Health professionals in Romania have joined forces to call for reforms to the country’s healthcare system. Romania has the most poorly funded health system in Europe and the situation has been made worse by the current economic crisis, resulting in the steady migration of Romania's health professionals to work in other countries. The new Health Professionals Coalition has been formed to lobby for changes to a system in which junior doctors are paid as little as €250 a month.
Background
The economic crisis in Romania has exacerbated the difficulties being experienced by the country’s health system, which some say is in crisis. Figures show Romania has the most poorly funded health system in Europe. Total annual health spending per Romanian resident in 2009, for example, was €310, and this had dropped from €353 in 2008. Health spending in France in 2009, for example, was ten times greater at €3,414 per person.
Health professionals have responded to repeated cuts to health budgets by forming the Health Professionals Coalition in July 2013. The group includes physicians, dentists, pharmacists, psychologists, biologists, biochemists and chemists, and also the trade union federations in the health sector.
From 9 to 13 September 2013, the coalition set up branches at county level which petitioned the county prefectures with their claims.
On 18 September 2013, members of the coalition began picketing the offices of the Ministry of Health and the Ministry of Public Finance. On 22 September 2013, the Minister of Health, Raed Arafat, invited coalition representatives to a meeting where the two sides agreed on a number of measures in response to the coalition’s claims.
Protests continue as the healthcare professionals’ demands remain unresolved.
Crisis affects health system
The economic crisis hit the economy of Romania badly, particularly after 2008. There was a big reduction in public spending, including spending on health.
In 2008, the health sector received 2.98% of the state budget expenditure, equal to 0.47% of Romania’s gross domestic product (GDP). In 2011, this had dropped to 2.3% of the state budget and 0.44% of GDP.
In 2009, Romania's average total health spending per inhabitant totalled €310, according to Eurostat data, 10 to 15 times lower than in Denmark (€4,644), the Netherlands (€4,110), Austria (€3,678), France (€3,414) and Germany (€3,399). Even compared with less-developed countries across Europe, Romania’s health spending appears low. It spends about 50% less per head on health than Estonia (€723), Lithuania (€601) and Latvia (€562).
The under-funding of the health system is also reflected in a drop in the number of people working in the sector from 269,603 in 2007 to 266,593 in 2011. During the same period, nursing staff numbers diminished even more drastically, from 136,353 in 2007 to 125,992 in 2011. Auxiliary healthcare personnel numbers were also cut from 62,292 to 60,130.
According to national statistics, between 2007 and 2011 some 42,079 graduates completed training at Romanian vocational medical schools, and 38,843 graduated from academic medical and pharmaceutical schools. Lack of jobs in the national health system and poor pay have been blamed for the increasing migration of these trained health workers to other countries.
Poor pay levels are confirmed by figures showing that in 2008, the average net monthly salary of health employees was €344, representing 96.7% of the national average net monthly salary. In 2011, average monthly net earnings in the health service had dropped to €286, representing 83.8% of the national monthly average. Junior doctors are typically paid as little as €250 a month.
The decrease in the number of health professionals has inevitably led to a loss of quality in working conditions due to overloading of health departments.
For years, decision-makers have been talking about reforming the health system. One suggested route has been to increase efficiency by reducing the number of health establishments, a view that has triggered fierce public debate.
Social partners call for change
Several professional organisations and trade unions have reacted to the perceived crisis in health, and on 18 July 2013 they formed the Coalition of Health Professionals.
The coalition’s founding members are the Association of Romanian Physicians (CMR), the Association of Romanian Dental Surgeons (CMDR), the Association of Romanian Pharmacists (CFR), the Association of Romanian Psychologists (CPR), the Sanitas Trade Union Federation (Federaţia Sanitas), the Federal Chamber of Physicians’ Trade Unions (CFSM) and the ‘Dr Cantacuzino’ Federation of Physicians’ Trade Unions (Federaţia Cantacuzino). The coalition was then joined by the Association of Biologists, Biochemists and Chemists in the Romanian Health System (OBBCSSR).
The coalition members all agreed on a calendar of protests in Bucharest and the rest of the country during September 2013. To put some pressure on the Government of Romania, members of the coalition announced their decision to request a meeting with the International Monetary Fund (IMF) to discuss the funding of the country’s health system.
The coalition’s also formed county branches between 9 and 13 September, and the local authorities were sent a petition detailing the main demands of the health professionals. The petition contained complaints about the ‘predicament of some 16,000 resident doctors who live in poverty’.
Psychologists, according to the coalition, are in a similar situation. There are too few of them working in Romania, and they are poorly paid despite the importance of their work. Dentists too have the same issues, and want better salaries, higher budgets and greater respect.
The coalition has demanded a gradual increase in the budget allocation for health in the next three years, with a target of 6% of GDP. They insist ‘the place for health professionals is in hospitals, by the patient’s bed, not in street protests’.
A day of protest was held on18 September 2013 in Bucharest in front of the buildings of the Ministry of Health and the Ministry of Public Finance, and protests continued the following day. Minister Arafat came out to the street to invite the protesters’ representatives to begin negotiations.
Protesters voice their claims
On 22 September 2013, a meeting took place at the health ministry offices. On the government side were the Minister of Health and three of his state secretaries, the Deputy Secretary General of the ministry and the Deputy Minister for Social Dialogue in the Ministry of Labour, Family, Social Protection and the Elderly (MMFPSPV). The 11 representatives of the coalition presented nine specific demands:
- the allocation of 6% of the GDP to the health system;
- a halt to the denigrating attitude towards the medical profession, and more respectful treatment for health workers;
- a recognition of the independence of the profession, and the introduction of severe punishments in the Criminal Code for breaches of confidentiality of discussions between doctor and patient, and between a doctor and the patient’s family;
- new wage legislation for medical personnel;
- the organisation of hospitals and other in-patient health establishments as public units, and the abandoning of the intention to reincorporate them as public companies or business entities organised on commercial principles, which would open the door to political interference;
- a solution to the problem of school and family doctors;
- the allocation of more money to dental services from the funds laid aside for health services;
- the inclusion of psychological counselling in the health system, and an increase in the number of jobs for psychologists in hospitals;
- doubling of resident doctors’ salaries.
Parties agree a way forward
Negotiations concluded with agreement on the following points.
- Sources of finance should be diversified, so that, by the end of 2016, the share of GDP for the health system should reach 6%.
- The internal rules of order existing in the system should be supplemented with provisions setting out liabilities for deprecatory behaviour towards doctors.
- The existing legislation should be amended to remove doctors from the category of public servants.
- New legislation should regulate professional careers and qualifications in the health system.
- Doctors’ salaries should be based on performance criteria.
- The salaries of nursing personnel should be indexed at successively lower rates, and specific legislation should be enacted to govern health workers’ salaries.
- A pilot project should begin to look at how to reorganise public hospitals as a new type of entity.
- A mixed working group should be appointed to advise on the development of school medicine.
- The basic package of health services for children should be extended to include dental care.
- Legislation governing dental surgeons should be amended to reflect the provisions of the relevant European directive.
- Research should be undertaken into how psychologists are classified in other countries.
The Minister of Health also promised to identify the necessary financial resources for an increase of 20% in salaries for resident doctors.
In support of and in addition to the demands of the coalition, the Solidaritatea Sanitară Trade Union Federation of Romania (FSSR) made its own demands. It called for:
- minimum wage rises of 100% for health workers with an excellent professional performance;
- the release of hospitals from the category of public pay institutions;
- the payment of compensation to patients who receive poor treatment;
- an efficient and free system of continuous vocational training;
- equitable scheduling of doctors’ round-the-clock duty obligations in all medical establishments, accompanied by equitable pay for hours on duty;
- employment of staff to make up the current shortfall in personnel caused by the loss, during the past five years, of 30,000 health workers, which has overburdened the remaining staff and worsened their working conditions;
- the clear stipulation of what the basic health services package contains.
The coalition said their protests would continue in support of other claims that had not been addressed by the government.
Commentary
The current level of finance of Romania’s health system is light years away from the 6% of GDP target demanded by the coalition and the trade unions. It is very unlikely that funding will be available to increase health system spending by a factor of more than 10 within the next three years.
However, there is no doubt that the migration of doctors and nurses to other EU Member States has generated what has been described by some as a ‘state of emergency’. The situation makes it imperative for those who hold the reigns to review the entire treatment system for health personnel in Romania.
Constantin Ciutacu, Institute of National Economy, Romanian Academy