240912 12/21/2009 11:21 09BUCHAREST843 Embassy Bucharest UNCLASSIFIED//FOR OFFICIAL USE ONLY 09BUCHAREST337 VZCZCXYZ0000 PP RUEHWEB DE RUEHBM #0843/01 3551121 ZNR UUUUU ZZH P 211121Z DEC 09 FM AMEMBASSY BUCHAREST TO RUEHC/SECSTATE WASHDC PRIORITY 0171 INFO RUEHVI/AMEMBASSY VIENNA PRIORITY 2119 RUEAUSA/DEPT OF HHS WASHINGTON DC PRIORITY UNCLAS BUCHAREST 000843
STATE FOR EUR/CE ASCHEIBE VIENNA FOR RMO WGREEN
E.O. 12958; N/A TAGS: ECON, AMED, EAID, EFIN, PGOV, RO SUBJECT: ROMANIA: HEALTH SYSTEM REMAINS ON LIFE SUPPORT
REF: BUCHAREST 337
SENSITIVE BUT UNCLASSIFIED. NOT FOR INTERNET DISTRIBUTION.
1. (SBU) Summary: The Romanian healthcare system is in serious trouble, beset by a convergence of the economic crisis, political instability, and government budgetary woes. A recent report by the Romanian Academic Society (SAR) highlighted the major problems plaguing the system. With expenditure on healthcare falling to 3.2 percent of GDP (979 million USD) even as GDP contracts by over seven percent this year, the resources necessary to ensure basic quality care to Romanian citizens are evaporating. The country's unsustainably low level of health expenditures can only add to the long-standing corruption, brain drain, inefficiency, and poor quality already plaguing the system. While the problems, and to some extent the solutions, are readily apparent, none of the key stakeholders yet appears willing to embrace substantive reforms. Instead, stakeholders would rather the Government simply increase funding for health by reallocating funds from an already shrinking state budget. With the exception of the pharmaceutical companies, who are opposed to the measure, most other stakeholders support higher taxes on medications to help pay the tab. End Summary.
2. (SBU) Of the 9.3 million active workers in Romania's labor force, whose social security contributions are meant to fund the health system, SAR estimates that only five million or so are actually contributing. While reliable figures are hard to come by--self-employed laborers, farmers, and others often under-calculate their contributions or opt not to pay at all--SAR's estimation suggests that only a quarter of the Romanian population foots the healthcare bill for all 21.5 million citizens. The result is chronic under-funding, even as costs continue to rise. The last of the 2009 annual health care budget was spent by the end of September, leaving a three-month funding shortfall which the Ministry of Health (MOH) has attempted to cover through a series of service cuts and other stopgap measures. With the Government forced to constrain spending under IMF requirements, supplemental funding has not been forthcoming and the MOH has had to tap into the (yet to be approved) 2010 budget.
3. (SBU) According to the SAR report, the overall decline in spending will be around 20 percent this year. This will drive healthcare's share of GDP down to 3.2 percent, making 2009 a real nadir for the Romanian healthcare system. The SAR report notes that Romania is well behind other EU nations both in terms of overall spending and quality indicators, placing 26th out of 27, ahead only of Bulgaria in percent of GDP spent on healthcare. A massive infusion of new resources would be required to bring Romania anywhere close to other EU countries, which spend an average of 8.6 percent of GDP on healthcare.
4. (SBU) As one means of addressing the funding gap, MOH has devised a much-ballyhooed decentralization project meant to transfer hospital financial and managerial responsibility to municipalities, in an attempt to decrease overall operating costs by 85 percent while improving the effectiveness of patient care. The project has already started in Bucharest, but plans to expand it throughout the country in 2010 are on hold. In a visit to nearby Cantacuzino Hospital, EconOff discussed the hospital's experience with decentralization. The hospital administration reported positive results in functionality, acquisition of equipment and psychological well-being of both patients and staff, but also expressed frustration with relatively limited authority in establishing salaries and staffing patterns.
5. (SBU) Cantacuzino is generally considered one of Bucharest's best hospitals, but EconOff was struck by the extreme cost-saving measures in place at even this leading institution--such as using only natural lighting, with windows open for ventilation, in at least one operating room where a patient was undergoing surgery. While the hospital appeared to have a fully stocked pharmacy, patients routinely reported that they must purchase their own medications outside of the hospital, including such basics as painkillers and antiseptics. The operating rooms only had a limited quantity of surgical supplies on hand, and according to numerous anecdotal reports, "disposable" surgical supplies are often reused without adequate sterilization, resulting in the occasional transmission of blood-borne illnesses such as Hepatitis C. Local authorities in other cities, such as Ploiesti, have told EmbOffs that they have refused MOH offers to hand over administration of hospitals to their communities because the Government only wants to transfer managerial responsibility while depriving them of central funding or granting local revenue-raising authority.
6. (SBU) Another MOH solution to the funding crunch has been to impose a "clawback" surtax on pharmaceutical sales retroactive to the beginning of the year. The surtax was passed in October as a Cabinet emergency ordinance, meaning it took immediate effect, but could still be reversed if Parliament eventually votes to overturn it. MOH is expecting the tax to raise approximately 100 million RON (35.17 million USD) in 2009 and 570 million RON (200.49 million USD) in 2010. Pharmaceutical companies protest that the GOR is unfairly targeting them, citing previous MOH measures (such as imposing a below-market currency exchange rate and a "minimum European price" rule for drug sales) that industry says are detrimental both to profits and to business relations.
7. (SBU) Low wages for medical staff drive the twin problems of corruption and brain-drain. The average Romanian doctor makes approximately 500 USD a month, with nursing staff earning significantly less. Low wages and inadequate staffing sometimes result in preventable medical mishaps, such as the recent case of a day-old infant being seriously burned in an (allegedly malfunctioning) incubator when the attending nurse, who was responsible for 29 other infants, left the room for an extended period. In this kind of a working environment, it is not surprising that Romania has lost 4,000 doctors to other EU countries in the last two years and that up to 80 percent of medical students declare an intention to leave following graduation. For those who do stay, "gratuity" payments (i.e., bribes) are considered de rigueur. The proposed solution, a formal co-payment system where patients would provide fixed additional payments to hospitals and doctors, was announced in early 2009. However, it failed to meet the June implementation deadline in the face of strong opposition. The public perception is that such a system would be inadequate to supplant bribery and would likely only supplement it.
8. (SBU) Romanians frustrated with the subpar public system now have the option, if they can afford it, of buying services from a small but growing network of private clinics in major cities. Private health insurance policies to cover care at these clinics (which public insurance will not pay for) are also being marketed. The two-tiered private insurance system that is evolving, and for which policies are now available, consists of a first tier of required payments into the state system, with a supplemental tier covering extra costs for treatment at private facilities. The supplemental insurance options in Romania, while still limited in scope and very pricey for the average citizen, should broaden when the MOH fully implements the decentralization process.
9. (SBU) Comment: While everyone agrees that the Romanian healthcare system is under-financed, a public accustomed to state-provided, cradle-to-grave care still believes that the solution is more government spending. Even were that money available, however, throwing it at the current system won't solve the system's many problems, because the underlying truth is that the Romanian state has proven incapable of providing adequate healthcare even with additional resources. With statistics that place Romania far below EU averages in terms of quality of care, the state monopoly has resulted in corruption, crumbling infrastructure, and widespread frustration. The political unwillingness to consider real alternatives to state control has left the system bereft of funds and has widened health disparities country-wide. Unless Romanians can be convinced that good healthcare is something they will have to pay for--either through higher taxes or consumer-borne costs on the private market--results will remain poor and the quality of the system will continue to worsen. End Comment.