Romania's health system lurches into new crisis

Abstract

As Romania's health system faces an acute funding crisis, the government is risking the wrath of patients and doctors by introducing a deeply unpopular system of co-payments. Ed Holt reports. A new system of patient co-payments has been dismissed by doctors in Romania, who say it will do nothing to save the country's ailing health-care system from total collapse. Designed to bring in more cash to a virtually bankrupt sector and put an end to endemic bribe taking by health-care workers, the payments have been criticised by doctors and experts. They warn it could lead to a huge rise in the number of patients putting off visits to doctors and arriving at hospitals in a critical condition, leave doctors targets for patient anger, and will do nothing to reduce corruption. “Co-payments will not solve anything. The amount of money that could be raised from this is just a drop in the ocean compared to what is needed”, Vasile Astarastoae, the head of the Romanian Doctors' College, told The Lancet. “The co-payments will generate nothing but social inequality and frustration among those that pay them.” The announcement by the health ministry in September that the new co-payments would be introduced next year comes as Romania's health system struggles with huge hospital debts, striking workers, and a horrific hospital tragedy that doctors and patients say has drawn attention to the system's drastic state. In August, six babies were killed when a fire caused by faulty wiring broke out at the Giulesti Maternity Hospital in Bucharest. The tragedy has been blamed on a lack of resources and negligence on the part of underpaid and under-motivated staff. There was only one nurse in charge of an entire maternity ward at the time of the fire and she had left the ward completely unattended for at least 12 minutes during which the blaze broke out. Bucharest authorities later admitted the Giulesti hospital did not have a water sprinkler system that could have averted the tragedy and that only three of the capital's 21 hospitals have a fire alarm system of any kind. But a lack of basic safety measures is just one of the problems at Romania's debt-ridden hospitals. Dire hygiene on wards is a regular complaint. Basic medical supplies are often completely absent in most hospitals, and many patients have to bring their own bandages, syringes, and sometimes medicines to ensure they are treated. Almost all hospitals are deeply in debt. According to official data, the total hospital debt to drug and medical equipment suppliers and utilities was more than €300 million by July. There are also severe staff shortages. Doctors say that 36-h shifts are the norm, often with one doctor left in charge of up to 100 patients on any shift. Understaffing means nurses are forced to do the work of orderlies such as cleaning floors and carrying patients. High-tech equipment is left to rust in storage rooms because specialists have moved abroad for salaries at least ten times those at home. According to the Romanian College of Physicians, a resident doctor earns an average of €200 a month. The average monthly wage in Romania is €320. Salaries are likely to fall in the near future as the government presses ahead with an austerity package that has seen wages for public sector workers, including those in the health sector, cut by 25%. The measures—part of conditions for an International Monetary Fund (IMF) loan that also include a freeze on new hirings in the sector—have already prompted tens of thousands of public sector workers, including doctors, to strike. State spending on health care has already been low for years, and last year was 3% of gross domestic product (GDP). The western European average is 8%. Authorities argue that the new co-payments will raise an estimated €160 million a year at the same time as making care more efficient. Health Minister Attilla Cseke said that many patients go to hospitals for complaints that could be resolved by a family doctor. He says the co-payments will make patients more responsible with their own health and reduce the workloads of hospital staff. At present Romanians contribute 6% of their monthly income to a state health insurance fund. The new co-payments will mean they pay up to an extra €150 a year for health services, with treatments given a designated price. The planned prices include €1 for a consultation with a family doctor, a further €3 for a specialist referral, and up to €50 for an MRI scan. Any treatment needed above that will be free, and emergency medical treatment is excluded from the scheme. But doctors say the system is unfair on the poor and point to numerous exemptions—including pensioners on low incomes, people under 18 years, those on welfare benefits, war veterans, disabled people, and pregnant women. Astarastoae told The Lancet: “The co-payment system is deeply wrong since it applies the same rules to all employed people. It doesn't matter whether someone makes €2000 a month or €200. They both have to pay the same amount for the same medical services. “People will still take the same route through the system as before [by going to hospitals first] and co-payments will not solve the financial crisis in the system. The amounts involved are just a drop in the ocean. 4·6 million people now pay 6% of their monthly income to the health insurance fund. There are millions who are exempt from paying health insurance, but nobody makes up those missing payments on their behalf. “The unemployed benefit from free medical assistance and health services but the Labour Ministry, paying their unemployment benefit, does not pay a penny towards the health insurance fund on their behalf. This means 4·6 million people pay health insurance to support Romania's 18 million permanent population.” Others say it will lead to people unable to afford the payments, delaying visits to doctors with the risk of ending up an emergency case. They also contend that doctors will bear the brunt of a patient backlash against the fees. Bogdan Popescu, Bucharest University Emergency Hospital spokesman, told local media that “many patients are low-incomers who will try to avoid paying. Doctors will be the first to be accused by patients who cannot afford co-payment because they are the ones who enter into direct contact with patients and this situation will worsen the patient–doctor relationship.” The co-payments have also been designed to help stamp out informal payments or bribes. Minister Cseke was quoted in Romanian media as saying that the payments would make treatment fees more “transparent”—a thinly veiled reference to rooting out bribery. It is hoped that with set fees being paid in advance patients will be reluctant to make further informal payments later. In a recent report the World Bank estimated that patients made informal payments to medical staff of €280 million a year. The same report stated that once checked into a hospital, a patient spends about 75% of their family's monthly income on such informal payments. Patients say payments are often expected from medics and can be anything from a few Euros to a ward sister to ensure clean linen to thousands so that the relevant specialist will be present at an operation. Critics of the apparently institutionalised corruption say that patients continue paying bribes because they are afraid of potentially life-threatening consequences if they do not. A national poll published in December last year by the local IMAS polling agency showed that 85% of Romanians believe that they will not get adequate care in hospital if they do not make informal payments to medical staff. The European Commission's yearly report on Romania earlier this month said that in another survey two-thirds of respondents said they had offered money to medical staff and that 81% believed those payments were crucial to ensure good treatment. In May this year, a 9-year-old boy admitted to Slatina Hospital, central Romania, with a broken arm died after doctors did not treat an infection he developed while there. The boy's mother Ionica Biculescu told local media: “they kept him for 3 days in the hospital and did not pay any attention to him. They asked me to buy medicine to treat him and I did. But I had no money to give to the doctors as my family is poor. As a result, my little boy was ignored.” The hospital's manager and medical director were both sacked and a criminal investigation was launched. Ionut Stancioiu, who became father to a baby girl in August, told The Lancet he paid out more than €3000 to staff at a Bucharest hospital during his wife's pregnancy. “It was a little bit here and a little bit there to make sure she and the baby got the best treatment. If you do not give the nurses or doctors some money, they will ignore you. If you do, it ensures medical staff listen to you, give your wife painkillers and explain to her how to handle the baby. Over all, with her pregnancy, we must have spent about €3000.” Doctors will not officially admit to any bribery in the system, but privately say that it is widespread and will continue whether co-payment fees for procedures are introduced or not. One senior doctor at a Bucharest hospital told The Lancet: “paying a bribe will always get someone to the front of the waiting list for an operation and every time a patient pays a doctor or nurse some money they see things get done and the staff's behaviour is different. This encourages more payments to be made and medical staff to expect a payment for services to be performed.” Meanwhile, critics of the co-payments scheme say that it will not stop the health system's terminal decline. Opposition MP Tudor Ciuhodaru, who is also head of the Emergency Department at one of Romania's largest hospitals in Iasi, eastern Romania, told The Lancet: “the Romanian health system is in its final stages and after that it will flat line. In the last 3 years, over 8000 doctors, dentists and pharmacists have been given certificates allowing them to work abroad. According to Doctors' College estimates, by 2015 over 50% of doctors will leave the country because of work conditions and low income. The economic crisis will affect Romanians' health and patient numbers will increase, while there will be fewer and fewer doctors, all of whom will face daily stress, violence and humiliation.”