“Ovidius” University Annals, Economic Sciences Series

Volume XIV, Issue 1 /2014

A Comparative Analysis of the Romanian and Swedish Public Health

Systems

Niţu Oana
Faculty of Economics, "Ovidius" University, Constanta, Romania
E-mail: oana.oprisan@yahoo.com
Ghiță Constantin
Universitatea Ovidius din Constanța
g.marga@yahoo.com
Dincă Gheorghița
Universitatea Transilvania din Brașov
gheorghita.dinca@unitbv.ro

Abstract Investments in health and education were not

This paper proposes a theoretical analysis
of the overall health system in Romania and
Sweden. Through a comparative approach of
the two systems, the purpose of this article is
to highlight the benefits of health services
provided by the public health sector
institutions correlated with spending levels
allocated by the two governments. The main
results point to the fact that Romania, by
allocating a small percentage of Gross
Domestic Product for the financing of the
health system, faces problems like migration
of health personnel, lack of medicines,
facilities and medical equipment, with
inadequate funding of prevention programs,
etc These results indicate the need for in-
depth reform of the public health.
considered national priorities in Romania,
even renowned authors have shown through
their research that they should be classified
as productive expenditures, and in long term,
they directly contribute to economic growth
[2]. In all European Union governments are
involved in the financing of health care; most
Member States use a combined system
between social security contributions and
direct government funding of health. As for
private insurance, it represents a supplement
rather than a substitute for primary health
care system [3].
A common feature of all health systems
from emerging economies is the shortage of
financial resources. This fact is currently
exacerbated by the economic crisis that has
led many governments to reconsider the level
of public spending in the health sector [4].

Keywords: Government Expenditures, 2. Characteristics for healthcare in

Public Health, Government Policy.
J.E.L Classification: I18, H51
1. Introduction
A good health is a key factor in ensuring
socio-economic development of a country.
The demand for health services is increasing
in terms of people aging under national and
European level. Currently, European
countries are increasingly concerned with
models of policies that should be
implemented in health care, based on the
demographic, technological innovations, and
given the current financial statements [1].
Romania versus Sweden
In most european countries, 'health' was
the second largest function in public
expenditure after social protection. As a ratio
to GDP, the highest levels of government
expenditure were found in Croatia (9.2 % of
GDP or 20 % of total public expenditure), the
Netherlands (8.9 %), Denmark (8.6 %),
France (8.3 %) and Finland (8.2 %) [5].
Health insurance is the means by which
the state protects the health of the population.
In Romania, the institution that deals
directly with these insurances is the National
Health Insurance House (NHIH). The unic
national fund of health insurance builds on

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the contributions of individuals and
businesses, grants from the state budget and
on donations, sponsorships, interest, income
derived from exploitation of NHIH heritage
and other income, including amounts from
revenues of the Ministry of Public Health [6].
In 2013, under Law no. 571/2003
updated, health social insurance contributions
in Romania are 5.5% for the employee and
5.2% for the employer. In employee case,
those contributions applies on gross salary
under an employment contract if it does not
exceed 5 times the average gross earning
used in underlying the state social insurances
budget [7].
In employers case, the contribution is
applied on the gross earnings of resident and
non-resident individuals deriving income
from wages.
The law 95/2006 on healthcare reform,
with subsequent modifications, (GEO
no.107/2010) provides that retirees with
pensions exceeding 740 RON are required to
contribute to the National Social Health
Table no. 1 Total health expenditures as % of GDP, Romania
2006 2007
TOTAL GOVERNMENT 35.5 38.2
EXPENDITURE (% OF GDP)
HEALTH (% OF GDP) 2.7
Source: European Commission
Table no. 2 Total health expenditures as % of GD, Sweden
2006 2007
TOTAL GOVERNMENT 52.7 51
EXPENDITURE (% OF
GDP)
HEALTH (% OF GDP) 6.6 6.6
Source: European Commission
Public expenditure on health (% of GDP)
of 3.1% in Romania in 2012 is well below
the EU average of 7.3% of GDP [9]. In this
respect, Sweden is very close to the EU
average as it can be seen from the table 2.
Health situation of the population can be
analyzed in the light of demographic factors
such as life expectancy or the evolution of
population.
For example, for 2006-2010, National
Institute of Statistics provided data on the life
expectancy of the population, on which we
can find that in Romania, people live on
average less than 80 years [10].
“Ovidius” University Annals, Economic Sciences Series
Volume XIV, Issue 1 /2014
Insurance Fund a share of 5.5% of monthly
pension. The same law provides that, after
the payment of the contribution, the pension
must not fall below 740 lei [8].
In Sweden, however, social health
insurance is part of the Social Insurance
Agency (Forsäkringskassan). The fund
through which health care is provided by
those who live and / or work in Sweden is
funded through taxes and dues. The
responsibility for health and medical care is
held both by the central government and by
county councils and municipalities.
On average, Swedes pay 31.73% of
income for taxes, and if monthly earnings
exceed 4200 euros, the percentage is applied
gradually to the size of income.
In tables 1 and 2 we can observe the
evolution of the share of GDP spent on health
in Romania and Sweden in the period 2006-
2012.
2008 2009 2010 2011 2012
39.3 41.1 40.1 39.4 36.6
3.1 3.2 3.8 3.6 3.4 3.1
2008 2009 2010 2011 2012
51.7 54.9 52.3 51.2 52
6.9 7.4 7.0 7.0 7.1
Table no. 3 The life expectancy in Romania
2006 2007 2008 2009 2010
The life 72.22 72.61 73.03 73.33 73.47
expectancy
Source: www.insse.org, statistical yearbook, 2011
In table 3 it can be seen that this indicator
has shown a slight increase over the years
exemplified (from 72.22 years in 2006 to
73.47 years in 2010), but without reaching
the threshold of 75. The situation is not much
different in 2012, when the average lifespan
was calculated to be 74.22 years, in fact
being among the lowest life expectancy in the
EU (after Estonia, Bulgaria and Latvia).
In 2012 Sweden ranked 4th in the EU in
terms of life expectancy (81.18 years). In the
past, Sweden has been among the countries
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with the highest life expectancy, its value
exceeding the threshold of 80 years.
A real problem facing our country is the
demography. In Romania, the population
number in the period 2005 - 2010 presented
an accelerated decrease and for Sweden, a
significant increase. The population of
Romania decreased by 0.89% in 2010
compared to 2005, while in Sweden the
population grew by 3.85% in 2010 compared
to 2005.
An example regarding how investments in
health can affect the benefits enjoyed by
taxpayers, are the health care facilities. In
table no. 4 is presented the number of beds
available in hospitals in Romania and
Sweden in the period 2005 – 2010.

Table no. 4 - The number of the hospital beds for 1000 inhabitants Romania vs. Sweden
Measures 2005 2006 2007 2008 2009 2010
Romania total population
21,624 21,584 21,537 21,504 21,470 21,431
(thousands)
Sweden total population
9,030 9,081 9,148 9,220 9,299 9,378
(thousands)
Beds no./1000 inhabitants.
6.6 6.6 6.4 6.4 6.5 6.2
Romania
Beds no./1000 inhabitants.
2.9 2.9 2.9 2.8 2.8 2.7
Sweden
Total no. of beds in health care
142,718 142,454 137,837 137,626 139,555 132,872
facilities. Romania
Total no. of beds in health care
26,187 26,335 26,529 25,816 26,037 25,321
facilities. Sweden
Source: www.insse.org, Statistical yearbook 2011 - Period series from 1990 to 2010, Health;
www.oecd-library.org, Country statistical profile Sweden

It can be seen in the data presented in Table no. 5 The medical staff in Romania
Table. 4 that in Romania the number of beds Medical 2006 2007 2008 2009 2010
in health facilities in 2005-2010 decreased in personnel
per
an accelerated manner (from 142 718 beds in 10,000
2005 to 132 872 beds in 2010), while in people
Sweden, the number of 26.187 bed decreased Physician 21.7 22.4 23.4 23.5 24.4
from 2005 to 25 321 by 2010. s
There is a noticeable difference between medical 2.7 2.8 2.6 2.6 2.4
staff
the number of beds in health facilities per
1000 people in Romania and in Sweden. Support 5.9 6.2 6.6 6.5 6.3
While in Romania in 2010 it is estimated to staff
be 6.2 beds per 1,000 people, in Sweden
Source: www.insse.org, Statistical yearbook 2011,
during the same period there were only 2.7 period series from 1990 to 2010
beds per 1,000 people. Hence, it can be In the analysed period it can be seen a
concluded that Sweden invests more in slight increase in the number of doctors per
preventive treatment of population. Thus, 10,000 inhabitants (from 21.7 in 2006 to 24.4
decreasing the number of people who require in 2010) and support staff (from 5.9 to 6.3)
hospitalization, so decreases the need for a and a decrease in medical staff. After 2010,
large number of beds In Romania the according to the data provided by the College
emphasis is not, unfortunately, on the of Physicians of Romania, the situation
preventive treatment, people getting sick changes. More and more doctors leave the
more easily, thus increasing the need for a country, seeking better working conditions
large number of beds in hospitals. and a salary commensurate with their work.
Table no. 5 present the medical staff in In 2012, the number of doctors in Romania
Romania in 2006-2010. fell to 38.813, thus affecting the Romanian
healthcare system.

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In Sweden, the evolution of the number of
doctors who professed, in 2005-2009, was
positive (increased with population), bringing
more confidence to the people seeking
medical care and paying taxes for the funding
of medical staff (see table no. 6).
Table no. 6 Physicians per 1,000 people in
Sweden, 2005-2009
2005 2006 2007 2008 2009
Physicia 3.5 3.6 3.7 3.7 3.8
ns per
1,000
people
Source: www.oecd-library.org, Country
statistical profile Sweden
3. Medical services in the public health
system in Romania vs. Sweden
Being two different systems of health
insurance, the benefits offered to
policyholders are also different for Romania
and Sweden.
In Romania, by signing the contract with
those who are registered in NHIH or with
employers, policyholders are offered a
package of basic health services in case of
illness or accident, a package of opptional
services following the contribution payment
to National Social Health Insurance Fund and
allowances for sick leave. [11] Medical
services offered varies depending on the
position of the individual: a package of basic
health services for those who are
unemployed, do not pay contributions and do
not fall into the category of insured persons, a
package of services for insured persons with
or without contribution and a set of optional
services.
Medical services that uninsured benefit
are: emergency medical services, surgical,
supervision, consultation to monitor
pregnancy and the postpartum period,
immunizations and issues of death
certificates (services provided by the family),
emergency care and detecting potentially
endemic-epidermal disease (services
provided by the practitioner) and solving for
dental emergencies. In addition to these basic
services provided to the uninsured, those who
are insured enjoy optional and curative health
services provided by the family and specialist
doctors. Insured persons in the records of
NHIH, in addition, benefit from: preventive
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Volume XIV, Issue 1 /2014
health care services, health promotion, health
monitoring for patients with chronic
conditions, consultations at home, medical
laboratory (ultrasound) and sick leave
certificate issuing, low reference tickets,
medical exemptions for children, medical
prescriptions, death certificate, etc. (services
provided by the family physician), the
physician consultations on a referral from the
family doctor, blood tests fully or partially
discounted by NHIH and dental services.
In Sweden, all citizens are insured
regardless of their quality, employed or
unemployed, and emergency services are also
guaranteed for those of the EU Member
States and other countries with which
Sweden has concluded bilateral agreements.
There is not a package of defined basic health
services, Swedish health system is organized
so that the individuals receive primary,
preventive, specialty, emergency care,
compensated or free medicine, care for
mental illness, recovery services, medical
services for the disabled, home care, free
dental services for children and young,
compensated adult dental services. Funding
this system is made in a 21 counties and its
operation differs depending on the region the
citizens belong to. The three basic principles
that applies regardless of the region those
requiring care live in are: equal health rights,
solidarity between people and fair ratio
between the costs of healthcare and the
benefits received [12].
In Sweden, health insurance is universal
and it covers the entire population, the
patients are protected by the state, the costs
covered by them are limited so as to not
affect too much the standard of living.
In the following we give some examples
of medical services the Swedes enjoy, and
their costs for 2011 [13]:
 Consultation on a general practitioner:
100-200 SEK;
 Consultation to a specialist: 230-320
SEK;
 A day of hospitalization: 80 SEK / day
for the first 10 days, and for the next days
60 SEK / day;
 For young people aged up to 20 years
old, free preventive controls;
 • For retirees and people with disabilities,
co-payments for medical services can not
exceed 1712 SEK / day;

 Persons under 20 years old receive free
dental care, and those aged over 20 years
old receive state subsidies worth 150-300
SEK/year, only valid for preventive
dental care. For other dental services
required by people over 20 years old, the
costs are borne entirely by them if the
value does not exceed SEK 3,000/year;
the costs with values between 3000-
15000 SEK/year are borne 50% by
patients and the values above 15,000
SEK/year are borne by the people in
proportion of at least 85%;
 No Swedish pays more than 1.100
SEK/year for medical advice. If this limit
is exceeded, medical appointments for
the next year (from the first necessary
appointment) are free. Adults do not pay
more than 2.200 SEK/year for
prescription drugs. For children within a
family, the maximum expenditure on
medicines, incurred in a year by their
descent, is 2.200 SEK.
In Romania, policyholders receive free
medical consultations on a referral from the
family doctor they are enrolled. Without this
reference ticket, costs are not reimbursed by
NHIH and they are fully paid by patients. A
major problem the insured are facing, is that
only certain medical services are reimbursed
by NHIH, so that their advantages compared
with the uninsured are not very high. For
example, in Brasov County Hospital, there is
a list of medical services unsettled by CJAS
Brasov, for which the patients bear the full
cost. For a better understanding we have
selected some examples of medical services
unsettled and their costs (see table no. 7).
Table no. 7 Examples of healthcare unsettled
by CJAS Brasov
Consult by a specialist 50 RON
Skull CT without contrast agent 100 RON
Native cranio-cerebral MRI 350 RON
Abdomen ultrasound 30 RON
Limbs radiography 20 RON
Upper gastrointestinal 100 RON
endoscopy
Source: hospbv.ro, Integrated Ambulatory
section, healthcare rates unsettled by CJAS
Brasov.
As it can be seen, the Romanian insurance
status does not offer any advantage for
complex medical services. However, there
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are situations in which people can feel the
benefits of the monthly contribution to the
fund. For example, based on a referral from
a family doctor or specialist, thepolicyholders
can benefit from a range of free common
analysis in medical laboratories contracted by
NHIH: calcium, glucose, blood counts, etc. A
common point in benefits through the social
insurance system in the two analyzed
countries are the compensated or free drugs
the insured persons enjoy.
In Romania, the insured people benefit
from drugs with or without own contribution,
based on the prescriptions issued by a GP or
a specialist. Prescriptions for medications
may contain 1-3 drugs for each condition
(except for children under 12 months and
patients included in health programs). Drugs
are compensated at a rate of 50%, 90% and
100%, those without personal contribution is
accessible to children aged under 18, young
people aged up to 26 years old if attending an
educational form, chilbed and pregnant
women and persons included in special laws
or people diagnosed with diseases free of
charge.
In Sweden, for drugs needed in a year
whose value does not exceed 1.100 SEK are
entirely out of pocket costs for the ones who
require them. Above this threshold, the drugs
are compensated progressively to 100% [14].
The Swedish health care system provides
some of the best outcomes when compared
with other developed nations that maintain
universal approaches to health care insurance
[15].
However, the Swedish health care system
is also not perfect. Larson (2008) points out
the existing problems in the system, and the
shortage of doctors and hospital beds which
has led to real drama. [16] Public health
bureaucracy led to the migration of highly
skilled personnel to the private sector [17].
4. Conclusions
Small budgets allocated to public health
can not lead to first-class medical services.
Financing the health system in Romania is
realised primarily on account of
contributions, and completing, on transfers
from the state budget. Assigning a rate of
approximately 3% of GDP (among the lowest
in the EU) public health system determines
the quality, sometimes inadequate, of health
 “Ovidius” University Annals, Economic Sciences Series
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services, migration of qualified medical [14] Idem

personnel to the private sector or abroad, and [15] Esmail, N., Health Care Lessons from
under-funding of prevention programs.. All Sweden, Lessons from Abroad. A Series on
these lead to the need of reforming the public Health Care Reform, 2013.
[16] Larson, Sven R. (2008). Lessons from
health system in Romania in order to improve
Sweden’s Universal Health System: Tales
it and to provide quality health services. It from the Health-care Crypt. Journal of
also requires the government to consider American Physicians and Surgeons, 13(1):
health and education as national priorities 21-22
and to allocate appropriate budgets for these [17] Glenngård, Anna H. (2012). The Swedish
areas. Health Care System, 2012.
The health system in Sweden is financed
primarily from general taxes. Swedish central
government is responsible for overall health
policy and it offer grants for the regional and
municipal governments in order to support
health care services. Swedish public health
system is in a continuous reform for
improving the quality of health care and the
access to the system by careful monitoring of
costs.

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[6] Order No. 617 of 13 August 2007, published
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[13] Idem

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