Romania is a country in Central Europe with access to the Black Sea on its southeast. It borders with Ukraine, Moldova, Bulgaria, Serbia and Hungary. Romania’s population was 19 million people as of 2023, and average life expectancy was 75 years in 2022. Romania is an upper-middle-income country that spent 6.5% of its GDP on health in 2021. It accounted for almost half of its current health expenditure (CHE) as a percentage of the European Union average GDP. In terms of per capita spending on health, Romania spent € 1,663 in 2021,[1] which was much lower compared to the EU average of € 4,030.
In 2021, 76% of CHE was funded from public sources, while 21% accounted for out-of-pocket expenditure.[2] It was reported that 80.8% of public spending on health care originated from social health insurance (SHI), and the remaining 19.2% was covered by the budgets that come from state and local authorities and the ministry of health. SHI collects its revenues mainly from monthly contributions of employers, employees and freelancers, as well as budget subsidies from state and local authorities.[3] Out-of-pocket expenditure is mainly spent on pharmaceuticals at 63%, followed by outpatient medical services and dental care.[1]
The ministry of health is in charge of the health system governance, regulatory framework and policies, while the National Health Insurance House administers and regulates the SHI system. Both the ministry of health and the National Health Insurance House have representation at the local level through district public health authorities and district health insurance houses. The positive list of medicines covered under SHI in Romania is administered by the National Agency for Medicines and Medical Devices.[1] Between 1999 and 2019, the percentage of salaries paid as SHI contributions dropped from 14% to 10%,[3] and local authorities were increasingly involved in financing the health system by supplementing the total budget with local funds.
In addition to the introduction of SHI, health system reforms included the reduction of state-funded hospitals and an increase in private investment in medical services; expansion of family physicians’ scope of practice to shift from the unnecessary reliance on specialized care in hospital settings; and health system modernization through infrastructure investments and e-health technologies.
Today, Romania’s SHI is highly centralized, and it operates under Law No. 95 of 2006. Almost 90% of the population has access to a comprehensive health service benefits package, while the remaining 12% are uninsured as of 2020, with limited access to a minimum package of services. Unequal geographic access to care is explained by the infrastructure that results in various levels of care in urban and rural areas. The system remains hospital-centric, and nearly half of all health financing allocated to inpatient care.
Key challenges include cost and quality issues related to insufficient health care funding and inefficiency in its allocation, use and administration. The World Health Organization estimated that Romania has a high incidence of catastrophic health spending observed among one in eight households. In addition, informal payments inhibit fair access to health services and contribute to financial hardship and unmet needs.
The National Health Strategy 2023–2030 continues furthering structural reforms and aims to promote public health, deliver top-quality health care services and ensure efficiency in the health care system.
References
[1] European Commission, State of Health in the EU, Romania country profile 2023
[2] World Health Organization, Global Health Expenditure Database, Health Expenditure Profile (choose country)
[3] Ciprian-Paul Radu, Bogdan Cristian Pana, Daniel Traian Pele, Radu Virgil Costea Evolution of Public Health Expenditure Financed by the Romanian Social Health Insurance Scheme From 1999 to 2019 National Library of Medicine (NIH)