Eva-Cristina Petrescu and Diana-Eugenia · Corresponding author, Eva-Cristina Petrescu...

Contribution of Services to Economic Development AE

Vol. XIV • Special No. 6 • November 2012 653

PERCEPTION OF PRIVATE AND PUBLIC MEDICAL SERVICES IN

ROMANIA

Eva-Cristina Petrescu1

and Diana-Eugenia Ioncică2

1) 2) Academy of Economic Studies of Bucharest, Romania

Abstract

This paper presents the Romanian medical system and the modality in which the State

through the government-funded public healthcare system protects its citizens. Legislation is

an important instrument which can create the premises for an adequate protection of health.

Recently, the Law on healthcare reform, which concerns the organization of hospitals, has

led to major debates. The private medical services are an alternative which started to

develop. In this context, we conducted an exploratory research in order to analyze the

perception of private and public medical services in Romania, by using quantitative market

research techniques (market survey). The research showed that the public system is

perceived as not satisfactory and a reform of the system is perceived as being opportune,

but the solution is not simply the diminution of the charges. Moreover, the research

revealed the fact that the private medical services in Romania are not sufficiently

developed. The subjects interviewed consider that the State plays a major role in the reform

of the medical system and that there are important measures that the state should

implement.

.

Keywords: private medical services, public medical services, perception of medical

services, market survey

JEL Classification: D12, I10, M31

Introduction: Romanian population, Romanian medical system and the Law on

healthcare reform

The content and complexity of defining the population’s health condition increase the

difficultness of showing exactly what a health system really is (Ristea, Stegăroiu, Ioan-

Franc and Dinu, 2009). Healthcare systems are confronted by evolving patterns of disease,

aging populations, and growing public expectations (Thompson and McKee, 2004).

In Romania, there are two major demographic trends: diminution and aging of population.

The population declined in the last years. The age structure of the Romanian population

was marked by the aging process, the young population, between 0 and 14 years decreased,

Corresponding author, Eva-Cristina Petrescu – [email protected]

AE Perception of Private and Public Medical Services In Romania

Amfiteatru Economic 654

and the percentage of population of 60 years and more was growing. In 2010, life

expectancy was in Europe of 75.9 years (79.9 years for women and 72 years for men);

while in Romania life expectancy was 73.83 years, respectively 77.62 years for women and

70.15 years for men (Matei and Pertache, 2012). The values are inferior to the European

average, but one positive aspect is the fact that life expectancy in Romania has increased

with 2 years, compared to 2000. In 2009 the average age in the world was of 29 years, in

Europe the average age was of 38 years. In Romania the average age grew from 38.8 years

in 2006, to 39.5 years in 2009, age specific to the countries with ”adult” population

(National Institute of Statistics, 2011). Also, according to statistic data, in 2009 the female

population represented more than 51% of the Romanian population.

The mortality ratio in Romania (9.79 dead to 1000 living newly born) is superior to the

average of Europe (7.3 dead to 1000 living newly born), and far from the average of EU

(4.18 dead to 1000 living newly born). In 2010, in Romania the fertility ratio was of 1.3

children/ woman, value inferior to the ratios of Europe (1.5 children/ woman), EU (1.56

children/ woman) and world (2.49 children/ woman) (Matei and Pertache, 2012).

In Romania, in the period 1990-2011, the largest number of deaths was in 1996: 286,158.

The increasing trend in the mortality ratio, manifested since 2007, did not continue in 2011,

as the number of deaths diminished from 259,723 in 2010 to 251,439 in 2011, the number

being higher among masculine population and in the rural areas. The population in rural

areas has increased, from 44.91% in 2006 to 45.12% in 2009. Health safety has become an

issue in Romanian rural areas as the services proved to be weaker, with few supplies,

poorly managed medical centres, as well as unsatisfactory hospital conditions and fewer

medical staff. The majority of rural population is facing serious threats as lack of health

education, family planning etc. Due to the fact that the poorest population lives in rural

areas, diseases related to lack of nutrition and hygienic conditions start to appear. The

migration phenomenon affects deeply health services in rural areas, as more and more

doctors and medical nurses leave the country to work abroad (Ghisa et al., 2011).

The principal causes of death are the same as in the previous years: maladies related to the

circulatory system, tumors, digestive maladies, maladies related to respiratory problems,

traumatic injuries and poisoning (Antal, Nanu and Ghenea, 2012). The standard mortality

ratio for all causes was higher in Romania (948.01%000) then the average for Europe

(812.66%000) or EU (608.25%000), also the mortality ratio for maladies of the circulatory

system (539.76%000) was superior to the European average (385.24%000), and also the

mortality ratio for cancer and the mortality ratio for maladies related to respiratory

problems are superior to the averages of Europe.

In these conditions, the medical resources are less developed in Romania compared to the

average situation in Europe, and in EU. In 2010, in the world, health costs represented 10.4

of the GDP and 949 $ were spent for each person for healthcare. In 2009, in Romania, the

health costs were 5.44% of GDP, while the average for EU was 9.76% of GDP. The same

situation can be noticed in the case of health costs /person: in Europe – 2178.25 $/person, in

EU – 3152.48 $/person, and in Romania only 773.2 $/person. In Europe, in 2009, there

were on average 329.83 doctors for 100,000 people, while in Romania there were 225.82

doctors for 100,000 people, a value inferior to the European average. The number of family

doctors in Romania was in 2009 of 83.05, while the average number in EU was 87.35.



According to data from The National Institute of Public Health, there was one positive

indicator: the number of hospital beds, which was in 2009, in Romania, of 662.33 beds at

100,000 people, superior to the average in Europe : 648.89 beds at 100,000 people, and in

EU 528.55 beds at 100,000 people.

The Romanian health system always faces losses which imply high costs for the entire

population (Sârbu and Zanfir, 2011). Nowadays, the health system relies for financing on

the mandatory contribution to health insurance. Due the demographic disequilibrium, to

insufficient funds and to improper management of the funds, the financing and the

functioning of the medical system is difficult.

In order to reform the medical system, a series of measures were taken. One disputed

measure in Romania was to close some hospitals and to transform others in asylums. Due to

the negative reaction of the population, and due to the negative impact of the measure on

the patients and medical personnel, in 2012, some of the closed hospitals started to be

reopened.

The Romanian medical system is centralized and the project of the Health Law proposes to

change it. The main proposed changes are: elimination of the monopoly of the National

House for Health Insurance (CNAS), autonomy in the management of the National Fund

for Mandatory Health Insurance (FNUASS), the mandatory health insurance should

become the main system of financing health services, and based on the payment of

mandatory health insurance the insured would have access only to a basic package of

medical services, then the persons desiring more medical services could choose

supplementary optional health insurance (Health Ministry, 2012). Private medical insurance

is an important ingredient of health systems in most OECD countries. Its characteristics and

prevalence vary across countries, being largely determined by the way in which the public

sector regulates healthcare. While in some countries private medical insurance acts mainly

as the only source of coverage for a large share of the population (USA, The Netherlands),

in other countries private medical insurance covers treatments that are also covered by

public insurance, improving some quality dimension on the public system, for instance,

shorter waiting times and a wider choice of healthcare providers (in the UK, Ireland, Spain,

Italy, Portugal, Greece, and New Zealand) (Nicolás and Vera-Hernández, 2008).

Other measures in debate are: the introduction of co-payment (which is a fix sum of money

to be paid to the supplier of medical services in order to have access to a basic package of

medical services, sum different to the contribution to FNUASS), the autonomy of hospitals

(based on the idea that the hospitals will be non-budgetary units, that can employ and pay

medical personnel function of the needs and of their own resources).

Bennedsen and Schultz (2011) consider that in many areas, such as health, child and elderly

care, etc. where it is difficult to describe, monitor and contract upon quality, the

outsourcing of public service provision involves a trade-off between cost and quality.

The reform of the Romanian medical system is a very difficult and challenging task, and

“for the last fourteen years decision factors have looked for the magic formula in

restructuring the healthcare sector” (Moisil and Jitaru, 2006), but the solution has not been

found yet. However, we have to underline that there are medical sub systems functioning

very well in Romania – for example, the emergency medical service: SMURD.



1. Objectives and methodological framework of the research

We started the research by studying the situation of the Romanian medical system, as it

results from laws, books, and articles in specialized journals and reports of the specialized

institutions and Romanian Ministry of Health. Then we used an exploratory quantitative

research in order to analyze the perception of private and public medical services in

Romania. The quantitative research aimed at quantifying the data and generalizing results

at the level of the entire population studied (Pop and Petrescu, 2008).

The point of view of the potential beneficiary of medical services in Romania was studied

in 2012 using a survey conducted on a sample of 463 people with a probability of 95% and

a margin of error of +/-4,55%. The instrument of the research was a questionnaire, which is

by far the most common instrument used to collect primary data (Kotler and Keller, 2006).

The interviews took place in May–June 2012, mainly in the urban area (89% of the

interviewed subjects were from the urban area and 11% of the respondents were from the

rural area). The structure of the sample function of the gender was: 40% male subjects and

60% female subjects. Function of the age: 67% of the subjects were young, between 18

and 34 years old, 30% of the subjects were adults, between 35 and 65 years old, and 3% of

the subjects had over 65 years. The secondary school was the last form of education for 4%

of the interviewed subjects. 48% of the interviewed subjects finished high school and 40%

of the respondents had higher education, 8% having other forms of education. 68% of the

subjects had monthly net revenues under 1500 lei (approx. 350 Euro), the monthly net

revenues of 22% of the respondents were between 1500 lei and 3000 lei and 9% had more

than 3000 lei/ month.

The research objectives were:

Identifying the medical services used by the interviewed subjects in the last three

years and their frequency (visits to the family doctor, public emergency medical services,

private emergency medical services, public hospital medical services, private clinics

medical services, dental care services – public vs. private, laboratory analysis - public vs.

private, medical services in foreign countries),

Studying the opinion regarding the medical services, the public and private medical

system,

Studying the opinion regarding the characteristics of medical services (quality of

services, price, promptitude, competence of the personal, services efficacy – their result)

and in particular the opinion regarding the characteristics of hospital medical services

(nutrition services, cleaning services, maintenance, hospital conditions, services of doctors,

services provided by nurses, quality / price),

Studying the opinion regarding the competence of the medical personal,

Studying the opinion regarding the corruption in the medical system,

Studying the opinion regarding the medical system reform,

Studying the degree of satisfaction regarding the medical services and the medical

system,



Identifying the necessary measures to improve the medical system.

2. Results of the research

The visits to the family doctor were the medical services used in the last three years by

most of the subjects. 75.16% of subjects have used these services (10.80% a few times per

month, 41.90% a few times per year and 22.46% at least once a year). The other medical

services used at least once a year were in descendent order: private dental care services

(65.01% of respondents), private laboratory analyses (50.76%), public laboratory analyses

(47.52%), public hospital medical services (43.84%), private clinics medical services

(40.60%), public emergency medical services (28.29%), public dental care services

(27.21%), private emergency medical services (19.22%) and only 6.05% of the subjects

have used in the last three years foreign medical services.

2,2%

1,1%

2,6%

3,0%

2,8%

5,0%

1,7%

1,3%

0,0%

41,9%

11,4%

6,7%

16,8%

18,6%

11,0%

37,4%

16,4%

17,7%

22,5%

14,7%

11,4%

24,4%

19,0%

13,4%

22,7%

29,4%

31,7%

3%

24,8%

71,7%

80,8%

56,2%

59,4%

72,8%

35,0%

52,5%

49,2%

94,0%

10,8%

3%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

family doctor

public emergency medical services

private emergency medical services

public hospital medical services

private hospital medical services

public dental care services

private dental care services

public laboratory analysis

private laboratory analysis

foreign medical services

a few times per month a few times per year once a year never

Figure no. 1: The medical services used in the last three years and their frequency

The medical services used a few times per month were in order: the visits to the family

doctor (10.8% of the subjects used the services of the family doctor monthly), private

dental care services (5% of the subjects), and private hospital medical services (3%). In the

case of emergency medical services and hospital services, a larger percentage of

respondents use rather the public medical services, than the private medical services, while

in the case of dental care services and laboratory analysis the interviewed subjects used

rather the private medical services, then the public medical services.

The opinion regarding the entire medical system was evaluated using a scale from 5 (very

favourable) to 1 (very unfavourable) and the score of 2.71 indicates an unfavourable

perception. In order to see if there are differences of perception between the public and

private medical system the subjects were asked to also evaluate them. The calculated scores

indicated an unfavourable opinion regarding the public medical system (score 2.7) and a

favourable perception for the private medical system (score 4.1). The differences of

perception between the public and private medical systems are important: 25.3% of

subjects had a very favourable opinion regarding the private medical system and only 1.5%

had a very favourable opinion regarding the public medical system, and also for the

negative perception: 12.3% of the subjects had a very unfavourable opinion regarding the



public medical system and only 1.5% had the same view regarding the private medical

system.

1,51%

17,06%

46,44%

22,68%

12,31%

25,27%

59,18%

12,31%

1,73%

1,51%

0,00% 10,00% 20,00% 30,00% 40,00% 50,00% 60,00% 70,00%

very favorable - 5

4

3

2

very unfavorable - 1

Public medical system Privat medical system

Figure no. 2: The opinion regarding the public and private medical systems

The results to the question concerning the perception of medical services indicates that the

subjects had a very good opinion regarding private dental care services (4.09), foreign

medical services (4.12), private laboratory analysis (4.02), a good opinion regarding private

clinics medical services (3.94), private emergency medical services (3.82), services of the

family doctor (3.64) and public emergency medical services (3.00) and a negative

perception of public hospital medical services (2.77) and public dental care services (2.67).

Table no. 1: The opinion regarding medical services

Very good 5 4 3 2 Very bad 1 Score

a) family doctor 24% 38% 22% 10% 6% 3.64

b) public emergency medical services 6% 26% 39% 18% 11% 3.00

c) private emergency medical services 23% 43% 28% 4% 2% 3.82

d) public hospital medical services 3% 19% 42% 22% 13% 2.77

e) private clinics medical services 27% 48% 20% 3% 2% 3.94

f) public dental care services 4% 15% 43% 19% 19% 2.67

g) private dental care services 36% 43% 16% 3% 2% 4.09

h) public laboratory analysis 7% 30% 41% 14% 8% 3.15

i) private laboratory analysis 33% 44% 18% 3% 2% 4.02

j) foreign medical services 52% 20% 19% 2% 6% 4.12

We have studied the opinion regarding five characteristics of medical services: quality of

services, price, promptitude, competence of the personnel and services efficacy (the opinion

regarding the results of the medical services) using the differential semantic scale (1 - very

poor, 5 - very good). The scores indicate that the medical services had a positive

perception. On the first place were the foreign medical services (4.3), also the subjects had

a good perception of private medical services: private dental care services (4.3), private

laboratory analysis (4.2), private clinics medical services (4.2), and private emergency

medical services (4.1). The scores for the public medical services were inferior to those of

the private medical services. The results indicated that foreign medical services (4.68),



private dental care services (4.50), private laboratory analyses (4.45), private clinics

medical services (4.40) and private emergency medical services (4.29) had a very good

perception of the quality of services.

Table no. 2: The opinion regarding the characteristics of medical services

services

quality price promptitude

personnel

competence

services

efficacy score

Family doctor 3.82 3.73 3.69 3.94 3.94 3.8

Public emergency 3.37 3.35 3.25 3.56 3.53 3.4

Private emergency 4.29 3.32 4.29 4.34 4.33 4.1

Public hospital 3.27 3.29 3.13 3.47 3.41 3.3

Private clinics 4.40 3.37 4.33 4.35 4.39 4.2

Public dental care services 3.18 3.17 3.20 3.42 3.35 3.3

Private dental care services 4.50 3.49 4.41 4.47 4.49 4.3

Public laboratory analyses 3.67 3.52 3.54 3.73 3.73 3.6

Private laboratory analyses 4.45 3.55 4.37 4.43 4.45 4.2

Foreign medical services 4.68 3.02 4.61 4.66 4.68 4.3

The opinions regarding the price showed that the perception is good for all the studied

services, the differences in perception between the price of private and public medical

services are not very important. The best score concerning the perception of price was

obtained by the price of services of family doctor (3.73)

0,00

0,50

1,00

1,50

2,00

2,50

3,00

3,50

4,00

4,50

quality of services

price

promptitudecompetence of the personal

services efficacy

family doctor public emergency medical services private emergency medical services public hospital medical services private clinics medical services public dental care services private dental care services public laboratory analysis private laboratory analysis

Figure no. 3: The chart of Romanian medical services

The opinions regarding the characteristics of hospital medical services (nutrition services,

cleaning services, maintenance and hospital conditions, services of doctors, services

provided by nurses, quality / price) are presented in Table no. 3 and indicates that the

perception was rather negative for nutrition services (score 2.29), cleaning services (score

2.19), maintenance and hospital conditions (score 2.10), services provided by nurses (score

2.51) and the quality / price (score 2.43). However, the subjects interviewed had a rather

good opinion regarding to the medical services provided by doctors (score 3.03).



Table no. 3: The opinion regarding characteristics of hospital medical services

5

very good

4 3 2 1

very poor Score

Nutrition services 2.38% 10.37% 29.59% 28.94% 28.73% 2.29

Cleaning services 0.86% 8.42% 26.57% 37.37% 26.78% 2.19

Hospital conditions 1.51% 6.48% 23.54% 37.15% 31.32% 2.10

Services of doctors 6.26% 24.62% 44.06% 16.41% 8.64% 3.03

Services of nurses 3.89% 12.10% 33.48% 31.97% 18.57% 2.51

Quality/price 1.94% 12.74% 32.18% 32.40% 20.73% 2.43

The opinions regarding the competence of the medical personnel indicated a positive

perception: on a five level scale from 5 (very good) to 1 (very poor) the score obtained was

of 3.26, 8% of the subjects having a very good opinion regarding the competence of the

medical personal.

competence of the medical personal

7,99%

34,56%

38,44%

13,39%

5,62%

0,00%

5,00%

10,00%

15,00%

20,00%

25,00%

30,00%

35,00%

40,00%

45,00%

very good 5 4 3 2 very poor 1

Figure no. 4: The opinions regarding the competence of the medical personnel

The corruption in the medical system was considered by 74.3% of the subjects as being

very high and high, only 11.4 % of respondents considering it as low or very low. The score

of 1.93 (on the scale very low = 5 to very high = 1) indicates that the medical system is

perceived as being corrupted.

corruption in the medical system

3,46%

7,99%

14,25%

26,78%

47,52%

0,00% 5,00% 10,00% 15,00% 20,00% 25,00% 30,00% 35,00% 40,00% 45,00% 50,00%

very low 5

4

3

2

very high 1

Figure no. 5: The opinions regarding the corruption in the medical system



The medical system reform was studied using the Likert scale. A series of statements

related to the reform measures were tested. The answers indicated that the subjects did not

agree with the closing of non-profitable hospitals (score -0.43), the turning of some

hospitals into asylums (score -0.04) and the co-payment for medical services (score -0.46).

The subjects disagree with the statement that “the medical system reform is progressing

well” (score -0.43). The subjects agree that “the introduction of the health card is

useful“(score 0.51).

Table no. 4. The opinions regarding the medical system reform

Total

agreement

+2

Agreement

+1

Disagreement

-1

Total

disagreement

-2

Score

Closing the non-profitable

hospitals was correct 11% 25% 38% 26% -0.43

Turning some hospitals into

asylums was necessary 13% 37% 33% 17% -0.04

The medical system reform is

progressing well 4% 31% 48% 17% -0.43

The co-payment for medical

services is necessary 6% 29% 43% 22% -0.46

The introduction of the

health card is useful 22% 47% 22% 9% 0.51

The degree of satisfaction regarding the medical system was evaluated using a differential

semantic scale (5 – very content, 1 – very discontent). The score of 2.62 indicates a state of

discontent. 40% of the interviewed subjects were discontent or very discontent with the

medical system and only 17% of the subjects were content or very content with the existing

medical system. Using the same scale we have studied the degree of content regarding

different medical services and the scores indicate a state of content for private dental care

services (score 3.82), services of the family doctor (score 3.60), private laboratory analysis

(score 3.53), private clinics medical services (score 3.44), private emergency medical

services (score 3.21), foreign medical services (score 3.12), public laboratory analyses

(score 3.04), and a state of discontent for public dental care services (score 2.70), public

hospital medical services (score 2.76) and public emergency medical services (score 2.85).

22%

4%

13%

4%

17%

5%

30%

8%

23%

22%

39%

16%

26%

15%

34%

11%

38%

22%

30%

10%

22%

53%

45%

49%

33%

52%

23%

48%

34%

47%

10%

13%

2%

18%

4%

15%

2%

11%

2%

2%

7%

13%

14%

14%

11%

18%

7%

11%

11%

20%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

family doctor

public emergency medical services

private emergency medical services

public hospital medical services

private clinics medical services

public dental care services

private dental care services

public laboratory analysis

private laboratory analysis

foreign medical services

5 very content 4 content 3 2 discontent 1 very discontent

Figure no. 6: The degree of satisfaction regarding different medical services



The higher degree of content was for the private dental care services: 30% of the subjects

are very content with these services.

The answers to the open question related to the measures necessary to improve the

Romanian medical system revealed that the subjects interviewed consider that the State

plays a major role in the reform of the medical system The measures considered necessary

by the interviewed subjects in order to improve the Romanian medical system can be

divided in two major categories:

Measures that have to be adopted by the State (privatisation of some hospitals and

clinics, proper financing of the medical organisations, bigger budget for the medical

services, adopting a health law in accordance with the health laws of the European Union,

introduction of the health card, better payment policies for the personnel, new hiring in the

public medical system, elimination of the corruption of acquisitions, measures to eliminate

the corruption of the personnel etc.)

Measures that have to be adopted by the medical institutions. The measures

considered necessary in order to improve the Romanian medical system that have to be

adopted by the medical institutions can be structured in:

- Measures related to the management of the institutions (better investments policies,

measures to eliminate the corruption etc.)

- Measures related to the product policy (cleaner hospitals, better sanitary conditions,

diversification of services, existence in Romanian hospitals of services similar with those

offered by foreign medical hospitals, new equipment, improvement of private medical

services etc.)

- Measures related to the price policy (adapted prices, differentiated prices, loan

facilities for the payment etc.)

- Measures related to the personal policy (more attentiveness and care for the patients

displayed by the medical personal, better payment of medical personnel, better financial

motivation of medical personnel in order to make possible the elimination of the corruption

etc.)

Conclusion

The key in attaining socially and economically productive lives – according to the Alma-

Ata Declaration – lies in the availability of and accessibility to appropriate primary health

care (Dib et al., 2010) so it is important for the medical services in Romania to be equally

available for all ages, in urban and rural areas, in similar qualitative conditions. The

research indicated that the family doctor was the medical service most used and it is

important that the State encourages the role of the family doctor, but also it is equally

important that the family doctors prove capable of social responsibility, adapting their

services to the exigencies of the community.

The opinion regarding the entire medical system resulted from the survey indicates an

unfavourable perception, so a change is necessary. In the reform of the medical system, the

State plays a major role and there are important measures to be taken, but those measures

should be accepted by the population before implementation. The success of the reform



relies not only on the action of the State, but also on the private medical system (and there

are measures suggested by the respondents to private actors) and on the social

responsibility of the community.

One important idea that we may consider is that the projects between the public and the

private sector may provide a better way for implementation of medical services, and may

facilitate realistic solutions for better pre-hospital care in developing countries (Ali,

Miyoshib and Ushijima, 2006).

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