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Cablegate: Romanian Healthcare Part 1: Ailing Public System Hobbles

VZCZCXRO9446
PP RUEHAG RUEHAST RUEHDA RUEHDF RUEHFL RUEHIK RUEHKW RUEHLA RUEHLN
RUEHLZ RUEHPOD RUEHROV RUEHSR RUEHVK RUEHYG
DE RUEHBM #0601/01 2121341
ZNR UUUUU ZZH
P 301341Z JUL 08
FM AMEMBASSY BUCHAREST
TO RUEHC/SECSTATE WASHDC PRIORITY 8534
INFO RUEHZL/EUROPEAN POLITICAL COLLECTIVE PRIORITY
RUEAUSA/DEPT OF HHS WASHINGTON DC PRIORITY

UNCLAS SECTION 01 OF 02 BUCHAREST 000601

SIPDIS
SENSITIVE

E.O. 12958: N/A
TAGS: ECON ELAB PGOV SOCI AMED RO
SUBJECT: ROMANIAN HEALTHCARE PART 1: AILING PUBLIC SYSTEM HOBBLES
TOWARD DECENTRALIZATION

Sensitive but Unclassified; not for Internet distribution.

SUMMARY

1. (SBU) Romania's public healthcare system is at a crossroads. At
present, the system's resources are distributed unevenly and
unreliably throughout the country. The quality and accessibility of
care, cost of services, and competence of personnel remain
unpredictable, ranging from tolerable to shockingly bad, with
pervasive petty corruption throughout the system. As Romania faces
increasing EU pressure to improve its public healthcare system,
plans are underway to decentralize hospitals, shifting
administration from the national to the local level, both in
Bucharest and in other parts of the country. While decentralization
may improve efficiency, it does not address another key issue
affecting quality: the exodus of medical personnel who continue to
search for higher wages and improved working conditions outside of
Romania.

2. (U) This is the first in a three-part series on healthcare in
Romania. Subsequent cables will focus on pharmaceuticals and the
emerging private healthcare sector. End Summary.

LOW FUNDING MEANS POOR QUALITY SERVICE

3. (SBU) On paper, Romania's healthcare system appears
comprehensive. CNAS is an insurance-based, universal coverage
system which is funded by the government. Payroll taxes collected
from both employers and employees are paid into CNAS, with the state
allocating an additional amount to cover the unemployed. Employers
and employees each pay 5.5% of gross wages, though this figure is
slated to decrease to 5.2% as of December 1, 2008. Public health
insurance covers medical services from the first day of sickness or
the date of accident until full recovery. The list of medications
covered by insurance is revised yearly. This year, more than 2,000
medications are included in the insurance provided under the CNAS
plan.

4. (SBU) However, despite the comprehensive nature of public health
insurance at first glance, the total official expenditures on
healthcare are actually very low compared to the rest of the EU. In
2007, spending on healthcare was equal to approximately 4.7% of GDP,
or about 350 USD per person. In contrast, EU average spending for
the same year was 1,200 USD per head. As a result, while all
treatments are theoretically available, shortages in medications and
even basic supplies are not uncommon, which means that those
patients who offer the largest "gratuities" to their caregivers are
usually served first. The low salaries for most medical staff
foster a culture whereby bribes from patients are an expected part
of the take-home compensation.

5. (SBU) The quality of healthcare in rural areas remains far below
even the poor standards of care available in larger cities.
Throughout the country, the lack of standard medical practices or
accountability to patients increases the likelihood of errors.
Thus, quality of patient care is particularly reliant on the
professional ability of doctors. Depending upon the time of the
month, hospitals may run out of supplies to perform even basic
tests. Hospitals and mental care facilities are overburdened by
persons abandoned by their families, without the staffing or
financial means to provide proper care.

DECENTRALIZATION AS A SOLUTION?

6. (SBU) At present, the Romanian healthcare system is owned and
controlled almost entirely by the state, but tentative efforts are
underway to decentralize the sprawling, over-consolidated medical
system. The first decentralization effort began ten years ago, when
general practitioners (GPs) were removed from the state salary rolls
and encouraged to set up private practices. As private
practitioners they compete with one another for patients. While
nominally independent, Romanian GPs in reality are essentially
contractors providing regulated services to patients under the
National Health Insurance House (CNAS) plan. Under this universal
coverage plan, general practitioners are the system's "gatekeepers,"
responsible for writing prescriptions and making referrals to
specialists. Most Romanian GPs serve only a limited number of
cash-paying clients outside of the regulated system.

7. (SBU) New efforts to continue decentralizing by shifting the
management of hospitals from the state to the local level are also
underway. Bucharest's newly-elected mayor, Sorin Oprescu, has
formed a working group with the national Ministry of Health to find
a way to administer Bucharest's 42 hospitals locally, rather than at
the national level (although they would still be funded out of the
national budget). Health Minister Eugen Nicolaescu has indicated
his support for this effort and plans to expand the idea of local
hospital administration to other municipalities over the next year.
The hope is that these efforts to decentralize will cut bureaucracy
and lead to improved conditions. For now, quality of care varies

BUCHAREST 00000601 002 OF 002


drastically for Romanians depending upon where they live, their
ability to make informal payments for care, personal connections,
and which medicines, staff and equipment happen to be available on a
particular day.

THE EU AND THE DIASPORA OF DOCTORS AND NURSES

8. (SBU) Pressure on Romania to conform to EU standards in the
healthcare sector continues to mount. A proposed directive
published by the European Commission on July 2, 2008 would require
the closure of all hospitals failing to meet EU accreditation
standards. Under this directive, each country will have to establish
its own accreditation agency. However, Romanian law has already
required hospital accreditation since 2001, but its Agency for
Hospital Accreditation has never been established. Since most
Romanian hospitals are far below EU standards, many would have to be
closed if the accreditation directive is actually applied and in the
unlikely event that Romania fails to receive a waiver of the law's
provisions.

9. (SBU) EU membership has also allowed medical staff to travel and
work freely, creating a brain drain in the public healthcare sector.
In 2007 alone, an estimated 5,000 to 7,000 doctors and nurses left
the country in search of higher wages and improved work
environments. Despite rising wages, this outward migration trend
shows no sign of abating. Young medical school graduates remain the
most likely to leave. The 300 euros per month they can earn as
residents in Romanian public hospitals pales in comparison with the
wages on offer elsewhere in the EU. As a result, there is a serious
and worsening shortage of medical personnel. The current ratio of
patients to nurses in public hospitals can be as high as 40 to one.

COMMENT

10. (SBU) Romanian public healthcare, while billed as a "universal
care" system, truly fails to provide universal care on a
non-discriminatory basis. The challenge for Romania moving forward
will be to reform the system while figuring out how to pay the
rising costs of healthcare in the future. The brain drain is too
acute for care provider wages to remain at their current level for
much longer. Anecdotally, patients are also becoming increasingly
intolerant of the opaque costs of healthcare and frustrated by not
knowing whether they provided the "correct amount" in gratuities to
ensure good treatment. This situation has opened the door to
private insurance and to a future hybrid system, in which some cases
are handled by the public system while private insurers guarantee
extra benefits and transparent costs to patients. The upcoming
cables in this series will look at the issues which arise when the
publicly run health system collides with private markets. End
Comment.

TAUBMAN

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