Romanian Journal of Bioethics, Vol. 10, No.

2, April - June 2012

INTEGRATING HEALTH SERVICES

WITHIN THE HEALTH REFORM
POLICY IN ROMANIA
Cristian Vlădescu*, Vasile Astărăstoae**
Abstract
Along with the change of the financing mechanism, based on the “money follows the insured
person” principle, the modification of the structure and functioning of the health services
delivery in Romania has also been proposed. The conceptual foreground also had the
competition and integration of services horizontally and vertically, as to ensure continuity and
quality of medical services at the most efficient costs. Therefore, the main changes within the
hospital care, emergencies, primary care, drugs and quality of medical services delivered in
Romania are presented.

Keywords: hospital care, primary care, integrating services, medical emergencies, competition
with regulated costs, quality of medical services.

The second level of significant Astărăstoae, V., 2012] is represented by

changes proposed by the health reform the segment consuming/using the most
law already mentioned within our resources from the health budget, the
previous article [Vlădescu, C., hospital sector, as seen in table 1.

*
Prof., Dr., “Victor Babeú” Univ. of Medicine and Pharmacy, Timiúoara, General Director of the National
Public Health, Management and Training School, Bucharest, Romania, e-mail: cristian.vladescu@gmail.com
**
Prof. Dr., „Gr. T. Popa” Univ. of Medicine and Pharmacy, Iaúi, Romania, President of the Romanian
College of Physicians

78
 Table. 1. Resource allocation within the Romanian health sector, HNI, 2011
2003 2004 2005 2006 2007 2008 2009
Administrative 5,95% 4,83% 6,40% 6,40% 5,61% 1,70% 1,53%
Expenses
Public Health 1,77% 2,64% 3,23% 3,23% 1,55% 1,37% 2,02%
Programmes
Hospitals 46,51% 40,65% 39,33% 38,35% 40,74% 39,10% 41,45%
Ambulatory Care 14,02% 13,90% 12,71% 12,22% 13,86% 16,33% 13,86%
Medical Products 20,98% 27,82% 28,57% 28,57% 27,23% 26,55% 25,55%
Suppliers
Residential Health 0,84% 0,91% 0,85% 0,78% 0,67% 2,09% 2,07%
Care
Others 9,91% 9,24% 10,44% 10,44% 10,34% 12,86% 13,49%

Essentially, the modification of founder or single shareholder (for

hospital organizational structure was
proposed such as to allow the
encouragement of effective practices and
penalty of the others, which currently
cannot be applied. Thus, a hospital
manager cannot hire personnel when
needed, with the necessary number and
structure, cannot fire the unnecessary
personnel, cannot pay differentially the
personnel according to their
performance, cannot change the number
and structure of the hospital wards,
cannot claim/access funds from financial
institutions, although their projects would
be financially reliable etc. Basically, in
our days, an efficient hospital manager
must have personal contacts in the
National Health Insurance Fund and
Ministry of Health allowing him to get
additional funds on any other criteria not
related to the development project for his
hospital. This happens mainly due to the
legal requirements that treats the hospital
as a pure budgetary unit similar to a
school or police station and gives a
political view to all managerial positions
in hospitals.
This could be remedied, in the
legislative proposal, by allowing the
hospitals to become facilities having their
legal status as a trust company,
association or even company. The
companies) would be the current owner
or the local community representative in
most cases. This simple change, also
combined with a change of the
insurance system, could massively
change the hospital running, inclusively
by the chance of accessing funds from
the private financial market. These
organizational models have been working
in the Great Britain for over 15 years, in
Spain and also Poland or Baltic
countries. The new structure would allow
the management team a greater freedom
of action at all levels, from personnel to
structure and technique, while
maintaining the ownership at the level of
public institutions (there is also the
option to entail new partners, in different
ways which legally are not possible
today). At the same time, the
responsibility of the management team
would be more clearly ascertained,
inclusively by adding patrimonial
liability provisions in the management
contract of that cannot be included in the
current organizational structure.
Within this context it would have
been much easier to set such performance
management criteria and assess the
health facilities that would justify their
activity, without the involvement of the
government or the corresponding

79
ministry in appointing the manager or
changing the hospital structure. At the
same time, the medical assistance
integration formula described in the
Presidential Commission Report could
have been developed faster and more
effectively, even if non-existent today,
assisting at a medical practice in
hospitals without a functional relation to
the primary medicine or with the
preventive services, yet with major
dysfunctions in medical care continuity
[Vlădescu, C., Astărăstoae, V., Scîntee,
SG, 2010].
In addition, as international practice
shows, additional funds could be
attracted much easier by those hospitals
presenting economically viable
development plans, including the access
to bank loans or to resources from
several health institutions. Hospitals may
affiliate /merge and simultaneously
develop, manage or have primary and
ambulatory care offices as well.
Consequently, a vertical integration of
the health services can be ensured, with
no need for permanent intervention of the
state; the purpose of this model is to
provide the patient with treatment at the
most appropriate level of the health
system, leading to efficient medical
services on one hand and to continuity of
care on the other hand, which is so
poorly present in the current health
model. Hospitals could be hence
encouraged, by means of the contract
with the insurance company and by the
need to keep the patients pleased and as
healthy as possible, using hospital
admissions and invasive, costly curative
services only for those cases which
cannot be solved differently; in the
current traditional model, hospitals gain
precisely from admissions and costly
invasive procedures, both directly
through the existing contracts with
financing agencies, and indirectly by
80
means of the formal and informal
payments from patients. Directing
hospitals to „extramuros” integrated
medical models is not just financially
unrewarded but also not legally allowed.
According to the law, hospitals may
sign contracts with many financing
agencies, within the limit of their
competencies and accepted volume of
treatments certified by the health
authorities, strengthening their role of
monitoring and evaluation the health
structures. In fact, contracts with several
financing agencies are also allowed by
the current legislation, while a hospital
may simultaneously have financing
contracts for delivering specific services
with a district health insurance fund, with
the transport fund (CAST), the military
structure fund (CASOPSNAJ), the local
public health authority, the Ministry of
Health and also with other private
structures (such as private insurance
funds or private companies for their own
employees); the major difference is that
in this proposed model, the medical
personnel could be paid according to
their medical performance, which is
actually impossible today; thus, there are
situations when, for example, a surgeon
may have surgeries every month, while a
colleague in the same hospital performs 6
surgical procedures every week. The
former may receive a salary equal or
even higher than the latter, based on the
work experience and not their medical
performance. Moreover, there may be
cases when the first surgeon discharges
patients who afterwards, on a regular
basis, need treatment for different
avoidable complications after the
procedure, compared to his colleagues.
Currently these cases are not even known
as there is no differentiation between an
effective medical practice and an
opposite one. In the proposed legislative
model, besides the financial
compensations connected to the volume
and quality of work, there is also the
option for insurance companies and
hospitals to sign selective contracts with
medical personnel according to their
objective performances. Essentially, the
legislative change as they have been
proposed did not request for additional
state funds in this case but on the
contrary it facilitated resource entailing
without increasing the state budget
deficit.
Corroborating the two legislative
aspects concerning insurances and
hospitals could also lead on medium term
to another beneficial effect for the
Romanian health system. Therefore, the
directive concerning cross-border
treatment for EU citizens will come into
force in 2013. This directive facilitates
the treatment of the EU patients in other
countries than the residence country,
facilitating the reimbursement of medical
service costs without the previous
approval from the residential country; in
essence, this mechanism will allow the
medical services to be reimbursed at
tariffs practiced in the country where the
patient is insured and not at those costs
practiced within the country where they
received the treatment [Vlădescu, C.
Busoi C, 2011]. Considering this aspect,
the directive could become a competitive
advantage for the health system for such
a country as Romania, given the relative
qualification of the workforce and the
healthcare costs still lower than within
the rest of EU. If Western European
patients wanted to be treated in Romania,
they should benefit from similar
conditions as those from their own
country which should encourage
companies and hospitals to invest both in
the modernization of the health system
and in the know-how needed for an
efficient organization, only if the legal
framework facilitates this undertaking.
81
As a matter of fact, this model did work
partially and at a small scale in the case
of private dental practice offices in
Romania, generating significant funds
from the services offered to several
patients from abroad, without any major
investment from the Romanian
government.
The proposed legislation aimed to
retrieve a current situation which is
unfavourable both to public hospitals and
patients, having a negative impact on
costs from the social health insurance
system, both in terms of allocative
efficiency and opportunity cost (money is
spent with less effect on the health
status). Nowadays, with almost a single
public insurance company, it is
considered that any insured person shall
benefit from the basic hospital services
package at system level, with no
requirements, regulations and consistent
monitoring at individual hospital level;
thus private hospitals funded (and) by
CNAS can - and often do - treat patients
for less complicated and less expensive
cases, transferring complicated cases to
the public hospital system, achieving a
transfer of costs and a “reverse subsidy”
as it is known in the specialized literature
[Morris S, Devlin N, Parkin D, Economic
analysis in health care, John Wiley &
Sons, 2007]. As a consequence, most
people paying taxes and insurance to the
public system do not have additional
resources for private hospitals which are
usually accessed by those with high
incomes who, when private resources are
exhausted, benefit from the public system
with priority (intra-hospital transfers or
specific references made by doctors
usually having concurrent contracts with
both hospitals). This leads to an unfair
competition to the detriment of public
hospitals that are forced to treat serious
and expensive cases refused / untreated
in the private system. Thus, despite
appearances, the current public system
actually supports the private hospital
system; legislative proposals have led to
"equal opportunity" for the two systems.
If private hospitals did not offer the
whole package of basic services they
either had no contract with the new
insurance companies or did not get any
reimbursement if continued to maintain
the current behaviour regarding patient
selection and costs transfer mentioned
above. On short, the proposed provisions
made no distinction based on ownership
but on the ability to offer continuous care
to insured patients, while the
beneficiaries were the competitive and
qualified hospitals providing the full
range of care according to accreditation /
classification obtained from the Ministry
of Health (MoH).
With respect to the emergency care,
the legislative proposal maintained the
current integrated emergency system
unchanged (SMURD, UPU,
ambulances), as it can be seen in Box 1.
The proposed project allowed the
Ministry of Health to approve public or
private emergency services or services of
different institutions (local governments,
employers, health insurance companies,
etc.) which, depending on the needs of
the system and on the available funds,
might have got the access to the public
emergency system, under the same terms
of payment as in public services.
Nowadays this model partially operates
in the current integrated emergency
system in the sense that for certain types
of emergency services the dispatch
emergency unit 112 may send private
ambulances on field (the so-called
medical transport and home care, A1 and
A2), the model proposed by the draft
legislation allowing the same approach
for major emergencies under the same
medical and financial terms as in the
current system and under the same
82
integrated service dispatching by the
same emergency call 112 across the
entire EU.
Thus, MoH has a procurement plan
for the next 3-5 years of approximately
1200 ambulances, with an estimated cost
of approximately 100 million USD. The
acquisition costs will be added to the rest
of the operating costs, both direct and
indirect costs. If the MoH approves half
of the number of required ambulances
purchased from other sources, accepting
them into the integrated emergency
system, this will make an investment
savings of approximately 50 million
USD, increasing accessibility of the
population (at least) to the same quality
and financial standards as now. In
addition, any maintenance costs, repairs
etc. are deferred to owners, relieving the
public system (MoH) of additional
expenses and possible overconsumption,
being able to assess the real costs of the
system, from procurement to
maintenance. Finally, it was the Ministry
of Health who decided annually whether
needing additional services or investing
money from the state budget to purchase
ambulances, instead of only paying for
services at pre-established quality
standards and rates. There is no claimed
option that the appearance of certain
private structures of ambulances (i.e.,
MoH) shall lead to lower quality of
services provided in the integrated
emergency system, since the same
structure of the MoH approved and
monitored the quality and performance of
medical act, according to the current
procedure in the above mentioned
segment of the emergency care (A1 and
A2). Another criticism related to this
field referred to the fact that some of the
doctors or emergency personnel working
in the public ambulances system could
leave towards the new structures,
attracted by higher material benefits; on
one hand this is happening today and
individual choice cannot be avoided but
on the other hand the proposed
legislation allows doctors and staff
wanting to leave the choice of working
within the same integrated emergency
care service in Romania and not abroad
as it happens now when there are no
alternatives to the circumstances offered
by the public emergency system, where
all staff are paid according to the
budgetary standards.

The box 1. Law no.95/2006 provisions regarding emergency care compared to the newly
proposed legislative provisions
Provisions of Law no. 95/2006 Proposed legislative provisions – the
differences from Law 95/2006 are in italic
and bold
The current operation of the integrated Current operation of the integrated
emergency service, outpatient section. emergency service, outpatient section.
1. Emergency care is provided for free to all 1. Emergency care is provided for free to all
patients regardless of their insured status patients regardless of their insured status
2. National central dispatch unit 112 2. National central dispatch unit 112
3. Participation: 3. Participation:
- Public ambulances - all types of - Public ambulances - all types of
emergencies emergencies
- SMURD - SMURD
- Private Ambulances, with the previous - Private Ambulances, with the previous
acceptance from the MoH for transport and acceptance from the MoH for transport,
medical home care medical home care and major emergencies
- Local authorities cannot buy ambulances - Local authorities can buy ambulances for
for major emergencies (i.e. with specific major emergencies (i.e. with specific medical
medical equipment), and cannot hire doctors. equipment), and can hire doctors.
The current operation of the integrated The current operation of the integrated
emergency service, hospital section emergency service, hospital section
1. The medical emergency care is provided 1. The medical emergency care is provided
for free to all patients regardless of their for free to all patients regardless of their
insured status insured status
2. It is provided in the UPU (Emergency 2. It is provided in the UPU (Emergency
Receiving Units) and CPU Emergency Receiving Units) and CPU Emergency
Receiving Rooms) of the emergency Receiving Rooms) of the emergency
hospitals, which can be only public hospitals hospitals, which can be only hospitals
according to Law 95/2006, Article 65 (2) approved by MoH, facilities that can be
3. All hospitals in the social health insurance foundations, associations or companies
system are required to provide first aid in belonging to central or local authorities or
emergency cases, until the transfer to a to other public or private entities
specialized medical facility. 3. All hospitals in the social health insurance
system are required to provide first aid in
emergency cases, until the transfer to a
specialized medical facility.
The emergency care in case of collective The emergency care in case of collective
accidents, calamities and disasters in the accidents, calamities and disasters in the
current legislation proposed legislation - identical
1. It is coordinated by The Emergency 1. It is coordinated by The Emergency
Situations Inspectorate at the national or local Situations Inspectorate, at the national or
level, according to national plans. local level, according to national plans.
2. In the event of collective accidents, 2. In the event of collective accidents,

83
 calamities and disasters, ambulance services
and hospitals, regardless of their organization
or property, are required to provide
emergency medical services upon the request
of the competent authorities.
3. The costs for these services will be
reimbursed according to the rates of the
social health insurance system.
The basic first aid and the qualified first
aid in the current legislation
The basic first aid, without specific
equipment, is provided by any person trained
in this respect or by persons without previous
training acting upon the instructions of the
specialized staff working in emergency
medical dispatch units or outpatient
emergency services such as SMURD and
county or Bucharest city ambulance service,
in order to prevent complications and save
lives until the arrival of the intervention crew
(Article 87).
With regard to emergency hospital
care it is worth mentioning that the 67
emergency hospitals spend today about
50% from the total health budget
allocated to hospitals in Romania,
according to the National Health
Insurance Fund for 2010 [Activity Report
2010].
By introducing the new insurance system
where money strictly follows the insured
person and maintaining the current legal
ban of having other emergency hospitals
than public hospitals, would have
impeded insurance companies to select
hospitals that provide integrated health
care having a different form of
organization, therefore limiting the
conceptual pivot of this legislative
framework, i.e. competition. In other
words, the insurance companies would
have been forced from the start either to
contract 50% of funds only with certain
hospitals to provide integrated care for
their own insured persons, or, on the
contrary to take emergency cases from
these hospitals and transfer them to other
hospitals that they would contracted for
84
calamities and disasters, ambulance services
and hospitals, regardless of their organization
or property, are required to provide
emergency medical services upon the request
of the competent authorities.
3. The costs for these services will be
reimbursed according to the rates of the social
health insurance system.
The basic first aid and the qualified first
aid in the current legislation - identical
The basic first aid, without specific
equipment is provided by any person trained
in this respect or by persons without previous
training acting upon the instructions of the
specialized staff working in emergency
medical dispatch units or outpatient
emergency services such as SMURD and
county or Bucharest city ambulance service,
in order to prevent complications and save
lives until the arrival of the intervention crew
(Article 87).
more efficient services, thus creating the
disadvantage for patients of not
benefitting from continuous care in the
same hospital. Moreover, a recent survey
shows that a third of the interviewed
Romanians would rather have a private
health insurance if there were private
emergency hospitals. In addition, 18%
from those who initially declared they
were not interested in private health
insurance, change their mind when they
were given the possibility to access
emergency services from private
hospitals, hence increasing the
percentage of those interested in private
insurance to more than 50% of the
interviewed persons [IMAS Marketing
and Polls, 2012].
On the other hand, this aspect would
be a disadvantage for hospitals if they
were willing to maintain the actual status
as emergency hospitals and they could
not change their organization and
implicitly their management and
financing mechanisms. Furthermore, this
would have led to the concentration of
the entire financial effort in ensuring the
equipment and maintenance of the
emergency units the UPU (Emergency
Receiving Units) and CPU Emergency
Receiving Rooms) solely on public
resources, which would have been
another disadvantage for patients (instead
of paying only medical services from the
public budget, it is necessary to support
the costs for investments, repairs and
miscellaneous costs which limits the
access of patients to the medical care.
These arguments were also used in the
case of the pre-hospital emergency care.
It should be noted that if a public or
private hospital wanted to create an
emergency department, the Ministry of
Health was again the competent body to
approve the department, upon the
evaluation of the equipment and
personnel in accordance with the norms
developed by the specialized directorate
of the Ministry of Health, which is also
the case. The Ministry of Health also had
the responsibility to decide the location
and the number of hospitals with
emergency departments that can be
financed from state budget.
Another proposal that could quickly
lead to the efficient use of resources was
related to medication area. Regarding
the National programs currently
consuming more than one third of the
compensated medication budget it was
provided the introduction of cost-volume
contracts and cost-volume-outcome
contracts. Consequently, (multiple)
annually negotiation between the
Ministry of Health and medicine
producers could establish the total
number of patients that can be treated
with the amount available from the
national budget. The number of treated
patients could be exceeded only if the
treatment costs were supported by the
producers, taking this additional number
of treated patients into account during the
negotiation of the next contract (namely
85
increasing the budget share allocated to
companies dealing with more patients
paid from public funds).
Where suitable, payment will be made
only according to the achievement of
certain parameters / outcomes agreed in
the contract (such as the improvement of
certain biological parameters, decreased
plasma viral concentration, etc.). The
medication area might also provide the
opportunity to become a "preferred
pharmacy", which could, based on
volume, negotiate with insurance
companies additional clauses to the
generally applicable ones, regulated by
the state (including terms of payment).
The primary health care at the
community level was also enacted to put
into practice the proposals of best
international practices in this area,
mentioned in the report: interdisciplinary
care teams locally, under the
coordination of local authorities
[Vlădescu, C., et al, 2008]. Currently, on
this segment, local authorities have no
mechanism enabling them to ensure the
health of residents.
According to that, there would be teams
formed by the family physician as
coordinator by the community nurse, the
social worker and the healthcare
mediator. Where there is no family
doctor the local council is allowed to
directly employ a doctor, with clearly
defined functions (the model that exists
in many countries, including in France
where many Romanian doctors were
employed by the local authorities).
Prevention activities should become a
liability shared by the local and national
authorities (there is no involvement of
local authorities today).
At the same time it was legally
encouraged to have the possibility of
integration between the hospital care and
pre hospital care, including the
possibility of having joint budgets to
ensure the continuity of care.
In this model, for example, methods of
prevention referring to the coronary heart
disease, considered to be the main cause
of death in Romania, could be more
easily promoted, since hospitals were
also interested in participating in this
process. Yearly increasing the number of
patients that were mounted coronary
stent decrease mortality from acute
myocardial failure only for a short term,
but on long term this is not a sustainable
method, as apart from requiring
considerable financial resources, it does
not decrease overall mortality or cardio-
vascular mortality. Consequently,
primary and secondary prevention
measures, jointly with primary care
system are necessary.
Another proposal was related to the
quality of medical services. In this
respect it was considered to create an
agency for information and quality in
care health area (NACIS). The agency
was essentially described in 2008 on the
Presidential Commission report and
proposes to concentrate all the existing
resources in this area as soon possible for
the new institution to become functional.
This goal was also maintained in the
mentioned legislative proposals, as a
mixed agency formula able to respond to
the needs of the public bodies and local
health market. ANCIS ought to
participate in creating quality standards
for medical services and information
provided in the health system, essential
for functioning on a competitive basis to
the proposed new scheme for financing
and delivery of health services.
According to that, ANCIS could
participate in the external quality
assessment of medical services, medical
technology with respect to the
institutions providing these services, by
assuming current organizational and
functional structure that deals with the
86
accreditation of hospitals in Romania
(CoNAS). Moreover, the proposed board
of ANCIS maintained the actual board of
CoNAS and added certain members from
the Ministry of Health on the Board of
Administration Council (CA). This
vision would ensure a certain decisional
autonomy, while structures represented
in CA were given full legitimacy. A very
similar model, in terms of functions and
structure, exists in France and it is named
the Haute Autorité de Santé (HAS). The
need of a specific quality control
structure was specified and required by
most international organizations that
were involved in the assessment / audit
of the health system in Romania in the
last decade [WB, 2010].
Conclusions and discussion
Latest report on the performance of
health systems in Europe ranks Romania
on place 32 out of the 34 evaluated
countries, first place being still occupied
by the Netherlands [Powerhouse, 2012].
From this point of view, Romania
maintains the same position as before the
EU accession. In this context, Romania
has the lowest percentage of GDP
allocated to health, with an annual rate of
about 5.5% over the past four years
[WHO, HFA] but nevertheless about one
sixth of the consolidated state budget is
spent on health, representing over 80% of
total health expenditure, one of the
highest rates of total public expenditure
in the EU health budget.
This makes tax free space to be very
limited for the public funds, being
necessary to increase funding solutions
for this system, without limiting
accessibility to services. At the same
time it is necessary to find solutions that
lead to more efficient allocation and use
of limited resources, mainly to those
areas that can lead to improved health for
more people, such as preventive services
and primary health care services.
Under these restrictive given
conditions, a comprehensive global
health reform was required to modify a
rigid bureaucratic and centralized health
system as to allow decision and the
allocation of resources at all levels to
take place on a competitive basis and
focus on the obtained results, namely on
better health, more effective resource use
and patient satisfaction.
The desire to have a change of all
health sectors at the same time was based
on the experience that came from the
previous failed attempts to change the
health system which, in spite of being
successful in their area of action, they did
not lead to the expected results for the
global health care and patient
satisfaction, mainly due to the lack of
coordination with the rest of the system.
The best known example is family
medicine, the first one to be changed
since 1993-1994, regarded in all
assessments as failing to fully achieve the
initial objectives, partly because the lack
of coordination with other segments of
the healthcare system and the lack of
complete integration [WB, 2010].
A more recent example may be the
emergency system, considered one of the
few successful examples in the
Romanian health system.
The table below shows the evolution of
data from 2005, the year before the
change of the emergency health care. The
data collected refer to the number of
admissions to emergency rooms or units
and the survival rate as they were
reported by hospitals in the DRG system.

Table 2 Situation of cases admitted in emergency rooms during 2005-2010 at national level,
Source: DRG National Data Base
Year No. of % acute No. of acute No. of % chronic No. of No. of
validated cases cases validated cases chronic deaths in all
cases in admitted in admitted in cases in admitted in cases cases
acute care emergency emergency chronic emergency admitted in admitted in
patient rooms rooms care rooms emergency emergency
rooms patient rooms rooms
rooms
2010 4,713,606 57.31% 2,701,584 349,709 13.17% 46,057 45,556
2009 4,963,141 56.53% 2,805,629 366,460 15.32% 56,131 45,290
2008 4,933,028 55.47% 2,736,217 368,732 15.85% 58,457 40,686
2007 4,769,030 55.01% 2,623,469 343,267 16.13% 55,372 37,452
2006 4,491,281 54.30% 2,438,830 304,868 17.90% 54,574 34,931
2005 4,495,430 51.77% 2,327,349 259,868 16.78% 43,604 33,296

It can be noticed the increasing of within the emergency admitted patients is

death numbers among the admitted cases
reported as emergencies from 33,296
cases in 2005 to 45,556 in 2010,
representing a 27% increase, while the
total number of admitted and reported
emergencies increased from 2,370,953 in
2005 to 2,747,641in 2010, which only
represents 16%.
Even if it can be argued that the
significantly increasing death number
due to the fact that a more performing
emergency system leads to the hospital
the more complicated cases that
previously did not have the chance to be
admitted, (by the decreasing time of
intervention, increasing and
diversification of ambulances number
and intervention cars, better technique,
the staff qualification, etc), finally the
mortality increasing with 27% is not a

87
desirable result, neither for patients nor
of the health system. This aspect is also
caused by the fragmentary approach such
as the increasing performance of the pre-
hospital emergency care system, without
a simultaneous approach of a segment of
hospital care (usually intensive care and
invasive services), at least in hospitals
with public emergency structures.
From the technical point of view, all
the proposed changes had strong
reasoning and justification yet from the
political point of view, the situation was
different. Every new option which has
been introduced in the reform legislation
resulted in the coagulation of different
opposing parties towards change.
Probably one of the biggest mistakes of
the new reform promoters was that they
underestimated the extent of possible
opposing parties and overestimated their
support for the health reform. While all
the opponents to the reform have quickly
allied, the promoters have not succeeded
(having no strategy in this direction) to
mobilize institutions and individuals
benefitting from the proposed reform,
believing that they will supporting more
favourable changes than the current
status quo. But it turned out once again
that, despite the numerous and daily
claimed problems and shortcomings, the
Romanian health system has a
remarkable resistance to change.
Furthermore, the 23 ministers of health
after 1989 are an eloquent proof not only
with respect to the major changes in the
health care system but even to the day to
day management of the system.
It was hoped that in a period of
general crisis, when the old norms
referring to the role of state within the
social sector are being questioned
everywhere in Europe, a proposal based
on an approach to ensure universality of
access to health services on a platform of
reforms oriented to the so called internal
88
market with regulatory competition,
keeping the access to health services,
would have become a consensual
platform for the majority of actors in the
system. Nevertheless, this reasoning did
not take into account the strong
conflicting realities of an election year,
when every idea, no matter how
technically persuasive, can be politically
used and distorted.
In addition, the fact that, from the
beginning, the reform attempt was
strongly and constantly supported by
President Basescu the law was criticized
and rejected mainly for this reason and
not for the proposals, acceptable or not,
promoted by the law which were not
even get to be discussed in the end. The
opposing parties considered this
approach as an opportunity to confront
President Basescu rather than a debate
and challenge of the law. Labelling it as
“Basescu's law” led to blending of public
feelings, for or against the President,
within the public debate, the requests
finally aiming to the President’s
dismissal rather than to change the law. It
was more a matter of accepting or
rejecting the President rather than the law
and therefore any substantial debate
became irrelevant, eventually
withdrawing the law from the debate.
It should be underlined that the
overlapping plans were nearly identically
applied in the (unsuccessful) health care
reform proposal of President Clinton
from 1992 to 1996 and even closer in
time in the case of the law promoted by
President Obama, which gained the
negative name of “Obamacation” as it
was expressed in the speech of his
political opponents, having a high social
impact and, according to polls,
negatively affecting elections. Because of
the proposed and adopted law, 36% from
American electorate declared that they
wouldn’t vote for Obama as president,
while 21% declared that the adopted law
would determine them to vote for him
[Page, S., 2012].
Another aspect that was mentioned as
a cause for the failure of the law, also
seen in the case of the failure of the
previously mentioned Clinton reform,
was related to the speculation that the
legislative proposal was drafted by a
group of experts who "secretly" worked
to produce the first draft of the law. In
fact, the situation was completely
reversed, firstly because it took place in a
significant public debate process, the law
draft beneficiated from a „white paper”
containing the situation analysis,
identifying priorities and proposing real
solutions to the existent needs and
resources, few other laws being provided
with such a complex intercession. The
entire project lasted 3 years as it was
shown in the previous article [Vlădescu,
C., Astărăstoae,V., 2012]. But even
without this approach any initiative
would have to be firstly drafted and later
be subjected to debate, reaching this
stage when the law had already been
withdrawn!
Finally, political communication
finds important what is said, how it is
said, who says it and when they say it [C.
F. Smith, 2009]! None of these rules was
attentively planned, and if “what”
includes a huge context that could have
been used (from the proposed law and its
connected documents to the Presidential
Commission Report and the debates for
the Health Pact), whereas for the rest
there was no strategy but on the contrary
there seemed to exist a non-combat
strategy from those who had to promote
it (MoH).
The positive side of the entire
approach is perhaps the one brought in
the national debate, even if highly
politicized and polarized, the health care
system in Romania. It seems to be a
89
broad consensus about the precariousness
of this system, from its funding to its
organization, remaining as a further
proposal to build on the lessons resulted
from the promotion of the draft health
law described in these articles.
Finally we will discuss the results of
an analysis on competition and
privatization in the health system
published after the law draft was
withdrawn from the public debate, one of
the main fears of the debate in Romania
concerning the negative role of the
private sector and of competition in
public health services. We should
mention that the report was drafted by
The Office of Health Economics in Great
Britain, the country with one of the most
"socialized" health systems in the EU.
Evidence both from the UK and other
countries suggests that quality based
competition with prices fixed by a
regulator can be beneficial, producing
higher quality care at the same cost on
average and, importantly, not leading to
increased inequity in accessing the health
care. It is therefore sensible to consider
the extension of quality competition with
fixed prices where it is feasible.
Competition is potentially useful to
stimulate the provision of better quality
and more health care for the NHS’s
budget beyond what is possible in the
absence of competition. Competition
does not require and does not equal
privatization. We would encourage
competition, where it looks to be both
beneficial and feasible, between publicly-
owned providers. We do not propose
changing the ownership of any existing
providers. But we also would not wish to
prevent private not-for-profit or for-profit
providers from joining in any
competition. The provision of accurate
and timely information on the quality of
services is fundamental to competition.
This is only valid when competition is
limited to quality (prices are fixed by a and price (i.e. prices are flexible) The
regulator) or simultaneously to quality Office of Health Economics, 2012.

Bibliography
[1]. Björnberg A. Euro Health Consumer Index Report, Health Consumer Powerhouse AB,
2012. [serial online] 2012 [cited 2012 May]. Available from: URL:
http://www.healthpowerhouse.com/files/Report-EHCI-2012.pdf
[2]. CNAS. Raport de activitate pentru anul 2010.
[3]. Institutul NaĠional de Statistică. Anuarul Statistic al României, 2011.
[4]. IMAS. Sondaj privind sistemul sanitar din România, accesat la http://medlive.hotnews.ro la
data de 22.05.2012.
[5]. Ministerul SănătăĠii. Comunicat de presă, publicat la 15.12.2011, pe site-ul www.ms.ro.
[6]. Morris S, Devlin N, Parkin D. Economic analysis in health care. John Wiley & Sons:
England; 2007.
[7]. The Office of Health Economics. Report on Competition in the NHS, Jan. 2012, accesat la
http://www.ohe.org/publications/article/report-of-the-ohe-commission-on-competition-in-
the-nhs-108.cfm în 4 feb. 2012.
[8]. OECD. Health at a glance; 2010.
[9]. OMS. Baza de date Health For All, accesată in 5 martie 2011.
[10]. Page S. Health care law hurting Obama. USA TODAY 28 Feb. 2012.
[11]. Smith CF. Writing Public Policy: A Practical Guide to Communicating in the Policy-
Making Process. Oxford University Press; 2009.
[12]. Vlădescu C, Astărăstoae V. Politica Reformei Sanitare din România. Rev Rom Bioet
2012;10(1):5-16.
[13]. Vlădescu C et al. Raportul Comisiei PrezidenĠiale pentru analiza si elaborarea politicilor din
domeniul sănătăĠii publice din România. Bucureúti; disponibil
la:http://www.presidency.ro/static/ordine/COMISIASANATATE/UN_SISTEM_SANITAR
_CENTRAT_PE_NEVOILE_CETATEANULUI.pdf; 2008.
[14]. Vlădescu C, Astărăstoae V, Scîntee SG. Un sistem sanitar centrat pe nevoile cetăĠeanului.
România. SoluĠii (II). Rev Rom Bioet 2010;8(3):5-14.
[15]. The World Bank, ECA, Romania Functional Review Health Sector; 2010.

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