2008年-世界发展银行全球_Romania___Health_Sector_Policy_Note_11页_265kb

Summary of Romania's Health Sector Policy Note

I. Core Content and Accomplishments

Romania has made significant progress in improving basic health indicators since the 1970s. Life expectancy for both males and females has increased, and infant and maternal mortality rates have declined. However, challenges persist, particularly in rural areas, where access to health services remains limited and infectious diseases are more prevalent.

Key Health Indicators (1970–2006)

• Female life expectancy at birth: 70 (1970) → 76 (2006)
• Male life expectancy at birth: 66 (1970) → 69 (2006)
• SDR for ischemic heart disease (males, 0–64 years): 26 (1970) → 85 (2006)
• SDR for all causes and ages: 1,236 (1970) → 1,026 (2006)
• Infant mortality rate (per 1,000 live births): 49 (1970) → 14 (2006)
• Maternal mortality (per 100,000 live births): 116 (1970) → 15 (2006)

Despite these improvements, Romania still lags behind EU countries in health spending as a percentage of GDP, which has contributed to systemic inefficiencies and poor service quality.

II. Main Challenges

1. Mismatch Between Service Package and Funding

• The basic service package is comprehensive, but underfunded.
• This has led to arrears in payments to pharmacies and suppliers, increasing costs.
• Hospitals face financial strain due to low base rates in the DRG system.
• Private insurers are unable to develop because the public package is too extensive.

2. Bias Toward Hospital-Based Care

• Over 46.4% of the National Health Insurance Fund is spent on hospital care, higher than the OECD average.
• High inpatient admission rates (24.3 per 100 population in 2006) reflect inefficient use of resources.
• Many services could be provided in outpatient settings, but the system does not encourage this.

3. High Pharmaceutical Expenditure

• Pharmaceuticals account for 30.5% of NHIF expenditures in 2007.
• Reimbursement list expansion has led to increased spending.
• Poor enforcement of prescription guidelines and co-payment rules contribute to drug shortages and public distrust.

4. Out-of-Pocket Payments

• Informal and formal out-of-pocket payments are widespread.
• These payments disproportionately benefit experienced doctors, especially in surgery.
• They increase the financial burden on the poor and create inequities in access to care.

5. Geographic Inequity in Access

• Rural areas face significant challenges in accessing health services.
• Lack of ambulatory services and poor infrastructure reduces access and worsens outcomes.
• There is a shortage of family doctors and other healthcare professionals in rural and urban poor areas.

6. Human Resource Issues

• Low salaries discourage young professionals from entering the health sector.
• A significant portion of current physicians is over 45, leading to potential future shortages.
• There is a risk of brain drain as professionals seek higher salaries in Western Europe.

7. Quality of Care Concerns

• Public dissatisfaction with health services has increased.
• Complaints are often directed at doctors rather than systemic issues.
• Quality assurance mechanisms are lacking, and there is poor monitoring of clinical practices.

III. Policy Recommendations

1. Define a Realistic Basic Service Package

• Align service offerings with available funding.
• Introduce co-payments to reduce abuse and support private insurance development.

2. Shift Resources to Primary and Ambulatory Care

• Restructure tertiary care to improve efficiency.
• Establish regional hospital holdings to manage resources and reduce bed capacity.
• Encourage ambulatory care models for chronic conditions.

3. Improve Hospital Efficiency

• Implement admission criteria and clinical pathways.
• Adopt Romanian relative values for the DRG system.
• Develop financial management models that reward efficiency and cost control.

4. Reposition Primary and Specialist Ambulatory Care

• Expand primary care services, especially in rural and underserved areas.
• Encourage group practice and adjust payment structures for GPs.
• Foster competition between hospitals and ambulatory services.

5. Estimate and Cover Reform Costs

• Aim for health spending to reach 4.5% of GDP by 2010.
• Use taxes on unhealthy products (e.g., sugar, salt) to finance reforms.

6. Focus on Quality Improvement

• Introduce quality topics in medical education.
• Establish an independent Quality Assurance Agency.
• Develop external evaluation mechanisms and financial incentives for better outcomes.

7. Address Human Resource Shortages

• Improve the status and payment of medical professionals.
• Enhance medical education and recruitment strategies.
• Consider immigration as a short-term solution.

8. Reduce Financial Burden on Patients

• Implement transparent pricing and co-payment mechanisms.
• Provide free health vouchers for low-income groups.

9. Improve Equity of Access

• Address geographic disparities through infrastructure and policy improvements.
• Encourage providers to set up facilities in rural areas.
• Expand ambulatory services for chronic diseases like diabetes and cancer.

10. Enhance Pharmaceutical Efficiency

• Increase competition among generic drugs.
• Adopt evidence-based criteria for drug reimbursement.
• Implement the Austrian model for drug list categorization:
  • Red Box: New drugs, restricted prescription, controlled volume, reference pricing.
  • Yellow Box: Proven effective drugs, less restricted prescription, volume discounts.
  • Green Box: Generics and proven drugs, unrestricted prescription, 100% reimbursement.

IV. Conclusion

Romania’s health sector has seen progress but faces significant challenges in funding, service delivery, and quality. A comprehensive, cross-sectoral approach is necessary to improve equity, efficiency, and quality of care while addressing the financial sustainability of the system. Policy reforms must focus on restructuring hospital services, enhancing primary care, improving pharmaceutical management, and addressing human resource shortages.