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Viewing cable 08BUCHAREST601, ROMANIAN HEALTHCARE PART 1: AILING PUBLIC SYSTEM HOBBLES

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Reference ID Created Released Classification Origin
08BUCHAREST601 2008-07-30 13:41 2011-08-25 00:00 UNCLASSIFIED//FOR OFFICIAL USE ONLY Embassy Bucharest
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 
 
SIPDIS 
SENSITIVE 
 
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. 
 
SUMMARY 
 
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 
 
BUCHAREST 00000601  002 OF 002 
 
 
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. 
 
COMMENT 
 
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. 
 
TAUBMAN