. The only data available on these indicators for 2015 is the HAI incidence in the sentinel surveillance medical units, which was 2.51% (Ministry of Health, 2016b). The 2016 values are not yet available.
CNSCBT (2015). [National Centre of Surveillance and Control of Communicable Diseases] Consumul de antibiotice, Rezistența microbiană și Infecții Nosocomiale în România-2015 [Antibiotic consumption, Antimicrobian resistance and nosocomial infections in Romania] (http://www.cnscbt.ro/index.php/analiza-date-supraveghere/infectii-nosocomiale-1/684-consumul-de-antibiotice-rezistenta-microbiana-si-infectii-nosocomiale-in-romania-2015/file, accessed 13 June 2017)
ECDC (2017). European Centre for Disease Prevention and Control. Exploring opportunities for support in healthcare-associated infections – Romania, 4–7 July 2016. Stockholm: ECDC; 2017. (http://ecdc.europa.eu/en/publications/Publications/mission-report-HAI-Romania-4-7-July-2016.pdf, accessed 13 June 2017)
Government of Romania (2016). Priorități strategice și planuri de acțiuni sectoriale ale ministerelor pe anul 2016 [Strategic priorities and sectorial action plans of ministries for 2016] 15 January 2016 (http://gov.ro/ro/obiective/strategii-politici-programe/prioritati-strategice-i-planuri-de-actiuni-sectoriale-ale-ministerelor-pe-anul-2016&page=1, accessed 13 June 2017)
Ministry of Health (2016a). Lansarea Planului Strategic de Prevenire şi Combatere a Infecţiilor Nosocomiale [Launch of the Strategic Plan for Prevention and Fighting of Nosocomial Infections 2016–2018]. Comunicate de presa[Press Release] 26 Aprilie 2016 Bucharest, Ministry of Health (http://www.ms.ro/2016/04/26/lansarea-planului-strategic-de-prevenire-si-combatere-a-infectiilor-nosocomiale-2/, accessed 13 June 2017)
Ministry of Health (2016b).Strategia Națională de Sănătate 2014–2020. Sănătate pentru prosperitate. Raport annual privind stadiul implementării. 2015. [National Health Strategy 2014–2020. Health for wealth. Annual report on implementing stage. 2015]. Bucharest, Ministry of Health (http://www.ms.ro/documente/Anexa%201%20-%20Strategia%20Nationala%20de%20Sanatate_886_1761.pdf, accessed 13 June 2017)