Romania's health-care system is in dire need of reform. Despite a number of modern clinics with highly trained medical specialists, Romania is suffering from an acute lack of funding, as well as a shortage of qualified personnel and modern equipment. Conditions in most of Romania's hospitals are precarious, while subsidized drugs are scarce and young doctors are leaving the country in droves. In part two of a five-part series on the state of health care in the former Soviet bloc, RFE/RL correspondent Eugen Tomiuc examines medical care in one of Europe's poorest countries.
Prague, 22 March 2002 (RFE/RL) -- In comments widely publicized by the Bucharest media on 19 March, Romania's former monarch, King Michael, praised the expertise of doctors and the quality of the Western-standard equipment at Bucharest's Fundeni Clinical Institute, one of the country's top hospitals.
At the same time, specialists at a heart clinic in the southwestern town of Timisoara announced they had saved the life of yet another critically ill patient using a cutting-edge procedure.
Meanwhile, the Romanian media largely ignored a more unflattering report, which detailed the poor conditions of some 200 tuberculosis patients at a hospital in Iasi. The patients were being fed a stew made from nettles because the hospital had no money for food.
Despite the existence of top-notch facilities, the latter story is more the norm in the troubled health care system of Romania, one of the largest and poorest nations in Eastern Europe.
Patients are often forced to bring their own food while staying in many of the country's hospitals, most of which lack basic utilities, let alone the latest drugs or medical equipment. Subsidized prescription drugs for low-income pensioners are difficult to find. In a country where the average monthly wage amounts to $100, many nurses and doctors accept bribes from patients in exchange for better treatment. Many young doctors -- discouraged by meager incomes and the absence of professional opportunities -- are choosing to emigrate to the West.
One Bucharest pensioner spoke for many when he expressed frustration with Romania's health care system: "[The system] is down, completely down, and it is unreliable. I have a pension of one million lei ($31), which can only buy my medicine for 10 days. What else should I say? The [health-care] system is not reliable."
Experts say Romania's health-care system is suffering from two challenges: an acute lack of money and half-hearted reform efforts. Between 1990 and 1996, annual health-care spending in Romania grew from 2.7 to 3.2 percent of the country's gross domestic product (GDP). A slight gradual increase since 1997 brought such spending this year to 4.2 percent of GDP.
By comparison, the Czech Republic's health budget amounts to more than 7 percent of the country's GDP, while the European Union average exceeds 8 percent. Romania spends less than $140 per person per year on health care -- one of the lowest levels in Europe. Only Albania, with $63, Ukraine with $128, and Moldova with $133, spend less.
At the higher end, the Czech Republic spends $640 per person and Hungary $370 per person annually on health care, while the EU average amounts to almost $1,700 per person.
After the fall of communism, Romanian officials delayed health-care reforms for years, for fear that a radical shakeup would lead to social turmoil and the collapse of the communist-style system.
It wasn't until 1997 that a new health-care system was introduced in Romania. That year, a new law on health insurance contributions was passed, providing for health-care funds to be collected and used separately within the budget.
Under the new law, employees and employers must each contribute 7 percent of an employee's salary to the national health fund. But many state employers have failed to pay their fair share, causing severe underfunding in medical care today.
The health-care system in Romania is three-tiered. The first tier is primary medical assistance provided by general practitioners, called family doctors. Patients are free to register with any family doctor and can switch doctors at any time. Family doctors are paid depending on the number of patients.
A second tier consists of outpatient clinics where medical assistance is provided by specialists. The third tier covers hospital treatment and comprises an overwhelming 70 percent of total medical assistance in Romania.
Critics of Romania's health-care system say hospital treatments consume such a large part of the nation's health budget that little or no funding is left for preventative care, which should be provided by family doctors and outpatient clinics.
The lack of proper preventative care is held up as the reason that one-quarter of Romania's 22 million people suffer from at least one chronic illness -- with high blood pressure and heart diseases in the lead. In addition, the country's infant mortality rate -- almost 19 per 1,000 newborns -- is the highest in the region. By comparison, Albania's infant mortality rate is 12 per 1,000 newborns.
Romania's Health Minister Daniela Bartos says the government is well aware of the lack of proper preventative care. Bartos says efforts are being made to give preventative care a dominant role within the system: "We must complete the transition from hospital care to preventative health care, because it is obvious that the costs are smaller in primary medicine, and efficiency increases if we manage to prevent or discover illnesses at an early stage, compared to treating serious illnesses, as is the case now in our hospitals."
Romania has a relatively large number of hospital beds -- almost eight per 1,000 inhabitants -- and Bartos says efforts are already under way to evaluate hospital care and make cuts wherever necessary. But she speaks highly of the country's several elite clinics, where difficult transplant operations are performed.
Bartos says the existence in Romania of hospitals with world-class equipment and specialists is a must if the country wants to keep in touch with modern medical developments. She says that despite daunting financial difficulties, Romania has lately invested hundreds of millions of dollars in top-of-the-line medical technology: "It is equally true that over the past several years we made considerable efforts to introduce high-tech medical equipment in Romania's hospitals. For example, the Health Ministry alone obtained government loans of more than $600 million for medical technology."
However, some top Romanian doctors say such elite units are simply an attempt by the government to improve its image.
Doctor Mircea Cinteza is a renowned cardiologist and the head of the Romanian doctors' professional association. He tells RFE/RL that Romania's top clinics and doctors represent the few exceptions to a generally faulty health care system: "Under the circumstances, the medical specialists who have managed to carry on in some academic centers with long-established traditions and a certain level of adequate equipment are islands of normalcy within a system that does not provide an adequate professional environment to doctors, since funds for technology are virtually nonexistent."
Many Romanian doctors and analysts say huge government investments in elite hospitals in such a poor country are a drain on the health-care system. They believe these funds should be diverted to primary and outpatient care.
These same doctors and analysts also warn that lack of money, incomplete reforms, and a high level of bureaucracy in the health-care system may trigger a long-term personnel crisis. With an average of less than two doctors per 1,000 inhabitants, Romania already trails behind other countries in the region. By comparison, Bulgaria and Hungary both have 3.5 doctors per 1,000 inhabitants, while Russia has 4.6.
And the number of doctors in Romania is continuing to dwindle, as an increasing number of medical school graduates -- disappointed by the lack of professional opportunities at home -- are leaving the country.
Cinteza says that after six years in medical school, young doctors must go through a training stage of up to seven years in top hospitals before becoming a specialist. Throughout this period, he says, these young graduates must survive on a salary of $100 to $150 a month, most of the time in expensive big cities. Even once they become a specialist, there is no guarantee they will be able to start a private practice.
Cinteza tells RFE/RL that, faced with such hardships, one in five young Romanian doctors emigrates to Western countries, where their professional skills are welcome: "These are the [main] reasons why the emigration rate among Romania's young doctors continues to be so high. According to many sources, about one-fifth of medical school graduates emigrate -- predominantly to the U.S. On the other hand, Romanian medical school's [level of quality] does not fail. I personally do not know any young Romanian doctor who did not pass all tests necessary to practice the medical profession in the U.S., for instance."
Furthermore, Cinteza says that because of the system's current problems, the number of young people opting to become doctors -- regarded as an elite field during communism -- is dwindling. Cinteza says that before 1989, the number of medical school candidates sometimes exceeded the number of available places by 10 times. Currently, he says, the number of candidates does not cover the available places in Romania's medical schools.
Doctors and analysts alike agree that if this trend is not reversed, Romania could face yet another health-care crisis -- a severe shortage of qualified medical personnel.
(Andrei Manolescu of RFE/RL's Romanian Service contributed to this report.)