2011年-世界发展银行全球_Romania_-_Functional_Review___Health_Sector_178页_3mb

Romania Health Sector Functional Review Summary

Core Content

This document presents a functional review of Romania's health sector conducted by the World Bank on behalf of the European Community and the Government of Romania (GoR). The review focuses on four main areas: service delivery, financing, stewardship, and resource management (including pharmaceuticals and human resources). It aims to assess the current state of the sector, identify key challenges, and propose recommendations for improvement.

Main Challenges and Achievements

1.1 The Demographic Challenge

• Romania's health outcomes lag behind those of the EU.
• Life expectancy has improved over the past three decades, but still lags behind the EU average.
• Maternal mortality and child mortality rates have significantly decreased, but the country continues to face challenges in other areas.

1.2 Health Outcomes Benchmarked Against Other European Countries

• Heart Disease: The leading cause of death in Romania, with a standardized death rate of 194 per 100,000, lower than similar-income countries but still below EU levels.
• Cervical Cancer: Mortality rates are rising or stable, unlike most EU countries where they are decreasing.
• Other Indicators: Romania has made progress in some areas but continues to underperform in prevention and public health.

1.3 Equity in Health Care

• Access to health services is a major issue, especially for the poor and vulnerable groups.
• Despite government subsidies, many poor individuals still pay out-of-pocket for services.
• Informal payments are widespread, particularly in hospitals, and undermine financial protection and equity.
• The poor are disproportionately affected by the lack of access to care and are not adequately protected from financial hardship.

Service Delivery

2.1 Introduction and Objectives

• The study aims to assess the performance of health services and identify ways to improve service delivery and responsiveness.

2.2 Health Needs vs. Service Supply and Demand

• Main Causes of Mortality: Heart disease is the leading cause, followed by other non-communicable diseases.
• Care for Specific Age Groups: The elderly and children face unique challenges in accessing health services.

2.3 Overview of Health Services

• Population-based Services: Include public health initiatives, immunization, and disease prevention.
• Personal Services: Encompass primary care, outpatient services, and hospital care.

2.4 Organization and Management of Service Production

• Geographical Distribution: The system is not evenly distributed, with some regions having better access than others.
• Fragmentation: The service delivery institutions are fragmented, affecting continuity of care.
• Emergencies: The system is not well-prepared for managing health emergencies.
• Innovative Arrangements: Limited in scope and impact.

2.5 Information Systems

• The health information systems are underdeveloped, leading to inefficiencies in service delivery and financial management.

2.6 Recommendations and Conclusions

• Streamline the health service network.
• Re-launch quality control systems.
• Increase preventive services and equity in access.

Financing

3.1 General Trends in Financing

• Public health sector revenues increased rapidly from 2005 to 2008.
• However, the sector's funding needs grew even faster due to expanded eligibility for subsidies and increased spending on high-tech services.

3.2 Financial Management

• The Ministry of Health (MoH) and the National Health Insurance House (NHIH) are responsible for financial management.
• The MoH remains heavily involved in the financing of high-tech services through national health programs.

3.3 Risk Pools and Associated Expenditures

• The health sector's financial sustainability is under threat due to increasing expenditures and insufficient revenue.

3.4 Provider Payments

• Payments to providers are not always aligned with quality and efficiency.
• The system lacks transparency and accountability in financial transactions.

3.5 Financial Incentives

• Financial incentives in primary care, outpatient, and hospital services are not effectively structured to promote quality and efficiency.
• The system is prone to inefficiencies and informal payments.

3.6 Recommendations and Conclusions

• Strengthen financial controls.
• Develop a system of health technology assessment.
• Increase the share of public financing for health.
• Encourage private sector involvement in a structured and regulated manner.

Stewardship

4.1 Stewardship of Health in Romania

• The Ministry of Health is responsible for developing national health policies, regulating the sector, and setting standards.
• However, the MoH has not fully developed its policy and regulatory capacity.

4.2 Leadership and Policy Capacity

• Strategic planning is weak, with the 2011-2013 Health Strategic Plan being a top-down document.
• There is a lack of stakeholder involvement in the planning process.
• Quality regulation is minimal, and the policy unit is under-staffed.

4.3 Regulatory System

• Regulation of health professionals and quality standards is not fully implemented.
• The system lacks enforcement mechanisms for quality assurance.

4.4 Accountability Relationships

• Accountability mechanisms are weak, especially at the local level.
• The NHIH has limited autonomy and transparency in financial management.

4.5 Recommendations and Conclusions

• Improve governance and management.
• Enhance accountability and transparency.
• Develop a robust regulatory framework for quality and safety.

Resource Management

5.1 Pharmaceuticals Management

• The main problems include poor inventory management, lack of transparency, and inefficient procurement.
• Informal payments for medicines are widespread.

5.2 Human Resource Management

• The physician and nurse workforce is growing, but not in a sustainable or efficient manner.
• There is a lack of financial incentives to promote quality and efficiency.
• The MoH and NHIH have limited capacity to manage and monitor human resources effectively.

5.3 Recommendations and Conclusions

• Strengthen financial incentives for health professionals.
• Improve the management and monitoring of human resources.
• Enhance transparency in pharmaceutical procurement.

Main Findings and Recommendations

6.1 Main Findings

• Romania's health system is underfinanced and inefficient.
• Informal payments are widespread and undermine financial protection and equity.
• The system is fragmented and lacks effective quality assurance mechanisms.
• The MoH and NHIH have limited capacity to manage and regulate the sector effectively.

6.2 Recommendations for an Action Plan

• Improve governance and management.
• Streamline the health service network and enhance quality control.
• Increase preventive services and equity in access.
• Develop a long-term strategy that includes both public and private financing.
• Strengthen financial controls and transparency.
• Enhance the capacity of the MoH and NHIH to manage and regulate the sector.

Key Acronyms

• A&E: Under-Secretary of State
• A-DRG: Australian Diagnosis-related Group
• AID/IMAS: Promoting Integrity in the Health Sector Association for Implementing Democracy
• AIDS: Acquired Immune Deficiency Syndrome
• ANAF: National Revenue Collection Agency
• ANMDM: National Medicines Agency
• BGD: Budget General Directorate
• CADREAC: Drug Regulatory Authorities in EU Associated
• CASAOPSNAJ: Social Health Insurance House of the Defense, Internal Affairs, and Justice Ministries
• CASMTCS: Health Insurance House of the Ministry of Transport, Construction, and Tourism
• CH: City Hall
• CT: Computed Tomography
• CoPh: College of Physicians
• DC: District Council
• DHIH: District Health Insurance House
• DPHA: District Public Health Authorities
• DRG: Diagnosis-related Group
• EMN: European Migration Network
• EU: European Union
• EU-12: EU members since 2004 or 2007
• EU-15: EU members before May 2004
• FFS: Fee for service
• GDP: Gross domestic product
• GFATM: Global Fund to Fight HIV/AIDS, Tuberculosis, and Malaria
• GMC: UK General Medical Council
• GNP: Gross national product
• GP: General practitioners (primary care doctors)
• GoR: Government of Romania
• HBS: Household Budget Survey
• HIH: Health Insurance House
• HIV: Human immunodeficiency virus
• HNP: Health, nutrition, and population
• HPV: Human papillomavirus
• HR: Human resources
• IMF: International Monetary Fund
• INPSAS: International Public Sector Accounting Standards
• ISO: International Organization for Standardization
• IT: Information technology
• LAPA: Local Authorities for Public Administration
• MDs: Medical doctors
• MoPF: Ministry of Public Finance
• MoH: Ministry of Health
• NCHA: National Commission for Hospital Accreditation
• NGOs: Non-governmental Organization
• NHI: National Health Institute
• NHIF: National Health Insurance Fund
• NHIH: National Health Insurance House
• NPTC: National Program for TB Control
• OECD: Organisation for Economic Cooperation and Development
• PCGNP: Per capita gross national product
• PHC: Primary health care
• PIAMGD: Institutions Accounting Methodology General Directorate
• PPP: Purchasing parity per capita
• PPU: Public Policies Unit
• QUOF: Quality and Outcomes Framework
• SDR: Standardized Death Rate
• SIUI: NHIH Information System
• TB: Tuberculosis
• TQM: Total Quality Management
• UK: United Kingdom
• UN: United Nations
• US: United States
• USAID: United States Agency for International Development
• WHO: World Health Organization
• WHO-HFADB: European Health for All Database

Conclusion

The health sector in Romania faces significant challenges in governance, service delivery, financing, and resource management. While some progress has been made, particularly in improving health outcomes and reducing mortality rates, the system remains underfunded, inefficient, and inequitable. The lack of a coherent long-term strategy, combined with weak institutional capacity and fragmented service delivery, hampers the sector's ability to deliver effective and equitable care. Strengthening financial controls, improving governance, and enhancing the quality and accessibility of health services are essential for the sector's future development.