Economic and geopolitical shocks continue to strongly influence the labour market both in Romania and globally. The border war, the negative impact of the pandemic, as well as the level of inflation have led to the globalisation of a cost of living crisis and the accentuation of social unrest with vast ramifications for governments, companies, and individuals.
Since the early 2000s, Romania has achieved significant economic progress. GDP per capita has reached over 60% of the OECD average compared to 30% in the early 1990s. However, the pandemic was a major shock affecting GDP, and although this had returned to pre-pandemic levels by early 2021, nevertheless the pandemic’s effects created longer-term risks. There were positive developments in terms of economic growth in 2022, especially in the first two quarters, followed by a decrease in growth in the third quarter, due to the effects of inflation and the decrease in exports of goods and services.
The inflation rate has increased in the last year well above the forecast level, reaching 16.76% in November 2022, as a result of the increase in food prices, non-food goods, as well as market services, according to a press release[13] issued by the National Bank of Romania (NBR). However, the NBR’s analysis in November 2022 estimated that the inflation rate would decrease starting from the first quarter of 2023, with the possibility that by the third quarter it will reach single figures. The economic forecast for Romania, according to the European Commission[14], indicates an increase in real GDP of about 2% in the coming years (1.8% in 2023 and 2.2% in 2024), which is lower than previous forecasts as a result of the rising inflation rate and the ongoing war in Ukraine. There are also signs of economic growth risks, according to European Commission data, following delays in the implementation of Romania’s National Recovery and Resilience Plan.
The unemployment rate, as calculated by the International Labour Organization (ILO) in 2021 was 5.6%; higher for men (6.0%) than for women (5%). The highest levels of unemployment were among young people (15-24 years old), at 21%. In 2022, the unemployment rate, according to data from the Ministry of Labour, grew slightly from 2.68% in January 2022 to 2.96% in October 2022. The same source indicates that, in October 2022, most unemployed people’s highest level of study was secondary level, representing 30.41% of the total unemployed. According to data from Eurostat, the percentage of young people aged 15-29 who are not employed and who are not following a form of education (NEETs) remained high in 2021, at 20.3%, giving Romania the second highest rate, after Italy.
The flexibility of the labour market has been under serious stress during the last year and the situation is expected to continue for this year as well.
It is now more than obvious that flexibility of work relations and the adaptability of employees are key in building a flexible labour market, that will absorb shocks well.
The voice of the business environment was heard by the Government, which took measures such as introducing ”Kurzarbeit” – short time work – and other flexibility measures. These have included allowing unilateral telework decisions, and enabling the organization of a work programme with different entry hours for employees. It is true that these measures are applicable only for the current, extraordinary situation (the health crisis) but we believe that if they prove efficient, there will be a good case for maintaining them as part of business as usual.
Other measures proposed included electronic signatures, and reduced bureaucracy in applying health and safety measures.
Recent years have been marked by a sharply ageing population[16], with the demographic ageing index rising in 2021 to 121.2 elderly people per 100 young people, putting pressure on social welfare systems. Although the number of young people decreased between 2011 and 2021 by 115.700, in line with the general decrease in the population of Romania, their share in the total population registered a slight increase from 15.9% in 2011 to 16.1% in 2021.
The negative demographic trend has an important impact on the indicators of demographic and economic dependenc and generates significant pressure on the active population, which has to support economic growth on the one hand and the dependent population on the other.
Data from the National Institute of Statistics show that in 2021 the active population was 8.214.682 of which 7.755.487 were employed, down from 2020. The employment rate of the working-age population (15-64 years) was 65.6%, below the EU average of 73.6%, but higher than in 2020, when the employment rate was 64.1% and compared to the pre-pandemic period (the employment rate was 60.7% in the fourth quarter of 2019). At the same time, there are significant regional discrepancies in the share of employed people, the highest being in the Bucharest-Ilfov Region, and the lowest being in the South-East Oltenia Region.
The economy’s ability to create new jobs saw an upward trend in 2021, similar to the pre-pandemic period, and the job vacancy rate in 2021 was 0.86%, up from 0.77% in 2020. However, in 2022, a slight downward trend could be observed, especially in the second and third quarter compared to the first quarter, from 0.95% to 0.91% and 0.90% respectively. The number of jobs continued to decrease slightly in the third quarter compared to the second quarter, and the data from the NBR show a slowdown in employment and a stagnation of companies’ concerns about identifying ways to manage the personnel shortage. The slightly downward trend is also felt at European level, with the average vacancy rate standing at 2.9% in the third quarter compared to 3% in the second quarter of 2022. Romania, along with Spain, with 0.9%, ranks penultimate, after Bulgaria (0.8%) in terms of the lowest job vacancy rate.
The activities of the national economy with the highest rates of job vacancies in the third quarter were public administration followed by water distribution, sanitation, waste management, decontamination activities, as well as transport and storage. The number of vacancies in the state sector accounted for 23% of the total vacancies in the third quarter of 2022. Although the second half of the year saw a slight decrease in demand for labour, in 2022 overall recruitment platforms reported increases in the number of vacancies compared to 2021.
In this context, rising inflation puts even more pressure on employers in terms of the impact on wage costs. Although the average salary was on an upward trend (in November 2022 the net average salary was RON 4.141, up 13.6% compared to the same month of 2021), in reality, the increase did not keep up with the inflation rate. According to data from INS, the real salary index in November 2022 was 97.3% compared to November 2021.
The labour shortage is increasing in Romania due to unfavorable demographic trends, especially due to the decrease in natural growth and the ageing of the population, as well as due to increased emigration. The natural increase rate increased in 2021 to -7‰, compared to -4.4‰ in 2020, as a result of the increase in deaths.
In terms of emigration trends, we can say from the analysis of data that Romania is still a country of emigration. The European Commission’s 2021 annual report on intra-European Labour Mobility shows that in 2020, the highest mobility of all Member States (24%) was represented by Romanians, followed by Italians (11%), Poles (7%), Portuguese (5%) Croats (5%), and Bulgarians (5%). In terms of the active population (20-64 years), Romanians accounted for 26% of the active immigrant population in the European area, an increase compared to 2019.
In an attempt to reduce the labour shortage, mainly due to structural issues such as negative demographic trends, emigration, and demographic ageing, companies are increasingly turning to recruitment from abroad. In September 2022, more than 60.000 employment/posting notices were issued from the quota established for 2022 of 100.000 foreign workers who can be admitted to the Romanian labour market, a quota that was double compared to 2021. However, immigration fails to cover the deficit created by emigration, with a difference of 16.000 people in 2021.
Estimates from the European Centre for the Development of Vocational Training (CEDEFOP) show that for Romania the average employment growth by 2030 will be 10.6%, with the highest rate being registered in the professional category (31.9%) and the lowest for workers in agriculture, forestry and fisheries (-27,5%)[1].
The imbalance in demand for and supply of labour in Romania is also influenced by the poor performance of the education system. In 2022, according to the European Skills Index, which measures the performance of EU competence systems, Romania ranks 25th, with the lowest scores for skills development and activation, but it registers good performance in terms of adapting skills (the degree of their use and the extent to which skills are adapted to the labour market) for which the country is ranked 7th out of EU Member States.
Human capital is the main instrument for competitiveness and growth, and the lack of investment in its formation can affect long-term sustainability. Further steps are needed to involve companies in initial, continuing education and adult participation in vocational training programmes. Although progress has been made in adult participation in lifelong learning (in 2021 the proportion of adults who participated in training programmes in the last 4 weeks prior to the Eurostat survey increased to 4.9% compared to 1% in 2020) the difference remains significant compared to the EU average of 10.8%.
The dual vocational education system is different from technical vocational education and deserves to remain a separate branch in order to be able to optimally match the requirements of the economy with regard to the qualification of the workforce.
The FIC recommends and supports dialogue between state authorities and the private sector , in order to create and make available on the labour market the learning experience and the skills required by the business environment. The ways to achieve this goal are:
We are confident that by implementing the necessary measures, an attractive environment will be created that will have a positive impact on the labour market.
The transition to a green economy and digitalisation are global priority objectives, and directly influence the labour market through the need for the right skills and abilities. In 2021, the most common skills in online job ads were accessing and analysing digital data, collaboration and teamwork, and solving complex problems, while processing information was the least common competence.
Ever-changing markets are leading to a number of changes in both skills and relevant jobs, with global and European studies predicting a future redesign of jobs. Data from the World Economic Forum show that up to 85 million jobs could be cut, and another 97 million jobs could emerge as a result of the new labour market reality[19]. In terms of the skills of the future, the most important will be those related to critical thinking, complex problem solving, resilience, stress tolerance and flexibility.
Current and future trends estimate that technological transformation will lead to new, more complex and more digital jobs, but understanding how digitalisation is re-shaping the labour market requires detailed analysis combining labour demand trends (demand for digital skills) with aspects of labour supply (development and use of digital skills in those positions). In Romania, according to the Study of the Confederației Patronale Concordia[20] on the impact of technology on two sectors in Romania: Automotive and oil & gas, in the two sectors of activity, technology adoption is increasing and it is anticipated that under the impact of digitalisation and technology a number of skills associated with repetitive activities will decrease in importance and there will be an increase in the importance of digital skills, as well as transversal and soft skills (mental flexibility, creativity, problem solving, analysis and decision-making, networking, teamwork, communication, persuasion, negotiation, emotional intelligence). In terms of the training and retraining of existing staff, the leaders of the companies participating in the study mention that they have started measures to support workers affected by the transformation of posts, but the pace of implementation differs.
Job dynamics, changing job complexity, and workers' perception of the benefits and risks associated with technology adoption at work are among the most important aspects that should be taken into account in managing organisations' transition to digitalization.
In 2022, Romania ranked last among the EU 27 member states in terms of the Digital Economy and Society Index (DESI)[21], which clearly indicates that we are facing a digital skills deficit. According to the DESI, only 28% of Romanians have basic digital skills compared to the EU average of 54% and only 9% of Romanians have competencies above the elementary level, compared to the EU average of 26%. At the same time, the total broadband usage rate remains one of the most important challenges to manage, together with increasing efforts to integrate digital technology and digitalize public services.
The pandemic has changed a number of paradigms in the labor market: ways of working and, by implication, the expectations of employees have changed, and this has led organisations to re-evaluate how they relate to employees and how they manage and respond to their needs. Phenomena in the US and Western Europe, such as the Great Resignation, which refers to the record number of resignations, brought to attention topics such as flexibility, employee well-being, stress tolerance, as well as better harmonisation of work and personal life. Its echoes have also been felt nationally, and for many companies and organisations, talent retention has become a priority. Then another phenomenon came, which specialists called Quiet Quitting, which has different definitions: for some it means setting clear limits between working time and personal time, while for others it means fulfilling only the minimum necessary tasks at work, or strictly the work regulated by the contract, without making efforts to improve performance or develop.
We are currently at the stage that specialists call the Great Consideration. This means that employers, on the one hand, are looking at what measures they have taken so far, what has worked and what has not, and what has not been done to ensure that employees are motivated enough to stay within organisations. On the other hand, employees are carrying out their own analysis. The financial component and benefit aspects are increasingly relevant in the current context of the rising cost of living, along with flexibility and sustainability (ESG) aspects. Employers will need to identify what motivational forces their employees have to stay within their organisations and what they can do to attract the workers they need from outsidethe country.
There is a need to rethink certain labour market measures to improve flexibility in work relations, such as:
Although the COVID-19 pandemic served as a magnifying glass on the Romanian health system's existing structural challenges, and significant progress has been made, we continue to face demographic challenges, poor population health, a lack of financial resources, and limited access to medicines.
In response to these challenges, the Romanian authorities should prioritize health innovation in 2023 because it benefits the health of the population and the wellbeing of society, and thus has a positive impact on the national health budget. Patients in Romania, like all other European patients, have the right to access to innovation. We believe that if people have timely access to innovation, it can save their lives.
Through cross-sector collaboration (public & private entities included), Romania can rethink and transform its health policies to increase patients’ access to healthcare. Important structural changes are needed, including an increase in financing and investments in the healthcare system, development of preventative, screening, and early diagnosis programmes, employment of more health workers, enhancement of technology as well as improvement of the infrastructure, coverage, and accessibility of health services to existing patients and citizens, in general.
In order to contribute to the reform of the health system, FIC continued the projects dedicated to medical staff, and also to medical students and residents, which were initiated in 2013 in partnership with the Ministry of Health to draw attention to the exodus of doctors. In 2019, 2021 and 2022, FIC organized courses for hospital managers through the “Leaders for Excellence in Healthcare” project.
The COVID-19 pandemic led to thousands of patients being hospitalised, triggered a significant contraction of GDP of over 4%[22] and left hundreds of thousands of people without jobs. Meanwhile, Romania has an ageing population and there is a constant increase in the burden of non-communicable diseases, likely negatively influenced by pandemic-related limitations in accessing primary, secondary and tertiary healthcare services. Each citizen who is unable to work or who dies prematurely as a result of non-communicable diseases represents a loss of workforce participation and this has an indirect impact on GDP, while workforce participation also continues to decrease due to emigration. Moreover, Romanians are among the biggest groups of EU citizens living in other EU Member States, at over 3 million[23], while the country is facing a shortage of skilled employees.
Investment in healthcare is an investment in the human capital of the country, for the current generation but also for forthcoming ones. Optimised allocations and prioritization of resources through evidence-based public healthcare policy investments are proved to have a positive return in terms of saving lives and improving the quality of life, while promoting economic growth and increased productivity, as seen in other European countries. The economic return could be $2 to $4 for each $1 invested in better health. In higher income countries, implementation costs are more than offset by productivity gains in healthcare delivery. For example, funding of cancer control with capital investments and funding of services ensures equitable financial and geographical access to high-quality cancer services. Investment in an essential package of cancer services and activities could avoid 7.3 million deaths globally from cancer between 2020 and 2030 with gains for the broader health system and economic benefits for governments, families and individuals, along with intangible benefits for citizens. The costs of inaction and the return on investment in healthcare have not been properly analyzed and considered over the past few years. According to recent studies, poor health reduces global GDP by 15 percent. Meanwhile, better use of currently available interventions, with demonstrated cost-benefit value, could bring down the global disease burden by about 40 percent over the next two decades.
Romania has a unique opportunity in 2023 to build on the progress that has been made until now, rebuild its economy and boost competitiveness. The main pillars in the Government’s healthcare programme focus on strengthening the role of prevention - screening and vaccination programs included - rethinking the claw-back tax, expanding patients’ access to new therapies and increasing the number of healthcare professionals.
With multiple EU funds available for Romania; (1) EU Centralized Funding Sources such as EU4Health and Horizon Europe – Health Cluster and (2) Allocated Funding Sources for Romania such as the Recovery and Resilience Plan (PNRR) and the Health Operational Programme, we must consider how we can use all these tools efficiently to raise the quality of care and increase efficiency in the healthcare system.
An adequate level of funding for the healthcare system should be ensured with a gradual increase in the share of GDP allocated to healthcare, with a clear aim of reaching the European average by 2025. This strategy should include an effective merging of public and private funding. In terms of its current health expenditure relative to GPD, Romania is in last place[24] among the EU Member States. Considering the strong economic growth Romania has enjoyed during the last three years, the FIC considers that this performance should also be reflected in healthcare funding. Healthcare authorities should change perspective and realise that healthcare is an investment in the country’s future and prosperity given that health affects economic growth directly through labor productivity and the economic burden of illnesses, and indirectly since aspects such as child health affect the future income of people through the impact health has on education[25]. For the first time, Romania has an Operational Programme dedicated to Health over the programming period 2021-2027.
Moreover, the financing mechanism that ensures access for Romanian patients to innovative therapies should be improved. While we acknowledge the efforts made by the Romanian authorities to include new innovative therapies in the reimbursement system in the last few years, Romanian patients still face significant limitations in terms of access to innovative treatments. Implementation of and adequate financing for the “Innovation Fund” program is essential.
Introduced as a temporary measure in 2009 during the economic crisis and amended several times, the clawback tax has become a tool through which the pharmaceutical industry has been forced to take full responsibility for covering the reimbursed medicines funding deficit, in the context of severe under-financing of the reimbursed medicines budget. The clawback tax was and still is a difficult burden for Marketing Authorization Holders (MAHs) to bear by themselves, as the tax is not shared by the whole distribution chain. More than 12 years since its adoption, medicine manufacturers/MAHs are still covering the full difference between the reimbursed medicines budget set by the budget law and the real consumption on the market. Up to December 2018, the calculation basis for this tax was a budget frozen at the level of 2012 (RON 6 billion), while the real consumption on the market was RON 1.5 billion higher.
On 20 December 2019, the Government approved an Emergency Ordinance, which increased the quarterly approved budget (BAT) for medicines covered by the Single National Health Insurance Fund (FNUASS) and the Ministry of Health’s budget. Specifically, starting from the fourth quarter of 2018 and until 31 December 2019, by applying the inflation indices calculated for 2012-2017 by the National Institute of Statistics, the BAT rose to RON 1.595 billion.
In May 2020, the Government approved an Emergency Ordinance, which increased the quarterly approved budget (BAT) for medicines covered by the Single National Health Insurance Fund (FNUASS) and the Ministry of Health’s budget. Specifically, starting from the 4th quarter of 2019, the BAT was increased to RON 1.688 billion, compared to the previous value of RON 1.595 billion. In March 2020, the clawback tax was capped at 27,65% for the first three months of the year through GEO no. 31/2020. On 15 May 2020, Law no. 53/2020 was published in the Official Journal of Romania and this introduced a differentiated clawback tax. This represented a significant and long-expected amendment to GEO 77/2011.
Specifically, starting from the first quarter of 2020, the clawback tax has been paid by considering three types of medicines:
These measures aim to improve th sustainability of the public health system through the efficient use of the allocated funds and also to encourage the introduction of new innovative medicines, together with the maintenance on the market of various innovative and generic medicines (for example, for generic medicines the lowest percentage is applied) which were at risk of being withdrawn from the market. According to the law, when medicines are manufactured in Romania, they should fall into Type II, regardless of whether they are generic or innovative medicines. In each case, the percentage will be applied to the centralised consumption of the relevant medicines communicated by the National Health Insurance authority (Casa Nationala de Sanatate).
The list of the three types of medicines should be published quarterly through an order issued by the Ministry of Health, and no later than 25th of the month following the end of a quarter. For the first quarter of 2020, the list was not published, and the National Health Insurance authority sent the notifications of the total consumption in accordance with the former provisions of the law, leaving the MAHs/legal representatives of the MAHs not knowing which percentage to apply.
Therefore, some of them applied the new differentiated clawback tax while others applied the percentage according to the National Health Insurance authority’s notification. For the second three months of 2020, the list was published in July 2020 through an Order issued by the Ministry of Health, while for the third three months the list was published in November 2020. Over the years, before the introduction of the differentiated approach, the tax reached unprecedented levels, far higher than in any other country in the EU which uses this type of taxation system.
As regards the tax inspection environment, in 2021, through Law no. 222/2021 for regulating certain measures concerning the Ministry of Finance’s powers to carry out inspections, as well as for the amendment and completion of certain normative acts, the powers to carry out inspections with respect to the legacy of declaring and paying the clawback tax were substantially amended. As a result, under the above legislation, the economic-financial inspection structure within the Ministry of Finance was attributed with the power to carry out inspections relating to the clawback tax, when previously only the tax authorities and the local structures for economic-financial inspection within the National Agency for Tax Administration had had the power to do so . Through this amendment, the stated intention of the legislator was to intensify audits relating to the clawback tax and to ensure an increased frequency of such audits as it is considered that the minimum time between general tax audits is too long (i.e 5 years).Considering the above, even in the context of the latest regulations, the FIC considers that this mechanism is unsustainable, and the tax is no longer justified considering the impact it generates on the availability of medicines on the Romanian market as well as the fiscal burden on manufacturing companies. The clawback tax in its present form continues to have a disproportionate impact on the pharmaceuticals sector, with a corresponding negative effect on investment and the availability of medicine on the local market. Considering a long-term perspective, the next step should be the total elimination of the tax. This could bring major economic benefits for the Romanian health sector and significant improvements in the quality of care.
We acknowledge the authorities' progress in providing Romanian patients with access to innovative treatments and medicines but there is still a significant gap between Romania and Western European countries.
Inequalities in the time it takes patients to access new medicines in different EU Member States are growing. The EFPIA's annual WAIT survey – the EFPIA Patients WAIT Indicator 2021 Survey[28] – shows that the average time to reimbursement for innovative treatments in EU and EEA countries continues to be around 511 days. Patients in Germany wait around 133 days to have access to new medicines, while patients in Romania have to endure a wait of over 899 days, once again placing Romania last in the ranking.
Only 38 (1 out of 4) of the 160 innovative medicines approved by the European Medicines Agency between 2017 and 2020 were included on the list of those compensated and free in Romania until January 1, 2022. Germany introduced 147 compensated medicines, Italy 127, Slovenia 78, Bulgaria 49, and Hungary 65. Thus, the rate of availability of innovative medicines in the compensation system for Romanian patients is only 24%.
Furthermore, Romania is ranked 34th out of 35 countries evaluated[29] (EU-28 and other Central and Eastern European countries), only 5 points behind last place, with a very large gap in areas such as treatment waiting times, patients' rights and general level of information, as well as population health, emphasizing the urgent need for health system support measures. Romania has the lowest score of all the areas evaluated in terms of access to pharmaceuticals, with 39 points out of a possible 100.
The main causes of delays are the time it takes to submit the reimbursement file (waiting for other countries to decide on reimbursement), the lack of clear deadlines for developing and publishing the List of Reimbursed Medicines and Therapeutic Protocols, a drug evaluation system that does not value innovation, and insufficient human resources in the responsible department within Romania's National Agency for Medicines and Medical Devices.
The Romanian National Health Insurance authority has developed three major projects related to e-health. Two of them have been financed with European Union funds: the e-prescription (implemented in 2012) and the electronic health record (implemented in 2014). One is self-funded – the e-health card (introduced in May 2015). Currently, the electronic card is the only way to obtain prescription medicines. Moreover, all reimbursed medicines are available only through this card, which is the access key to the national health insurance system (except for emergency medical services). All these systems are integrated into the existing centralised sole integrated information system (SIUI). The Reporting and e-Invoice project started in 2013 as part of the extension of the SIUI system to Romania. It includes a web-based connection of health institutions for reporting purposes (including expense forms and invoices). Reporting of activity and subsequent invoicing is carried out based on xml and zip uploads (by type of activity) made by medical providers.
Despite the integrated systems, there are many complications which generate problems in data crosschecks and delays of several days in processing information.
1. The e-Prescription - SIPE (Sistemul Informatic de Prescriptie Electronica) project started in 2012 and became operational in 2014 under the regulation of the national health authority for the public and private medical sector (under contract from the national health authority). The objective of SIPE is to track patients’ medical records, report payments and prevent fraud. Currently the platform manages subsidised prescriptions. The system continues to malfunction frequently, affecting the activity of healthcare professionals and the way data is centralised; a platform registers all these setbacks (www.siui-monitor.ro).
2. The patients’ electronic health files project (DES), launched in 2014, aims to include information on medical treatment as well as on each patient according to the health e-Card stored data. The most important feature should have been the electronic medical registry of all the patients in the country. Even though a Government Decision has been issued that all doctors should upload the information about patients, only those doctors who are under a contract with the national health authority are doing it. The accuracy of data in the system should be improved by the extension of monitoring to the overall prescription process.
3. The e-Health cards began to be distributed from September 2014. However, the data registration on the card is limited or non-existent. The card is used for accessing medical services and authentification of the patient. Even though the use of e-Health cards is mandatory in Romania, there are still several medical units that do not have card readers.
Future developments envisaged by the Ministry of Health: a) The possibility for e-Prescriptions issued in Romania to be used anywhere across the EU to buy prescribed medicine; b) A single platform to be launched in the next few years (based on EU funding) with the aim of jointly organising patients’ electronic health files and the list of medical service providers available for the medical investigations required by patients as per the e-files. A list of over 100 e-files will be prepared and uploaded on to this platform in time for its introduction.
In 2020, during the COVID-19 pandemic, various measures were taken which aimed to ensure safe access to medical services for doctors and patients, by limiting travel and interaction with others. Thus, for the period of the state of emergency and alert, the requirement to use the national health card was suspended so that patients could avoid an extra physical visit to the doctor in order to obtain, for example, a prescription. Consequently, in order to have a consultation with the doctor but avoid a physical meeting, the patient and his/her doctor have the option to have a medical call / videocall based on which the patient can obtain medical advice virtually and be given electronic prescriptions. So doctors have been able to send an e-prescription to the patient, based on his/her medical history, by e-mail, or even through various mobile applications, in situations in which the patient’s medical problems can be handled remotely. This can be considered significant progress, and is an important step towards the development of telemedicine in Romania. The COVID-19 situation accelerated the digitalisation of Romania’s healthcare system, helping patients and doctors to minimise physical contact. However, the legislation still needs updating to adapt Romania’s health system more closely to the new situation in which online communication and digitalization has become vital.
The adoption of legislation on telemedicine which would make remote medical consultations part of the minimum and basic packages of medical services would be an important step forward.
In 2021, Romania was ranked third highest in the EU after Estonia and Greece for unmet medical needs. Disparities in access to care are persistent and many rural areas are underserved, Romanians living in these areas continue to face unequal access due to imbalances in the distribution of the health workforce across the country.
Besides the unbalanced distribution, there is still a gap in the number of healthcare staff needed in Romania. The significant increase in salaries offered to physicians and nurses in 2018 (although not performance-related), has reduced this gap in the last few years, but only partially tackled the migration of staff to other countries. Besides salaries, there are other important reasons why Romanian medical staff continue to migrate: the inadequate working conditions, the demotivation caused by the lack of performance criteria, the lack of equal opportunities for employment, the limited professional development opportunities and the absence of a clear and transparent career pathway.
Moreover, there is a lack of specialists in public health as well as of skilled health service managers. Such specialists should play a key role in developing health policies, and in designing strategies to solve the problems mentioned above.
Consequently, the FIC believes that it is still critical for the authorities to take steps to deal with this problem, bearing in mind that a healthy business environment depends on a healthy community.
Public Health in Romania could significantly benefit from a shift of the healthcare system towards prevention and health promotion, while the capacity of the Romanian healthcare system to decrease the burden of disease through prevention and early detection should be developed.
While health promotion and health education are the cornerstone for prevention, healthcare indicators show that mortality from preventable and treatable causes is very high in Romania as a result of chronic systemic focus on curative services. Access to preventative care was suboptimal, and undersized for several decades in Romania. According to the latest studies, the preventable mortality rate is the fourth highest in Europe. The main causes of preventable mortality are ischemic heart disease, lung cancer, alcohol-related deaths, and accidents. Currently, most resources are allocated to hospital care, but a proactive and robust Public Health System, prepared to address current as well as future health needs, should keep an appropriate balance between curative healthcare (whether inpatient or outpatient) and preventative care. With only 1.8 % of health expenditure allocated for prevention, Romania ranks last in the EU.
Prevention-orientated interventions mainly focus on supporting national vaccination policies, while those aimed at increasing the level of health education among the population of all ages in relation to risk factors, healthy behaviour, and about health promotion in general are poorly financed and implemented. While the complexity of treatments offered by the healthcare system increases year after year, health literacy among the general public is poorly and only sporadically supported. A low health literacy level, which it not necessarily related to socio-economic status, constitutes a barrier to the adoption and pursuit of healthy behaviours and even to accessing curative care services.
According to the WHO, “Health literacy implies the achievement of a level of knowledge, personal skills and confidence to take action to improve personal and community health by changing personal lifestyles and living conditions. Thus, health literacy means more than being able to read pamphlets and make appointments. By improving people’s access to health information, and their capacity to use it effectively, health literacy is critical to empowerment.” The WHO has called upon governments to assume the leadership in “providing the foundation on which citizens are enabled to play an active role in improving their own health, engage successfully with community action for health, and push governments to meet their responsibilities in addressing health and health equity”.
The report "The power of European patients - options and implications", published in Brussels, shows that Romanian patients are among the least informed in Europe, occupying only 30th place in a ranking of European populations. While countries such as Germany, Italy, Spain and Portugal pay more attention to the concepts of “health literacy”, “medical literacy” and “health knowledge”, in Romania they are seldom in circulation even among professionals. Moreover, the European Health Literacy Survey[1] shows that 1 in 10 European citizens (12.4%) has inadequate health knowledge, with considerable differences both between EU Member States and within different regions at national level and between urban and rural areas. The same study shows that an inadequate level of medical knowledge exists mainly among people with poorer health, who use a higher number of health care services, have a low socio-economic status and who are older. The highest prevalence of low health literacy was observed among people with “very bad” or “poor” self-perceived health status (78.1% and 71.8%, respectively), those with more than one long-term illness (61%) and those who report six or more visits to the doctor during the last 12 months (58.9%). In conclusion, poorer health and therefore higher demands for health services seem to be accompanied by lower levels of health education. Although Romania organised a national health strategy in 2014-20 with the aim of improving health education and promotion, access to these have continued to be suboptimal in general and unequal, especially within vulnerable groups.
The PNPS aims to develop, for the first time in Romania, a unitary, multi-sectoral and integrated concept of health promotion at national level, aligned with the UN Sustainable Development Goals and with the key principles of the WHO. The plan aims to create a strategic framework for:
Priorities for vaccination:
Priorities for screening: