164158 7/30/2008 13:41 08BUCHAREST601 Embassy Bucharest UNCLASSIFIED//FOR OFFICIAL USE ONLY VZCZCXRO9446 PP RUEHAG RUEHAST RUEHDA RUEHDF RUEHFL RUEHIK RUEHKW RUEHLA RUEHLN RUEHLZ RUEHPOD RUEHROV RUEHSR RUEHVK RUEHYG DE RUEHBM #0601/01 2121341 ZNR UUUUU ZZH P 301341Z JUL 08 FM AMEMBASSY BUCHAREST TO RUEHC/SECSTATE WASHDC PRIORITY 8534 INFO RUEHZL/EUROPEAN POLITICAL COLLECTIVE PRIORITY RUEAUSA/DEPT OF HHS WASHINGTON DC PRIORITY UNCLAS SECTION 01 OF 02 BUCHAREST 000601
E.O. 12958: N/A TAGS: ECON, ELAB, PGOV, SOCI, AMED, RO SUBJECT: ROMANIAN HEALTHCARE PART 1: AILING PUBLIC SYSTEM HOBBLES TOWARD DECENTRALIZATION
Sensitive but Unclassified; not for Internet distribution.
1. (SBU) Romania's public healthcare system is at a crossroads. At present, the system's resources are distributed unevenly and unreliably throughout the country. The quality and accessibility of care, cost of services, and competence of personnel remain unpredictable, ranging from tolerable to shockingly bad, with pervasive petty corruption throughout the system. As Romania faces increasing EU pressure to improve its public healthcare system, plans are underway to decentralize hospitals, shifting administration from the national to the local level, both in Bucharest and in other parts of the country. While decentralization may improve efficiency, it does not address another key issue affecting quality: the exodus of medical personnel who continue to search for higher wages and improved working conditions outside of Romania.
2. (U) This is the first in a three-part series on healthcare in Romania. Subsequent cables will focus on pharmaceuticals and the emerging private healthcare sector. End Summary.
LOW FUNDING MEANS POOR QUALITY SERVICE
3. (SBU) On paper, Romania's healthcare system appears comprehensive. CNAS is an insurance-based, universal coverage system which is funded by the government. Payroll taxes collected from both employers and employees are paid into CNAS, with the state allocating an additional amount to cover the unemployed. Employers and employees each pay 5.5% of gross wages, though this figure is slated to decrease to 5.2% as of December 1, 2008. Public health insurance covers medical services from the first day of sickness or the date of accident until full recovery. The list of medications covered by insurance is revised yearly. This year, more than 2,000 medications are included in the insurance provided under the CNAS plan.
4. (SBU) However, despite the comprehensive nature of public health insurance at first glance, the total official expenditures on healthcare are actually very low compared to the rest of the EU. In 2007, spending on healthcare was equal to approximately 4.7% of GDP, or about 350 USD per person. In contrast, EU average spending for the same year was 1,200 USD per head. As a result, while all treatments are theoretically available, shortages in medications and even basic supplies are not uncommon, which means that those patients who offer the largest "gratuities" to their caregivers are usually served first. The low salaries for most medical staff foster a culture whereby bribes from patients are an expected part of the take-home compensation.
5. (SBU) The quality of healthcare in rural areas remains far below even the poor standards of care available in larger cities. Throughout the country, the lack of standard medical practices or accountability to patients increases the likelihood of errors. Thus, quality of patient care is particularly reliant on the professional ability of doctors. Depending upon the time of the month, hospitals may run out of supplies to perform even basic tests. Hospitals and mental care facilities are overburdened by persons abandoned by their families, without the staffing or financial means to provide proper care.
DECENTRALIZATION AS A SOLUTION?
6. (SBU) At present, the Romanian healthcare system is owned and controlled almost entirely by the state, but tentative efforts are underway to decentralize the sprawling, over-consolidated medical system. The first decentralization effort began ten years ago, when general practitioners (GPs) were removed from the state salary rolls and encouraged to set up private practices. As private practitioners they compete with one another for patients. While nominally independent, Romanian GPs in reality are essentially contractors providing regulated services to patients under the National Health Insurance House (CNAS) plan. Under this universal coverage plan, general practitioners are the system's "gatekeepers," responsible for writing prescriptions and making referrals to specialists. Most Romanian GPs serve only a limited number of cash-paying clients outside of the regulated system.
7. (SBU) New efforts to continue decentralizing by shifting the management of hospitals from the state to the local level are also underway. Bucharest's newly-elected mayor, Sorin Oprescu, has formed a working group with the national Ministry of Health to find a way to administer Bucharest's 42 hospitals locally, rather than at the national level (although they would still be funded out of the national budget). Health Minister Eugen Nicolaescu has indicated his support for this effort and plans to expand the idea of local hospital administration to other municipalities over the next year. The hope is that these efforts to decentralize will cut bureaucracy and lead to improved conditions. For now, quality of care varies
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drastically for Romanians depending upon where they live, their ability to make informal payments for care, personal connections, and which medicines, staff and equipment happen to be available on a particular day.
THE EU AND THE DIASPORA OF DOCTORS AND NURSES
8. (SBU) Pressure on Romania to conform to EU standards in the healthcare sector continues to mount. A proposed directive published by the European Commission on July 2, 2008 would require the closure of all hospitals failing to meet EU accreditation standards. Under this directive, each country will have to establish its own accreditation agency. However, Romanian law has already required hospital accreditation since 2001, but its Agency for Hospital Accreditation has never been established. Since most Romanian hospitals are far below EU standards, many would have to be closed if the accreditation directive is actually applied and in the unlikely event that Romania fails to receive a waiver of the law's provisions.
9. (SBU) EU membership has also allowed medical staff to travel and work freely, creating a brain drain in the public healthcare sector. In 2007 alone, an estimated 5,000 to 7,000 doctors and nurses left the country in search of higher wages and improved work environments. Despite rising wages, this outward migration trend shows no sign of abating. Young medical school graduates remain the most likely to leave. The 300 euros per month they can earn as residents in Romanian public hospitals pales in comparison with the wages on offer elsewhere in the EU. As a result, there is a serious and worsening shortage of medical personnel. The current ratio of patients to nurses in public hospitals can be as high as 40 to one.
10. (SBU) Romanian public healthcare, while billed as a "universal care" system, truly fails to provide universal care on a non-discriminatory basis. The challenge for Romania moving forward will be to reform the system while figuring out how to pay the rising costs of healthcare in the future. The brain drain is too acute for care provider wages to remain at their current level for much longer. Anecdotally, patients are also becoming increasingly intolerant of the opaque costs of healthcare and frustrated by not knowing whether they provided the "correct amount" in gratuities to ensure good treatment. This situation has opened the door to private insurance and to a future hybrid system, in which some cases are handled by the public system while private insurers guarantee extra benefits and transparent costs to patients. The upcoming cables in this series will look at the issues which arise when the publicly run health system collides with private markets. End Comment.