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Advisory Services Agreement on

Strengthening Planning and Budgeting Capacity and Supporting the Introduction of Performance Budgeting (P156889)

Output No. 3Institutional Strategic Plan 2017-2020 for the Ministry of Health

April 2017

Project co-financed from the European Social Fund through the Operational Programme for Administrative Capacity 2014-2020

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This report has been delivered under the Advisory Services Agreement on Strengthening Planning and Budgeting Capacity and Supporting the Introduction of Performance Budgeting signed between the General Secretariat of the Government and the International Bank for Reconstruction and Development on June 8, 2016. It corresponds to Output 3 under the above-mentioned agreement.

Disclaimer

This report is a product of the International Bank for Reconstruction and Development / the World Bank. The findings, interpretation, and conclusions expressed in this paper do not necessarily reflect the views of the Executive Directors of the World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work.

This report does not necessarily represent the position of the European Union or the Romanian Government.

Copyright Statement

The material in this publication is copyrighted. Copying and/or transmitting portions of this work without permission may be a violation of applicable laws.

For permission to photocopy or reprint any part of this work, please send a request with the complete information to either: (i) the General Secretariat of the Government (1 Victoriei Square, Bucharest, Romania); or (ii) the World Bank Group Romania (Vasile Lascăr Street, No 31, Et 6, Sector 2, Bucharest, Romania).

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Table of Contents

List of Acronyms..................................................................................................................................................

List of Figures......................................................................................................................................................

List of Tables.......................................................................................................................................................

List of Boxes........................................................................................................................................................

I. Context............................................................................................................................................................

II. Mission and Vision........................................................................................................................................

III. Strategic Objectives, Programs, Measures, Indicators...................................................................................

Strategic Objective 1: Improving the health of the population through measures of morbidity prevention and control.........................................................................................................................................................................................

Strategic Objective 2: Cross-cutting measures to increase the performance of the healthcare system......................................

Strategic Objective 3: Develop the institutional capacity of management structures in the healthcare system.........................

IV. Arrangements for implementation, monitoring and evaluation of the ISP....................................................

V. Financial resources........................................................................................................................................

Annex 1a: Budgetary Programs and Financial Resources by financing source 2017-2020 (thousand RON).................................................................................................................................................................

Annex 1b: Budgetary Programs and Financial Resources by main credit officer 2017-2020 (thousand RON).................................................................................................................................................................

Annex 1c: Measures and Financial Resources by financing source 2017-2020 (thousand RON)...........................

Annex 2: Institutional Strategic Plan (summary table)........................................................................................

Annex 3: Programs and related Measures (summary table)...............................................................................

Annex 4: Institutional profile, internal and external assessment........................................................................

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List of Acronyms

AIDS Sindrome de l’Immuno-Deficience AcquiseDALY Disability Adjusted Life-YearsDCPPHI Department for Centralized Procurement, Property and Healthcare

Infrastructure DHMS Department for Healthcare Management and Structures DMMDP Department for Medicine and Medical Device Policy EMS Emergency Medical ServiceEU European UnionGD Government Decision GDBA General Department for Budget and Accounting GDHAPH General Department for Healthcare Assistance and Public Health GDHRLAD General Department for Human Resources, Legal and Administrative

LitigationGEO Government Emergency Ordinance GO Government Ordinance GSG General Secretariat of the Government HIV Human Immunodeficiency Virus HRD Human Resource Development ISP Institutional Strategic PlanMARD Ministry of Agriculture and Rural Development MoH Ministry of Health MoNE Ministry of National Education MoPF Ministry of Public FinanceNAHP National Agency for Health ProgramsNAHQM National Authority for Health Quality Management NAMMD National Agency for Medicines and Medical DevicesNGO Non-Governmental Organization NHIF National Health Insurance FundNHIH National Health Insurance House NHS National Health Strategy 2014-2020NICE National Institute for Care ExcellenceNIS National Institute for StatisticsNPHI National Public Health Institute NPHSA National Program for Health Status AssessmentNSPHMTH National School for Public Health, Management and Training in HealthcareOEC Operative Emergency Center OPAC Operational Program Administrative CapacityOPC Operational Program Competitiveness OPHC Operational Program Human Capital OPR Operational Program RegionalSHI State Healthcare Inspection WHO World Health Organization

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List of Figures

Figure 1. Structure of public financing of healthcare in 2015.................................................................7Figure 2. Structure of NHIF spending in 2015.........................................................................................7Figure 3. Main causes of death in the European Union and Romania for adults over 45 years old (deaths/ 100.000 population)...............................................................................................................11Figure 4. The share of selected services in total current public spending in healthcare in Romania and selected EU countries...........................................................................................................................21Figure 5. Monitoring Cycle for the Healthcare ISP................................................................................39Figure 6. Annual ISP financing by strategic objective (bn. RON)...........................................................40Figure 7. Annual ISP financing by main credit officer (bn. RON)...........................................................41Figure 8. Annual ISP financing by source of funding (bn. RON)............................................................41Figure 9. Hospital cases classified under the DRG system....................................................................91Figure 10. Multiannual trend of acute cases by complexity (2010=100%)...........................................91

List of Tables

Table 1. Strategic Objective 1: Breakdown of financing by budgetary program (thousand RON)........14Table 2. Measures included in Program 1.1.........................................................................................16Table 3. Measures included in Program 1.2.........................................................................................17Table 4. Measures included in Program 1.3.........................................................................................19Table 5. Measures included in Program 1.4.........................................................................................20Table 6. Strategic Objective 2: Breakdown of financing by budgetary program (thousand RON)........25Table 7. Measures included in Program 2.1.........................................................................................27Table 8. Measures included in Program 2.2.........................................................................................29Table 9. Measures included in Program 2.3.........................................................................................31Table 10. Measures included in Program 2.4.......................................................................................32Table 11. Strategic Objective 3: Breakdown of financing by budgetary program (thousand RON)......35Table 12. Measures included in Program 3.1.......................................................................................36Table 13. Pieces of legislation to be enacted in the healthcare sector in 2017....................................93

List of Boxes

Box 1. Main tasks of the regulatory bodies in healthcare......................................................................6Box 2. Strategic Objective 1: Impact and outcome indicators..............................................................14Box 3. Strategic Objective 2: Impact and outcome indicators..............................................................24Box 4. Strategic Objective 3: Impact and outcome indicators..............................................................35

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Acknowledgments

This report was prepared by a team led by Catalin Pauna (TTL) and included Cristina Petcu, Radu Comsa, Costel Todor, Mihai Vilnoiu, and Raluca Banioti. The report benefited from thoughtful comments from Gary Reid, Marcelo Bortman and Corina Grigore, and overall guidance from Ivailo Izvorski and Elisabetta Capannelli.

The team would like to thank the staff at the General Secretariat of the Government for the support and excellent collaboration provided throughout the elaboration of this report, and in particular to Mr. Radu Puchiu, state secretary, and Mr. Dragos Negoita, general director. Counsellor Radu Iacob and the project team provided outstanding advice and project management.

The team wished to acknowledge the support and contributions made by the members of the working group set up with the task of developing and implementing the Institutional Strategic Plan for the healthcare sector, including experts from the Ministry of Health, the National Health Insurance House, National Authority for Health Quality Management, National Public Health Institute and National School for Public Health, Management and Training in Healthcare. The team wishes to thank in particular to Mrs. Corina Pop, state secretary in the MoH, Mr. Radu Țibichi, general director of the NHIH, Mrs. Mihaela Bardoș, head of the NAHP, and Mrs. Monica Isăilă, head of the Public Policy Unit, for their involvement and cooperation.

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I. Context

The Romanian healthcare system relies on social health insurance, which coexists with public health interventions and private provision of services. Overall, spending has averaged between 5% and 5.5% of GDP over the last 10 years, with 80% of the total from public sources, mainly social health insurance, and 20% from direct payments. The level of spending places Romania at the bottom of the EU-28, significantly lower than the EU average of 8.4% of GDP.

Healthcare is regulated by a complex array of legislation of which the most important is Law no. 95/2006 on healthcare reform. Apart from the latter, over 25 pieces of primary legislation and numerous by-laws set provisions for the organization, delivery, financing and evaluation of health and health-related services and institutions. The complexity of legislation oftentimes impairs the behavior of service providers and regulatory bodies alike and, as a result, has a distortive impact on quality and access to services1.

A National Healthcare Strategy was approved in 20142 outlining the main challenges, priorities and objectives of the sector until 2020. The Strategy includes a detailed Action Plan with activities, indicators and estimated financial needs for all components of the sector.

The main public stakeholders in the healthcare sector are the Ministry of Health, the National Health Insurance House, the National Public Health Institute, the National Agency for Medicines and Medical Devices, and the National Authority for Health Quality Management3.

Box 1. Main tasks of the regulatory bodies in healthcare

1 A list of full-name regulations in the healthcare sector is available in Annex 5.2 Government Decision no 1028/2014 on the National Health Strategy for 2014 - 2020 and the Action Plan.3 A complete list of the public bodies in the healthcare sector is provided in Annex 5.

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The MoH is mainly responsible for preparing the strategy and regulating the sector, but also retains significant responsibilities in service provision and financing. To this end, it runs 53 hospitals, ambulance service, emergency care and 15 national public health programs. MoH also finances a significant part of the capital investment of public hospitals. At the county level, MoH has 42 county health departments (including the city of Bucharest).The NHIH is the single payer in the social health insurance market. It runs 42 county health insurance houses (including in the city of Bucharest) and the insurance house for defense, public safety and justice employees. The NHIH is an autonomous institution under the coordination of the MoH. The head of the NHIH is appointed by the Prime Minister.The NPHI is responsible for the development and enforcement of public health policies. It plays a major role in epidemiological surveillance and control and health promotion. It is subordinated to the MoH.The NAMMD is the regulatory and authorizing body for drugs and medical devices. It conducts pharmacovigilance and health technology assessment for medicines. It is subordinated to the MoH.

In terms of human resources, the MoH and its subordinates employ 6,000 staff, while NHIH employs over 3,000 staff. The MoH also runs the ambulance services, which employ over 11,000 staff. In 2015 total public funding for healthcare amounted to 28 billion RON, i.e. 4% of GDP. The NHIF has historically accounted for more than 80% of public funding of healthcare, with most of its resources being allocated to hospital services and reimbursed medicines (see Figure 1&2).

Figure 1. Structure of public financing of healthcare in 2015

83%

16%

2%

NHIF MoHlocal governments

Source: MoF

Figure 2. Structure of NHIF spending in 2015

37.4%

11.4%

37.6%

13.7%

reimbursed drugs

out-patient services

hospital care

other spending (dialisis, emergency, medical leave, medical goods)

Source: MoF

As for the human resources across the entire healthcare sector, recent data published by the NIPH for 2015 counted a total number of 302,000 professionals, of which 56,000 were physicians and 132,000 nurses. The breakdown by type of provider reveals that 60% of physicians and close to 70% of nurses work in public settings.

In comparison to the other countries of the EU, the size of Romania’s healthcare personnel is lagging behind. The number of physicians per 100,000 population stands at 271, which represents 77% of the EU average4. To make matters worse, both physicians and nurses have been migrating to better-off EU countries in search for improved remuneration and working conditions. Data on the yearly dynamics of physicians’ cohort indicates between 1,000 and 1,500 persons emigrating yearly throughout 2009-2015. As a result, the annual growth rate of physician number at national level decreased from 4% in 2008 to less than 2% in 2013 and 20145.

The constraints related to cohort size are amplified by the skewed distribution of workforce across the country. Comparisons between predominantly rural and urban counties indicate an average rate of physicians per 100,000 population more than double in the latter, i.e. 383 to 170. For nurses, the

4 Eurostat, healthcare resources database, data available for 2006-2014.5 National Statistics Institute, Tempo database.

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difference is smaller, but remains significant: predominantly urban counties have 30% more nurses per 100,000 population than predominantly rural counties. An additional distortion concerns the overstaffing in counties where medical universities are placed. The lack of effective incentives for practicing in rural and economically worse-off urban communities led to a concentration of almost half of all physicians in six out of 42 counties (including the city of Bucharest). As a result, the counties in the top decile have four times more physicians than those in the bottom decile6.

The prevalent delivery model in healthcare is service provision, which absorbs 93% of all public funding in the sector. Half of funding is disbursed or transferred to health service providers in outpatient and inpatient care and 30% to pharmacies. In the vast majority of cases, the providers are contracted either by the health insurance houses or the county health departments. As for the services directly provided, the most important is the ambulance, which accounts for 2% of total service provision.

Operational management of the healthcare sector is comprised of administrative costs – i.e. payroll and running costs of regulatory institutions – and transfers to individuals, e.g. sick leave allowances. The former accounts for only 2% of total spending.

The biggest service purchaser is the NHIH, whose health insurance houses sign contracts with more than 25,000 providers every year. While the vast majority of NHIH providers are private, especially in outpatient care, around half of the funds are eventually disbursed to public providers, i.e. hospitals 7 and their outpatient clinics.

Population health status

As a result of the negative balance between birth, death and migration, the resident population of Romania has significantly decreased between 2002 and 2015 (from 21.6 down to 19.8 million inhabitants). In parallel, the nominal and relative decrease of the young and increase of those over 60 (up to 23.9% in 2015) have led to the ageing of the population.

Life expectancy at birth – a measure of the quality of life and an indicator of the potential yield of investments in human capital – has had a favorable evolution in the past two decades for both genders, and has currently reached 71.4 years for men and 78.7 years for women8. According to life expectancy, Romania ranks second to last in the EU-28, with the gap from the EU average wider for men (-6.7 years) than women (-4.9 years)9.

The needs which the Romanian health system must satisfy have changed as a result of the demographic and epidemiologic transition which took place in the country. The burden of morbidity in Romania, previously dominated by illness among mothers and children and by communicable diseases, has been overtaken by chronic and non-communicable diseases. The predominance of chronic, non-communicable diseases (NCDs), especially cardio-vascular diseases (CVD), diabetes, cancer and chronic respiratory diseases, continue to increase rapidly and, with it, invalidity rates.

6 Ibid. 7 Of the 367 public hospitals, 53 are owned by the MoH and rest by local governments, mainly county councils.8 Eurostat, 2014.9 Ibid.

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Causes of death 10 . The latest data on the causes of death reveals that diseases of the circulatory system and cancer have been the main causes of death in Romania for the last two decades. The mortality generated by circulatory diseases has reached 58.9% by 2015, while that of neoplasms 19.7%. The following causes of death, in order of frequency, are diseases of the respiratory system (5.7%), digestive system (5.5%) and external causes11 (3.7%).

The main causes of death differ by age group. For teenagers and young adults, the primary causes of death are external (also including road accidents). From 45 years old onwards, diseases of the circulatory system, tumors and diseases of the digestive system prevail. Deaths caused by the above-mentioned pathologies are significantly higher in Romania than the EU average, which may point to systemic failures in preventive services.

Infant mortality maintained its decreasing trend down to a minimum level of 8.4 deaths per 1,000 live newborn babies in 2014, but still continues to be the highest rate in EU-28 countries and 2.3 times the European average (~3.7‰ in 2014). The most frequent causes for infant death relate to perinatal conditions, respiratory diseases and congenital pathology. Remarkably, mothers’ deaths per 100,000 births dropped considerably from 77 in 2000 to 27 in 2015, but remains significantly above the EU average.

10 Detailed information on the causes of death and morbidity are available in annex 6. The source of data is the statistical center of NPHI.11 Traumatic lesions, poisoning or other external causes.

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II. Mission and Vision

The Ministry of Health, the National Health Insurance House and the National Authority for Health Quality Management are the central authorities for healthcare in Romania, responsible for the formulation of polices, strategies and action plans in healthcare; coordinating and monitoring their implementation thereof at national, regional and local levels; implementation of healthcare reforms; delivery of health services at adequate quality levels.

The Mission of the institutions tasked with healthcare policy formulation and administration is:

to prepare and implement strategies, policies and programs to promote public health and the development of a modern and highly performing health system, in line with the population’s needs and compatible with EU standards.

A highly performing healthcare system requires equitable access to cost-efficient and high-quality health services, with a focus on prevention.

Achieving a highly performing system requires appropriate, consistent and stable public policies, supported by broad consensus of healthcare service providers, and upgrades of obsolete and outdated medical infrastructure.

National healthcare policies need to be integrated within the EU’s framework. This does not mean passively adopting EU policies, but rather actively promoting solutions suitable for Romania’s needs and agreed with national partners.

Dedicated support to promote public health generates benefits for Romania, but also for the region. Such benefits should exceed the short- and long-term costs of this support, which confirms the responsibility to prepare consistent and sustainable public policies and sectoral strategies.

The Vision of the institutions tasked with healthcare policy formulation and administration is:

to serve the interests of the population and respond to its needs by facilitating access to high-quality preventive and curative services with effective and efficient distribution and use of resources, that results in a nation of healthy and productive people.

To develop the healthcare system by putting the patient at its core and bring service provision as close as possible to his home.

To undertake responsibilities with the highest standards of transparency, liability and integrity, in cooperation with other public institutions, the private sector, professional associations of physicians, pharmacists, nurses and other healthcare professionals.

To improve the managerial and organizational performance, to comply with its responsibilities set forth in the Governance Program, sectoral strategies and policies.

To pay due attention to the concerns, opinions and dialog with citizens and monitor the impacts of decisions to enable adjustments as needed to better meet the public’s requirements.

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III.Strategic Objectives, Programs, Measures, Indicators

Strategic Objective 1: Improving the health of the population through measures of morbidity prevention and control

Romania has a mixed health profile. It resembles developed countries as a result of the high burden of chronic diseases, but also developing countries, given the significant burden of certain communicable diseases (e.g. tuberculosis, viral hepatitis B and C, inherited prevalence of HIV/AIDS).12

Moreover, the surveillance and control of nosocomial infections and of antibiotic-resistance are insufficient and could potentially have a high impact on the quality and effectiveness of health services.

The high prevalence of behavioral determinants of health - smoking, alcohol abuse, diet/obesity and physical inactivity – weigh heavily on the health status of the population and lead to higher mortality rates than the EU-28 averages (see Figure 3). At present, health promotion activities are underfunded, unfocused and insufficiently based on evidence. To change behaviors for the better, a more coherent, targeted and better resourced approach is needed for health promotion programs. As a result, the National Healthcare Strategy 2014-2020 requires the development and implementation of a national prevention plan which would combine health promotion and prevention interventions.

Figure 3. Main causes of death in the European Union and Romania for adults over 45 years old (deaths/ 100.000 population)

2,219

197 654 581

96

2,767

538

1,175

556 155

European Union (28 countries) 2013 Romania 2013

Source: Eurostat

12 Bygbjerg IC, Double burden of noncommunicable and infectious diseases in developing countries. Science. 2012 Sep 21;337(6101):1499-501.

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The NHS outlines cardiovascular diseases, cancer and diabetes as strategic sectoral priorities and mandates the development and implementation of specific national control plans which would integrate interventions across the entire spectrum of health services: primary and secondary prevention, treatment, monitoring, palliative care and long term care.

The NHS also puts emphasis on communicable diseases with the aim of monitoring, controlling reducing the burden towards EU average levels. As such, it makes a priority out of (i) strengthening the national system of surveillance and response, (ii) reducing the incidence of vaccination-preventable disease, (iii) reducing the morbidity and mortality rates from tuberculosis, HIV/AIDS and viral hepatitis.

Apart from high prevalence diseases, the NHS gives due importance to rare diseases. It mandates the development and implementation of a national plan for rare diseases, which would integrate interventions across the entire range of care, from clinical guidelines to genetic risk assessment, diagnostic and treatment, palliation and recovery services.

This strategic objective is made of programs and measures aiming to reduce the disease burden, advance healthy lifestyle and protect the population against environment risks to health.

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Program 1.1: Prevention and control of non-

communicable diseases

Measure 1.1.1.1 Develop and implement mechanisms for prevention, diagnostic, treatment and control of cardiovascular diseases

Measure 1.1.1.2 Develop and implement mechanisms for prevention, diagnostic, treatment and control of oncologic diseases

Measure 1.1.1.3 Develop and implement mechanisms for prevention, diagnostic, treatment and control of diabetes mellitus

Measure 1.1.1.4 Prevention and control of mental and behavior disorders

Measure 1.1.1.5 Promote a healthy lifestyle and combat the main risk factors

Measure 1.1.2.1 Develop medical services for patients with special pathologies

Program 1.2: Prevention and control of communicable diseases

Measure 1.2.1.1 Strengthen the system of prevention, surveillance and control of communicable diseases

Measure 1.2.1.2 Strengthen the system of prevention, surveillance and control of priority communicable diseases – tuberculosis

Measure 1.2.1.3 Strengthen the system of prevention, surveillance, detection, diagnostic, treatment and monitoring of priority communicable diseases – viral hepatitis

Measure 1.2.1.4 Strengthen the system of prevention, surveillance and control of priority communicable diseases - HIV/ AIDS

Measure 1.2.2.1 Protect the population health against main communicable diseases that can be prevented through vaccination

Program 1.3: Improving mother

and child health

Measure 1.3.1.1 Early detection and assessment of risks during pregnancy for both mother and child

Measure 1.3.1.2 Measures of early detection and assessment of child diseases with increasing incidence, such as autism spectrum disorders

Measure 1.3.1.3 Measures aimed at improving child nutrition and other measures for specific diseases

Program 1.4: Monitoring public health

in connection with the environment

Measure 1.4.1.1 Monitor and report on the determining factors from the living and working environment

Measure 1.4.2.1 Consolidate monitoring services for the determining factors from the living and working environment

Box 2. Strategic Objective 1: Impact and outcome indicators

Table 1. Strategic Objective 1: Breakdown of financing by budgetary program (thousand RON)


2017 2018 2019 2020

Program 1.1: Prevention and control of non-communicable diseases

6.087.871 6.553.819 6.839.249 7.142.141


1.850.795 2.134.166 2.799.135 2.859.451

Program 1.3: Improving mother and child health 32.006 33.606 36.055 38.703

Program 1.4: Monitoring public health in connection with the environment 1.838 27.522 60.974 2.447

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Reduce the gap between the life expectancy and healthy life expectancy in men from (Baseline) 12.4 years to Target 2020: 12.2 Target 2030: 12;Reduce the gap between the life expectancy and healthy life expectancy in women Baseline: 19.7 years to Target 2020: 19.3 to Target 2030: 19;

Impacts

(1.1.1.) Reduce the prevalence of risk factors for non-communicable diseases: Standardized rate of deaths caused by chronic diseases in persons aged below 65 to drop from_219.15/100,000 to 217/100,000 (1.1.2.) Ensure access to early detection, diagnosis and / or treatment for specific diseases: Coverage of target group for cervical cancer screening to increase from 9.2% to 10%; Cervical cancer incidence to vary from 34.24/100,000 to 34/100,000 (1.2.1) Reduce the incidence and prevalence of priority infectious diseases: Standardized TB incidence 63/ 100,000 to 60/ 100,000; Standardized HIV incidence 1.99/ 100,000 to 1.9/ 100,000; Standardized hepatitis B incidence will drop from 1,11/ 100,000 to 1/ 100,000 (1.2.2) Increase the compliance rate to the vaccinations included in the National Immunization Calendar: Vaccination coverage for children of 12 and 24 months as part of the national immunization calendar will increase from 80% to 85% (1.3.1) Improve mother and child health: Infant mortality rate (0-1 years) to drop from 7,97/ 1,000 live births to 7.9/ 1,000 live births; Mother birth mortality will stay at 0.1/ 1,000 live births (1.4.1) Reduction in diseases linked to environmental risk factors: Number of occupational diseases to drop from 1025 cases to 800 cases (1.4.2) Reduction of the negative impacts of environmental catastrophes occurring at infrastructure sites exposed to environmental risks: Map of areas posing risks for human health to be developed and operational

Program Outcom

es


Rationale. Romania’s population is decreasing and aging; it is estimated that, by 2050, the largest population segment will be made up of the elderly (aged 60 and above). The demographic changes place a significant burden on the health care system, as they are associated with a shift in epidemiologic patterns of each age group13.

The needs that the healthcare system must meet have changed following the demographic and epidemiologic transition of the last decades. While in the XXth century the morbidity burden in Romania was dominated by mother and child diseases and by communicable diseases, at present it is dominated by chronic and non-communicable diseases. Therefore, Romania faces the challenge of reprioritizing its health care efforts to give higher priority to addressing chronic and non-communicable diseases.

In the field of preventive medicine, Romania does not do well compared to other EU Member States. As emphasized by NHS 2014-2020, the healthcare system should focus on primary prevention, with the goal of decreasing the prevalence of risk factors, and on secondary prevention, with the goal of the early detection and treatment of the diseases before they become symptomatic, to avoid complications. To this end, it is necessary to gradually increase the percentage of prevention programs and activities in the budget of the health sector, with an emphasis on family physicians and outpatient services. The conclusion of the most recent evaluation of the efficiency of allocation conducted by international experts is that “there is a relative underfinancing of the primary care and outpatient services”14, which is associated with structural and financing anomalies.

Patients with chronic diseases tend to have more frequent and uncoordinated contacts with the health care system: diagnosis services, specialists, emergency rooms, outpatient clinics, pharmacies. Without a proper coordination and without an adequate algorithm for the care that their health status requires, chronic patients often fail to receive effective treatment in due time. This leads to acute complications, repeated or overlapping services, to the improper use of drugs, as well as to an increase in costs for individuals, for NHIF and for the state budget.

Objectives: Program 1.1 is intended to achieve the following results by 2020:

- (1.1.1.) Reduce the prevalence of risk factors for non-communicable diseases:

Standardized rate of deaths caused by chronic diseases in persons aged below 65 to drop from_219.15/100,000 to 217/100,000

- (1.1.2.) Ensure access to early detection, diagnosis and / or treatment for specific diseases:

Coverage of target group for cervical cancer screening to increase from 9.2% to 10%

Cervical cancer incidence to vary from 34.24/100,000 to 34/100,000

Overview. Preventive activities should be encouraged in all fields, cross-sectoral and at all healthcare levels, at population and individual level; the use of primary care, of family physicians, has a high potential for strengthening prevention. Activities of planning, assessment and monitoring should be encouraged to better manage prevention activities and programs, to improve population coverage and the assessment of individual programs, and to allow for better coordinating, streamlining, encouraging and conducting prevention activities in the community.

13 World Bank, Romania – Healthcare Functional Review, Bucharest, 2011.14 NICE International, Romania: Final Report, Bucharest, 2012.

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Reconsidering the information required and strengthening IT systems will be of considerable use, not only for managing and implementing prevention programs, but also for supporting evidence-based decisions in the healthcare system.

Success factors. The main success factors are: (i) the payment system induces providers to supply more preventive services and put more emphasis on chronic-disease case management, (ii) clinical guidelines are available and disseminated for all levels and types of care, (iii) electronic patient file is fully operational, (iv) more providers in primary care are trained and qualified to carry out early detection services, (v) patients are offered incentives to seek preventive services, including early diagnosis.

Measures: The primary measures that will contribute to the achievement of the program- results are included below. The allocated budgets are indicated in Annex 1c, and the measure-related outputs and targets are indicated in Annex 3.

Table 2. Measures included in Program 1.1

(1.1.1) To Reduce the prevalence of risk factors for non-communicable diseases

Measure 1.1.1.1 Develop and implement mechanisms for prevention, diagnosis, treatment and control of cardiovascular diseases

Measure 1.1.1.2 Develop and implement mechanisms for prevention, diagnosis, treatment and control of oncologic diseases

Measure 1.1.1.3 Develop and implement mechanisms for prevention, diagnosis, treatment and control of diabetes mellitus

Measure 1.1.1.4 Prevention and control of mental and behavior disorders

Measure 1.1.1.5 Promote a healthy lifestyle and combat the main risk factors

(1.1.2) To Ensure access to early detection, diagnosis and / or treatment for specific diseases

Measure 1.1.2.1 Develop medical services for patients with special pathologies


Rationale. Although the morbidity burden in Romania, previously dominated by mother and child diseases and by communicable diseases, is at present dominated by chronic and non-communicable diseases, and the mortality caused by infectious diseases is just 1% of the total deaths, there are further aspects to be improved with respect to the monitoring and control of communicable diseases.

Additionally, the effects of climate changes require the consolidation of public health infrastructure and instruments. They impact health in a number of ways, some related to extreme weather events – natural calamities such as floods, storms, heat waves, droughts – whereas some have a more complex route, resulting, in time, in changing the patterns of infectious diseases or in new pathogens, such as emerging diseases.

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In order to meet the challenges posed by continuous climate changes, the Ministry of Health includes the surveillance of events impacting public health in various ways, including climate changes. Moreover, developing a national level surveillance system is recommended, enabling the detection, assessment, notification and response to all events and risks related to public health which can represent a threat to population health. Hence, new algorithms for syndromic surveillance should be developed and implemented, with the help of electronic surveillance systems.

Objective: Program 1.2 is intended to achieve the following results by 2020:

- (1.2.1) Reduce the incidence and prevalence of priority infectious diseases:

Standardized TB incidence from 63/ 100,000 to 60/ 100,000

Standardized HIV incidence from 1.99/ 100,000 to 1.9/ 100,000

Standardized hepatitis B incidence from 1,11/ 100,000 to 1/ 100,000

- (1.2.2) Increase the compliance rate to the vaccinations included in the National Immunization Calendar:

Vaccination coverage for children of 12 and 24 months as part of the national immunization calendar will increase from 80% to 85%

Overview. Preventive activities should be encouraged in all fields, cross-sectoral and at all healthcare levels, at population and individual level; the use of primary care, of family physicians, has a high potential for strengthening prevention. Activities of planning, assessment and monitoring should be encouraged to better manage prevention activities and programs, to improve population coverage and the assessment of individual programs, and to allow for better coordinating, streamlining, encouraging and conducting prevention activities in the community.

Success factors. The main success factors are: (i) sufficient financing is made available to the public health infrastructure and to interventions seeking to diagnose, treat and control infectious diseases, (ii) clinical guidelines are available and disseminated for all levels and types of care, (iii) electronic patient file is fully operational, (iv) national registry for infectious disease is developed and operational, (v) the government approves the transfer of Cantacuzino NIRDMI to the Ministry of Health, (vi) European surveillance and response network is effective, (vii) Romania is safe from pandemics or new epidemics, (viii) external or national vaccination accidents do not occur.



(1.2.1) To Reduce the incidence and prevalence of risk factors

Measure 1.2.1.1. Strengthen the system of prevention, surveillance and control of communicable diseases

Measure 1.2.1.2 Strengthen the system of prevention, surveillance and control of priority communicable diseases – tuberculosis

Measure 1.2.1.3 Strengthen the system of prevention, surveillance, detection, diagnosis, treatment

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and monitoring of priority communicable diseases – viral hepatitis

Measure 1.2.1.4 Strengthen the system of prevention, surveillance, detection, diagnosis, treatment and monitoring of priority communicable diseases – HIV/ AIDS

(1.2.2) To Increase the compliance rate to the vaccinations included in the National Immunization Calendar

Measure 1.2.2.1 Protect the population health against main communicable diseases that can be prevented through vaccination

Program 1.3: Improving mother and child health

Rationale. Romania’s population is decreasing and aging. The trend can be noticed across the European Union, but comparative analysis puts Romania among the countries with the biggest population decline in the last 10 years (-0.7% annually)15. This situation is the combined result of negative net migration, low fertility and high mortality.

Mother and child health, in general, and infant mortality, in particular, deserve special attention, both as a synthetic indicator of health and development and due to its significant correlation with the availability and quality of medical care.

Indicators concerning mother and child health have improved between 1995 and 2015, although child mortality in 2008 was equal to the average WHO level for the Europe Region, but twice the rate in high income countries (11 and respective 6 deaths per 1000 live births).

In 2010, Romania had the highest rate of child mortality in the EU: 9.8 deaths in children aged below 1 year per 1000 live births, more than double the European rate of 4.1 deaths per 1000 live births.

Objective. Program 1.3 is intended to achieve the following results by 2020:

- (1.3.1) Improve mother and child health:

Infant mortality rate (0-1 years) to drop from 7.97/ 1,000 live births to 7.9/ 1,000 live births

Mother birth mortality will stay at 0.1/ 1,000 live births

Overview. The public health program of the Ministry of Health regarding women and children includes a variety of interventions with the following aims: the promotion of breastfeeding; the micronutrient diet supplementation of the pregnant woman and infant baby; the early diagnosis of congenital, neonatal conditions and neuropsychological conditions in children. In addition, the social insurance system offers all children and pregnant women monitoring, diagnostic and treatment services at all levels of care, within the scope of the basic service package.

The main priority of the program concerns (i) the reduction of infant and mother mortality and (ii) newborn death risk through increased access to adequate healthcare in regional facilities for newborn children at risk and (iii) the strengthening of the newborn screening component.

Success factors. The main success factors are: (i) financing available to the program is sufficient for the scale-up of the diagnostic interventions; (ii) hospital diagnostic infrastructure is adequate; (iii)

15 Eurostat, population database, 2006-2015 time series, accessed in January 2017.

18

coordination of interventions between the main payers, the MoH and the NHIH; (iv) increased expertise and focus on prevention by family physicians; (v) pregnant women seek early-diagnosis services.



(1.3.1) To Improve mother and child health

Measure 1.3.1.1. Early detection and assessment of risks during pregnancy for both mother and child

Measure 1.3.1.2 Measures of early detection and assessment of child diseases with increasing incidence, such as autism spectrum disorders

Measure 1.3.1.3 Measures aimed at improving child nutrition and other measures for specific diseases

Program 1.4: Monitoring public health in connection with the environment

Rationale. The World Health Organization and the EU Directives on health surveillance provide that Member States should meet the essential demands for surveillance and response, in order to early detect, investigate and respond to public health-related events, such as natural calamities. Various climate zones and their potential health impact should be looked into. This mechanism is based on collecting and disseminating information to the authority in charge, which can take the adequate measures and requires a consolidated coordination and a close cooperation with all stakeholders, from the healthcare sector and outside of it.

As a EU Member State, Romania is deeply involved in this international effort. The National Strategy on climate changes and low-carbon economy for 2016-2020, as well as the National Action Plan for implementing the Strategy has been promoted under the Government Decision no. 739/2016.

The Ministry of Health works together with the Ministry of Environment, Waters and Forests so as to correlate their environment surveillance activities that could negatively influence public health or the quality of the environment with monitoring population health.

The actions provided under the National Action Plan on Climate Changes 2016-2020 provide the allocation of funds, including from the state budget, for developing studies required for implementing the National Action Plan on Climate Changes 2016-2020.

Objectives. Program 1.4 is intended to achieve the following results by 2020:

- (1.4.1) Reduction in diseases linked to environmental risk factors:

Number of occupational diseases to drop from 1025 cases to 800 cases

- (1.4.2) Reduction of the negative impacts of environmental catastrophes occurring at infrastructure sites exposed to environmental risks:

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Map of areas posing risks for human health will be developed and operational (industrial facilities, large chemical plants, routes of transportation for chemical, radioactive or hazardous materials, areas with high risk of floods of earthquakes etc.)

Overview. Activities under this program refer to conducting studies to analyze the quality of the environment and its impact on human health and designing procedures and interventions based on their findings. They will employ real time procedures for planning, managing data and setting up a database, information processing (statistical analysis, GIS techniques) and database integration, drafting graphical and cartographic materials, drafting the scenarios for the evolution of the quality of the environment in relation to identified or possible changes, forecasts, environment maps on the quality of the human environment.

Success factors. The main success factors are: (i) employees and employers are aware of the environmental risks and implement necessary preventive actions; (ii) optimal cooperation of all public agencies involved in regulating, monitoring and responding to environmental catastrophes; (iii) owners of critical infrastructure support mapping activities; (iv) responders to accidents and catastrophes have adequate capacity and resources.



(1.4.1) Result Reduce diseases linked to environmental risk factors

Measure 1.4.1.1 Monitor and report on the determining factors from the living and working environment

(1.5.2) To Reduce the negative impacts of environmental catastrophes occurring at infrastructure sites exposed to environmental risks

Measure 1.4.2.1 Consolidate monitoring services for the determining factors from the living and working environment

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Strategic Objective 2: Cross-cutting measures to increase the performance of the healthcare system

The health needs to be tackled by the Romanian healthcare system have changed as a result of the demographic and epidemiologic transition that occurred in the country. The burden of morbidity in Romania is currently engrossed by chronic and non-communicable diseases, which will continue to grow rapidly.

However, healthcare provision is still reliant on the old model focusing on reactive, hospital-based and episodic treatment of acute conditions and insufficient emphasis on preventive services. The primary care sector is skewed towards urban areas, offers a limited range of services and fails to provide equal access to all population groups. Long-term care and palliative care are underdeveloped and underfinanced and fail to alleviate quality of life for patients with advanced or end-stage diseases. The comparative analysis of healthcare spending between Romania and EU countries with a better track record reveals our country’s overreliance on hospital services, the high share of pharmaceuticals, low emphasis on outpatient care and prevention and the irrelevance of long-term care (see Figure 4).

Figure 4. The share of selected services in total current public spending in healthcare in Romania and selected EU countries

Austria France Germany Romania Slovenia Spain Sweden sample average

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

38% 35% 31%

46%

34% 31%25% 29%

23%

14% 22%

10%25%

27%

27%24%

11%

14%

14%

28%13% 16%

6%11%

16%

15%11%

2%14% 10%

29% 18%

2%

2%3%

1%3%

3%3%

3%

Inpatient curative and rehabilitative care Outpatient curative and rehabilitative care

Pharmaceuticals and other medical non-durable goods Long-term care (health)

Preventive care

Source: Eurostat

21

Services are fragmented and lack coordination across care settings, due to several underlying structural characteristics such as misaligned financial incentives, weak systems for information sharing, unevenly distributed human resources and a prevailing preference among patients for hospital services. Quality of care is often overlooked although Romania ranks last in-patient satisfaction surveys among EU countries.

A major obstacle to better health services is outdated or inadequate infrastructure. Most hospitals do not comply with the requirements derived from current quality standards of care, while numerous primary care practices are dispersed and fail to offer comprehensive and integrated services . In many rural and isolated settings, the absence or poor state of health infrastructure proves a major deterrent for setting up new physician practices.

The National Health Strategy 2014-2020 seeks to overturn the current pyramid of services by gradually ensuring better coverage of health needs through the services currently at the base of the system, namely community care, family practices and specialized outpatient services16. To this end, the ISP strategic objective related to cross-cutting measures puts forward a multilayered approach which aims for improvements in all areas deemed essential for the access, continuity, comprehensiveness and quality of care: (i) human capital, (ii) financial resources and flows, (iii) information management, (iv) health services at all levels of care, (v) medicines and medical devices and (vi) infrastructure.

16 Government Decision no 1028/2014 on the National Health Strategy for 2014 - 2020 and the Action Plan.

22

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Strategic Objective 2: Cross-cutting measures to increase the performance of the healthcare system

Program 2.1: Ensure the functional framework and

the resources for the healthcare system

Measure 2.1.1.1 Human

resource Developme

nt Initiatives

Measure 2.1.2.1

Initiatives to improve

the manageme

nt of financial

resources

Measure 2.1.3.1

Initiatives designed to

improve informatio

n manageme

nt

Measure 2.1.4.1

Initiatives aimed at

promoting research

and innovation

in the health sector

Program 2.2: Improve the efficiency and quality of healthcare services

Measure 2.2.1.1

Develop the

community healthcare

services

Measure 2.2.1.2

Extend the role of family

medicine services

Measure 2.2.1.3

Develop the

services in the

specialty clinic and para-clinic outpatient

care

Measure 2.2.2.1

Increase the

efficiency and

performance of

hospital services

Measure 2.2.2.2

Reinforcement of

emergency healthcare services

Measure 2.2.3.1

Develop the long-

term healthcare services,

rehabilitation/medical recovery,

home caregiving, palliation

Measure 2.2.4.1

Improve the quality

of healthcare

services

Measure 2.2.5.1

Strengthen services for

organ, tissue and human cell transplant

Measure 2.2.5.2 Ensure

demand and

security of blood

products

Program 2.3: Ensure patient

access to medicine

and medical devices

Measure 2.3.1.1

Increase patient

access to compensat

ed medicines

in financially

sustainable conditions

Measure 2.3.2.1

Increase patient

access to medical devices

Program 2.4: Upgrade the

healthcare system infrastructure

Measure 2.4.1.1

Upgrade service

provider infrastructure to the

current standards

of healthcare

services and the

patients’ needs

Measure 2.4.1.2

Development of public

health infrastruct

ure

Measure 2.4.1.3

Development of the

infrastructure for

emergency services


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Territorial distribution of physicians (ratio between averages of quartile 4 and quartile 1 of county rates of physicians per 100,000 population): Baseline 2016: 2.9; Target 2020: 2.6; Target 2030: 2.2Territorial coverage with primary care services (No of local government units without family physician): Baseline 2016: 165; Target 2020: 130; Target 2030: 100Number of reimbursed hospital admissions for conditions treatable in outpatient care: Baseline 2016: 1035; Target 2020: 950; Target 2030: 900

Impacts

(2.1.1) Ensure the needed human resources in order to provide healthcare services at an agreed quality level: Coverage with available medical staff to increase from 280/100,000 physicians and 653/100,000 nurses to 287/100,000 physicians and 595/100,000 nurses(2.1.2) Ensure sustainable funding for the healthcare sector: Total healthcare expenditures to increase from 5.1% of GDP to 5.3% of GDP(2.1.3) Develop the Health Integrated IT System, by implementing sustainable e-health solutions: Level of development of the IPSI (Information Platform of Social Insurance) to reflect the operationalization of all its’ components (from 4 to 6) (2.1.4) Develop the research and innovation capacity in the health sector: Applications resulting from research projects transferred into medical practice (no) to increase from 0 to 5(2.2.1) Increase the provision of preventive services for the population through family healthcare: % of local government units (LGU) where there is at least one family doctor for every 2000 inhabitants will increase from 50% to 53%; number of towns without specialist outpatient care providers will drop from 57 to 0(2.2.2) Rationalize and increase efficiency for hospital healthcare services: Number of acute care beds will decrease from 4.2 per 1,000 inhabitants to 4 per 1,000 inhabitants; Admission rate for acute cases will decrease from 19 cases per 1,000 inhabitants to 18 cases per 1,000 inhabitants(2.2.3) Develop the palliative assistance to be provided to terminal patients and for long-term recovery: Beds for long term care will increase from 5 per 1.000 inhabitants at least 65 years old to 6 per 1,000 inhabitants at least 65 years old; Beds for palliative care will increase from 18 per 100,000 inhabitants to 20 per 100.000 inhabitants(2.2.4) Increase the quality of healthcare services, irrespective of the level where they are supplied: Legal framework allowing the integration and/ or coordination of services providers will be approved and applicable(2.2.5) Improve the outcomes of blood transfusions and organ transplant services: Number of transplants per %0000 inhabitants to increase from 65 to 68; The quantity of transfused blood and plasma to remain at 180000 liters(2.3.1) Increase the number of patients that have access to medicines needed to control or treat chronic conditions: Updates to the reimbursed medicines list will remain at least 3 per year (2.3.2) Reduce waiting lists for medical devices: Medical devices registry will be developed and operational(2.4.1) Decrease the inequity as regards access to healthcare services through the development of infrastructure: Population covered by newly-built regional hospitals (as % and number of regions) to increase from 0 to 39% and 3 regions, respectively; Density of operational radio-therapy equipment compliant with EU standards, per types of equipment will increase from 0.36 units/ 100,000 to 0.45 units/ 100,000

Program Outcomes


Strategic Objective 2: Cross-cutting measures to increase the performance of the HC system

2017 2018 2019 2020

Program 2.1: Ensure the functional framework and the resources for the healthcare system

15.000 252.750 261.150 107.600

Program 2.2: Improve the efficiency and quality of healthcare services 18.283.225 19.121.517 21.493.437 23.311.519

Program 2.3: Ensure patient access to medicine and medical devices 3.282.641 3.446.773 3.619.112 3.800.068

Program 2.4: Upgrade the healthcare system infrastructure 261.794 473.191 1.014.537 1.366.555

Program 2.1: Ensure the functional framework and resources for the healthcare system

Rationale: For the past years between 1,000 and 1,500 physicians have been migrating annually to other countries in search of better working conditions, better pay or professional recognition. As a result, the total number of medical staff has been increasing slowly; in public hospitals the dynamic was even slower than the national average17. The territorial distribution of the medical staff is unbalanced. In the six counties with medical university, the number of physicians amounts to 49% of the national total, while the other half is distributed among the remaining 36 counties. Furthermore, the ratio between the averages of quartile 4 and quartile 1 of county rates of physicians per 100,000 population stands at 2.9, while the ratio between deciles 10 and 1 reaches 5.2. The differences remain high between predominantly urban and rural counties: the ratio between the averages of physicians per 100,000 population is 1.9. All data points to an uneven distribution of staff resources at county level with the population of poorer and predominantly rural facing inadequate access to providers of care.

In recent years the digitization of medical services increased, even at the hospital level, but the level is still suboptimal on several pillars, whereas the management of the national health programs requires the development and/ or consolidation of disease registries. In short, the system`s capacity to collect, process, analyze and report the data in the existing IT or information systems, as well as reflecting the information and data in public policies are faulty, whereas the component related to the communication with/ access to relevant information for patients and the population is not well adequately developed. The ITC can play a significant part in increasing competitiveness in the health sector, including in terms of its efficient and effective e-government. A single integrated information system on public health with an integrated architecture, using interoperable IT applications, would allow generation of quality information and its efficient use for drafting health policies and ensuring more effective system management.

17 NPHI data reveal that the number of public hospital physicians increased by 1.6% from 2014 to 2015, mostly with resident physicians. The six counties with medical schools accounted for almost 60% of the growth.

25

According to the World Bank18, in Romania the total healthcare expenditures are a little over 5% of the GDP, compared to the European average19 of 6.5% and an EU average of 8.7%. The difference arises, on the one hand, from the fairly low public expenditure on health and also from the small share of private expenditure for health, compared to other countries20, lack of tax incentives as well as the financial crises, which contributed to a halt in the private insurances market. The health sector needs a long-term strategy, in order to ensure its sustainable funding. In the strategic directions proposed it is necessary to pair an action plan designed to increase efficiency of the health sector, with the introduction of better cost control measures, with a sustainable increase in public funding and defining a regulatory framework that stimulates private funding in the health sector, including the development of voluntary health insurance.

Objectives: Program 2.1 is intended to achieve the following results by 2020:

- (2.1.1) Ensure the needed human resources to provide healthcare services at an agreed quality level:

Coverage with available medical staff to increase from 280/100,000 physicians and 653/100,000 nurses to 287/100,000 physicians and 595/100,000 nurses

- (2.1.2) Ensure sustainable funding for the healthcare sector:

Total healthcare expenditures to increase from 5.1% of GDP to 5.3% of GDP

- (2.1.3) Develop the Health Integrated IT System, by implementing sustainable e-health solutions:

Level of development of the IPSI (Information Platform of Social Insurance) to reflect the operationalization of all its’ components (from 4 to 6)

- (2.1.4) Develop the research and innovation capacity in the health sector:

Applications resulting from research projects transferred into medical practice (no) to increase from 0 to 5

Overview. The sustainability of the human resources from the healthcare sector will be ensured through retention policies that aim at granting financial incentives and improving the professional evolution perspectives of the medical staff. Simultaneously, it is necessary to give incentives to those practicing medicine in disadvantaged areas or in specialties where there is a deficit, whereas the staff training capacities will have to be adjusted to the health sector`s need for specialists.

The Program aims at developing the strategic and regulatory framework to optimize human resources in the health sector, both in the fields of clinical services and in that of public health. At the same time, the Program also aims at reviewing the funding and reimbursement system for healthcare services, a rigorous control of public expenditures incurred with healthcare services and defining more clearly the healthcare services package covered from NHIF.

Moreover, it is envisaged to develop an efficient vertical and horizontal information system that integrates all the components of the healthcare system (including HR, financial management, etc.). The information system will be supported by integrated IT platforms that do away with redundancies and ensure access to valid data and information. This Program also focuses on developing the

18 World Bank, Functional Review of the Health Sector in Romania, Final Report, April 2011.19 WHO Europe region.20 18% in Romania, compared to 41% in Bulgaria and 28% in Poland.

26

research, development and innovation capacity in the health sector and developing research in public health and healthcare services, in view of preparing evidence-based policies.

Success factors. The main success factors are: (i) the government puts more financial resources into healthcare to implement staff retention policies; (ii) local governments contribute to the MoH and NHIH initiatives to encourage physicians and nurses to medically underserved areas; (iii) EU-funded operational programs dedicate sufficient resources to all planned IT projects in healthcare; (iv) NHIH IT systems are adapted to pay-for-performance reimbursement; (v) medical schools and research institutes put forward solid research projects to be financed from national or/ and EU funds.



(2.1.1) To Ensure the needed human resources in order to provide the healthcare services at an agreed quality level

Measure 2.1.1.1 Human resource development initiatives

(2.1.2) To Ensure sustainable funding for the healthcare sector

Measure 2.1.2.1 Initiatives to improve the management of financial resources

(2.1.3) To Develop the Health Integrated IT System, by implementing sustainable e-health solutions

Measure 2.1.3.1 Initiatives designed to improve information management

(2.1.4) To Develop the research and innovation capacity in the health sector

Measure 2.1.4.1 Initiatives aimed at promoting research and innovation in the health sector


Rationale. Healthcare services are one of the three strategic areas of the National Health Strategy for 2014-2020 and make the biggest part of healthcare spending in Romania. Every year they are allocated more than 50% of the combined budgets of the NHIF and the MoH. In 2015, the value of budget appropriations exceeded RON 14 billion21, which amounted to 2% of the GDP.

NHS 2014-2020 underlines a series of structural weaknesses of healthcare services: (i) the poor development of primary healthcare22 and rehabilitation, recovery, long-term caregiving services; (ii) the incomplete coverage at the territorial level of primary care; (iii) the flawed management of chronic conditions, which focuses on patient interaction during acute episodes, but less so on the mitigation of risk factors, early diagnosis and continuous monitoring; (iv) the lack of comprehensive 21 Data processed from the budget implementations of SNFSHI and MoH, available on the website www.mfinante.ro. 22 NHIH data reveals that curative services are the vast majority of services provided by family doctors: in 2015 they supplied 50 million curative healthcare services, but only a little over 2 million preventive and prophylactic medical services.

27

http://www.mfinante.ro/

guidelines for all levels of care, poor coordination of care between providers, lack of clinical pathways and, therefore, (v) inefficient use of services.

In this context, the efficiency of healthcare services expenditures is low, because a disproportionate portion of resources is absorbed by hospitals, despite the fact that in many cases patients admitted to the hospital could have been more inexpensively prevented or treated in primary care.

Against this background, the goals laid down in the Strategy for the field of healthcare services are as follows:

Decentralization and regionalization of care;

Development of universally accessible primary care with emphasis on prevention and health promotion;

Integration of care and setup of care networks;

Restructuring of hospital services.

Objectives: Program 2.2 is meant to achieve the following results by 2020:

- (2.2.1) Increase the provision of preventive services for the population through family healthcare:

% of local government units (LGU) where there is at least one family doctor for every 2000 inhabitants will increase from 50% to 53%

Number of towns without specialist outpatient care providers will drop from 57 to 0

- (2.2.2) Rationalize and increase efficiency for hospital healthcare services:

Number of acute care beds will decrease from 4.2 per 1,000 inhabitants to 4 per 1,000 inhabitants

Admission rate for acute cases will decrease from 19 cases per 1,000 inhabitants to 18 cases per 1,000 inhabitants

- (2.2.3) Develop the palliative assistance to be provided to terminal patients and for long-term recovery:

Beds for long term care will increase from 5 per 1,000 inhabitants at least 65 years old to 6 per 1,000 inhabitants at least 65 years old

Beds for palliative care will increase from 18 per 100,000 inhabitants to 20 per 100,000 inhabitants

- (2.2.4) Increase the quality of healthcare services, irrespective of the level where they are supplied:

Legal framework allowing the integration and/ or coordination of services providers approved and applicable

- (2.2.5) Improve the outcomes of blood transfusions and organ transplant services:

Number of transplants per %0000 inhabitants to increase from 65 to 68

The quantity of transfused blood and plasma to remain at 180,000 liters

28

Overview. The budget program “Improving the efficiency and quality of healthcare services” is aimed at (i) increasing public access to healthcare services, by developing the outpatient component of the system and long-term caregiving, (ii) improving the efficiency of public fund use, by revising the payment systems and carrying on the reorganization of hospital sector and (iii) improving the quality of healthcare services, by fostering healthcare based on evidence, integrating the suppliers involved in the therapeutic pathways, extending the accrediting system for suppliers and reinforcing communication with patients.

In preparing the budget of the program, consideration was given to all services provided at the above-mentioned levels of care, irrespective of their financing sources, NHIF or the budget of MoH, including services supplied as part of national public healthcare programs or national curative programs. This program did not include, for each healthcare branch, medical services for patients suffering from disorders which fall under the scope of other budget programs in the strategic objective “Improving the health of the population through measures of morbidity prevention and control”, more specifically communicable diseases, cardiovascular diseases, oncologic diseases, diabetes, rare diseases or mental and behavioral disorders.

Success factors. The main success factors are: (i) development and implementation of regional and county health service plans; (ii) financing mechanisms offer providers incentives to extend preventive services, advance chronic disease management and improve quality of care; (iii) electronic patient file is fully operational; (iv) local governments provide support to the MoH for the development of community care; (v) local governments get involved on initiatives to attract and/ or retain medical staff and to health improve infrastructure; (vi) staff numbers are sufficient to ensure implementation of quality standards and clinical guidelines requirements; (vii) health personnel is trained on clinical guidelines, care coordination, clinical pathway enforcement.



(2.2.1) To Increase the provision of preventive services for the population through primary care

Measure 2.2.1.1 Develop the community healthcare services

Measure 2.2.1.2 Extend the role of family medicine services

Measure 2.2.1.3 Develop the services in the specialty clinic and para-clinic outpatient care

(2.2.2) To Rationalize and increase efficiency of hospital services

Measure 2.2.2.1 Increase the efficiency and performance of hospital services

Measure 2.2.2.2 Reinforcement of emergency healthcare services

(2.2.3) To Develop the palliative assistance provided to terminal patients and for long-term recovery

Measure 2.2.3.1 Develop the long-term healthcare services, rehabilitation/medical recovery, home caregiving, palliation

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(2.2.4) To Increase the quality of healthcare services, irrespective of the level where they are supplied

Measure 2.2.4.1 Improve the quality of healthcare services

(2.2.5) To Improve the outcomes of blood transfusions and organ transplant services

Measure 2.2.5.1 Strengthen services for organ, tissue and human cell transplant

Measure 2.2.5.2 Ensure demand and security of blood products

Program 2.3: Ensure patient access to medicine and medical devices

Rationale. The National Health Strategy 2014-2020 sets as strategic objective “developing and implementing an evidence-based medicine policy, granting fair and sustainable access to medicine for the population”. The lines of action listed include reviewing the list of compensated medicines, based on cost-effectiveness criteria; implementing the medical technologies assessment system and developing the necessary capacities at central level; introducing cost-volume mechanisms for new medicine with high costs or for which an increase in usage is envisaged; biannual revision of the medicine prices and monitoring the doctors` medicine prescription behavior23.

Compensated medicines and medical devices represent about 35% of the total expenditures of the National Health Insurance Fund (NHIF), respectively 34% for medicines with and without personal contribution or medicines provided from the national curative health programs and 1% for medical devices24. On top of this, there is also the value of medicines covered from (i) the MoH budget, through public health national programs, the funding programs for emergency units and priority actions, as well as (ii) those indirectly funded through NHIF for continuous and day hospitalization and for dialysis patients. All in all, the consumption of medicines covered by the NHIF or from the MoH budget, in 2015, amounted to RON 8.18 billion, that is 1.15% GDP25.

As for the volume and the beneficiaries of the compensated medicines and medical devices, the numbers confirm the importance of this budgetary program. In 2015, 52.1 million prescriptions for compensated medicines were issued and 50.7 million prescriptions were released through the open circuit pharmacies, a 4% increase against the previous year26. As for the medical devices, according to the NHIF data in 2015 the number of insured beneficiaries for which the request for medical devices was approved amounted to 266,000. At the end of the year, the waiting lists for medical devices included 16,000 requests, 30% less than at the end of 201427.

As for patients access to new medicines, 46 new International Nonproprietary Names have been included in the list of reimbursed medicines since 2014. Of these, 40 are unconditionally reimbursed, whereas 6 medicines are the subject of 5 managed entry agreements implemented between 2015-2016. For other INNs there is a conditioned reimbursement decision from the National Agency for

23 National Healthcare Strategy 2014-2020, p. 64, Government Decision no 1028/2014.24 According to the FNUASS execution data, available on http://www.NHIF.ro/page/bugetul-fnuass.html.25 According to quarterly reports on consumption of medicines covered by FNUASS- MoH, available at http://www.NHIF.ro/page/consum-medicamente.html.26 The 2015 NHIF Activity Report 27 The NHIF Reports on medical healthcare for 2014 and 2015, available on http://www.NHIF.ro/category/rapoarte-i-situatii.html

30

http://www.cnas.ro/category/rapoarte-i-situatii.html

http://www.cnas.ro/page/consum-medicamente.html

http://www.cnas.ro/page/bugetul-fnuass.html

Medicines and Medical Devices; market authorization holders are awaiting the negotiation of managed entry agreements.


- (2.3.1) Increase the number of patients that have access to medicines needed to control or treat chronic conditions:

Updates to the reimbursed medicines list will at least 3 times per year

- (2.3.2) Reduce waiting lists for medical devices:

Medical devices registry will be developed and operational

Overview. The Program refers to patient access to reimbursed medicines and to medical devices. The medicines included are those funded from the NHIF or the MoH budget, respectively medicines with or without personal contribution, as well as medicines included in the national health programs. The Program does not include the compensated medicines for patients suffering from conditions covered by the budget programs falling under the strategic objective “Improving the health of the population through measures of morbidity prevention and control”, as well as those administered during the procedures performed in the emergency units, the intensive therapy wards, continuous and day hospitalization and dialysis centers.

As for medical devices, the program includes elements from the basic package for medical devices for the recovery of organic or functional deficiencies in the out-patient care, as well as those from the national health programs.

Success factors. The main success factors are: (i) the financing of reimbursed medicines is predictable and sufficient to cover expenditure needs; (ii) the clawback tax mechanism remains in force; (iii) prescription guidelines are available and disseminated for all levels and types of care; (iv) electronic patient file is fully operational; (v) patient registries are operational for the costliest or most frequent chronic diseases.



(2.3.1) To Increase the number of patients who have access to medicines needed to control or treat chronic conditions

Measure 2.3.1.1 Increase patient access to compensated medicines in financially sustainable conditions

(2.3.2) To Reduce waiting lists for medical devices

Measure 2.3.2.1 Increase patient access to medical devices

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Program 2.4: Upgrade the healthcare system infrastructure

Rationale. The healthcare system relies on an infrastructure that was designed 50 to 60 years ago, when the need for healthcare services and medical technologies was very different from nowadays. Although certain hospitals have been upgraded and emergency services have been improved, the distortions in the services supply structure have not been removed. In many cases adapting old infrastructure to current challenges and requirements is costlier than building anew. Access to high technology is limited; a comparative analysis based on Eurostat data reveals that Romania is placed at the bottom of the chart in terms of patient access to CT scanning, MRI scanning, PET-CT scanning, angiography and mammography28.

NHS 2014-2020 views health infrastructure development as a priority objective and sets actions and targets for investment in public health, primary care, hospitals and emergency services infrastructure.

Objectives. Program 2.4 is meant to achieve the following results by 2020:

- (2.4.1) Decrease the inequity about access to healthcare services through the development of infrastructure:Population covered by newly-built regional hospitals (as % and regions number) to increase from 0 to 39% and 3 regions, respectivelyDensity of operational radio-therapy equipment compliant with EU standards, per types of equipment will increase from 0.36 units/ 100,000 to 0.45 units/ 100,000Overview. The Ministry of Health has identified hospital healthcare units which form part of the strategic network and where the required infrastructure investments are to be channeled, in accordance with its vision referring to the development and priorities in financing healthcare sector investments between 2014 and 2020 to contribute to the achievement of the performance goal proposed for this level of services. The type of anticipated measures for certain types of hospitals depends on their positioning in the hierarchy of healthcare units with beds in Romania (at the national, regional, county and local level). Regional and county service plans are under development, containing provisions referring to the rationalization of physical (buildings) and medical (medical equipment) infrastructure.

Success factors. The main success factors are: (i) development and implementation of regional and county health service plans and maps; (ii) development and approval of the multiannual investment plan for public hospitals; (iii) standardization of hospital equipment requirements based on competency level; (iv) ensuring sufficient funding from EU and other external sources.



(2.4.1) To Decrease the inequity of access to healthcare services through the development of infrastructureMeasure 2.4.1.1 Adjustment of hospital network to the current standards of healthcare services and the patients’ needs Measure 2.4.1.2 Development of public health infrastructureMeasure 2.4.1.3 Development of the infrastructure for emergency services

28 Eurostat, healthcare resources database, accessed in December 2016. The numbers of countries in the samples were 22, 21, 17, 15 and 18 respectively.

32

Strategic Objective 3: Develop the institutional capacity of management structures in the healthcare system

The MoH, NHIH and NAHQM are the most relevant public stakeholders for improving the health condition of Romanians and for achieving health convergence with the European Union. All three institutions set forth legislative enactments, public policies and strategies for the allocation of health funds. In this context, they aim at developing high institutional capacity standards including for the subordinated and deconcentrated units.

Over the life-cycle of the ISP, the priorities related to institutional capacity development aim at (i) improving the personnel skills; (ii) the optimization of strategy and policy-making processes; (iii) evidence generation for public policies; (iv) increasing the efficiency of information and counselling for patients, providers and other stakeholder organizations; (v) efficient and effective use of domestic and international financial resources.

33

P

34


Program 3.1: Improve the performance of institutions with strategic, regulatory, administration, representation role in the healthcare system

Measure 3.1.1.1 Develop integrity, transparency and

professional ethics

Measure 3.1.1.2 Develop the

administrative capacity of

centralized public procurement

Measure 3.1.1.3 Increase

institutional performance by improving the management

systems

Measure 3.1.2.1 Promote healthcare

in all policies

Measure 3.1.2.2 Promote evidence-

based public policies

Measure 3.1.3.1 Develop the human

capital from the MoH, NHIF and

other subordinated/coordinated institutions

Measure 3.1.3.2 Ensure the optimum

functioning of public institutions




2017 2018 2019 2020


4.356.016 6.014.291 6.419.925 6.351.975

35

Percentage of Romanians content who trust the healthcare system: Baseline 2016: 27%; Target 2020: 30%; Target 2030: 40%

Impacts

(3.1.1) Implement and use best practice tools in the healthcare administration: Number of best practice tools used in the healthcare administration to increase from 2 to 4(3.1.2) Increase efficiency of the public policy formulation and implementation processes in the healthcare sector: Percentage of draft pieces of legislation with impact studies to increase from 10% to 15%(3.1.3) Increase productivity of the human capital in the healthcare administration: Percentage of management personnel who has to meet annual performance targets to increase from 0 to 15%

Program Outcomes

Program 3.1: Improve the performance of strategic, regulatory and administration institutions in the healthcare system

Rationale. The internal environment analysis revealed an administrative incapacity of healthcare institutions with a strategic, regulatory, administration and representation role. In order to successfully manage such a complex sector, several tasks have to be performed in an integrated, coherent and sustainable manner. Human resources and good practice tools are the corner stones of this process of efficiently and effectively managing the healthcare sector. For several reasons, this resource is significantly undersized, both from a qualitative and a quantitative perspective. Failures of past reforms and the incapacity to formulate evidence-based sectoral public policies are the direct outcome of these systemic deficiencies, which have been underlined before by the Government, the World Bank and the European Union.


- (3.1.1) Implement and use best practice tools in the healthcare administration:

Number of best practice tools used in the healthcare administration to increase from 2 to 4

- (3.1.2) Increase efficiency of the public policy formulation and implementation processes in the healthcare sector:

Percentage of draft pieces of legislation with impact studies to increase from 10% to 15%

- (3.1.3) Increase productivity of the human capital in the healthcare administration:

Percentage of management personnel who has to meet annual performance targets to increase from 0 to 15%

Overview. The institutional modernization of the MoH, NHIH and the subordinated institutions focuses on several fields. Firstly, implement and use best practice tools in the healthcare administration. Secondly, increase efficiency of the public policy formulation and implementation processes in the healthcare sector. Thirdly, develop the human capital, by introducing modern HR management tools, by conducting needs assessment of the human capital in the MoH and NHIF, as well as in the subordinated/coordinated entities, by improving staff recruitment and motivational factors, introducing performance-based incentives, developing the organizational culture and staff skills.

Success factors. The main success factors are: (i) civil servants’ annual appraisal puts more emphasis on performance targets; (ii) reform of the public policy cycle at Government level is continued; (iii) budgeting process is reformed so as to rely of program budgeting.



(3.1.1) To Implement and use best practice tools in the healthcare administration

Measure 3.1.1.1 Develop integrity, transparency and professional ethics

Measure 3.1.1.2 Develop the administrative capacity of centralized public procurement

36

Measure 3.1.1.3 Increase institutional performance by improving the management systems

(3.1.2) To Increase efficiency of the public policy formulation and implementation processes in the healthcare sector

Measure 3.1.2.1 Promote healthcare in all policies

Measure 3.1.2.2 Promote evidence-based public policies

(3.1.3) To Increase productivity of the human capital in the healthcare administration

Measure 3.1.3.1 Develop the human capital from the MoH, NHIF and other subordinated/ coordinated institutions

Measure 3.1.3.2 Ensure the optimum functioning of public institutions

37

IV.Arrangements for implementation, monitoring and evaluation of the ISP

To be relevant, an institutional strategic plan must link to the government’s core policy and financial planning processes. Accordingly, the healthcare ISP 2017-20 must guide the preparation of this year’s budget request, which will be prepared in 2016 for 2017-20. It is noted that, although the budget contains expenditure projections for three years, it only provides activity and expenditure details for one year. However, over time, it is anticipated that greater attention would be paid to the second and third years.

Accountability: With the parliamentary approval of the State Budget, the implementation of the strategic plan begins. The ISP working group, through MoH Public Policy Unit and with the help of technical units, will prepare annual operational plans for the implementation of the ISP. They will serve as a basis for monitoring. This activity is extremely important as it enables senior management to identify and resolve potential challenges in advance.

Monitoring and evaluation framework: A monitoring and evaluation framework is laid out in Annexes 2 and 3, and provides indicators and targets for the various planning levels (see Table below). Annex 1 provides an overview of the financial inputs.

Data collection and management: An IT system for strategic planning and performance assessment has been developed with the format of the proposed structure of ISP. The application will illustrate key functions of ISP. The IT application is connected with GSG and MPF and the progress of ISP implementation is seen at all levels of execution and management. The progress against indicators is seen by all interested stakeholders and citizens, through an interface available for the public at large.

Reporting: in deciding what to monitor and with what frequency, it is important not to overburden operational departments. Typically, different levels of performance indicators require different reporting time frames. Thus:

Input and process/product indicators will be measured monthly, or at least quarterly

Output indicators will be measured quarterly,

Outcome indicators will be measured semi-annually

Impact indicators will be tracked annually.

A diagram of the monitoring cycle of for the healthcare ISP is provided below.

38

Figure 5. Monitoring Cycle for the Healthcare ISP

It is important to report to the Government, Parliament, stakeholders and general public on the progress being made towards the planned results, as per performance indicators and targets established. Although annual progress reports are not currently prepared, it will be critical that annual reports be produced and publicly released by MOH in the future.

Evaluation: MOH and its partners have not yet developed a formal approach to ex-post evaluation of its other programs and policies. In the future, this activity will provide important information for implementing changes to the way in which programs and policies are delivered. These changes will not affect dramatically the strategic plan.

It will be desirable to strengthen the periodic evaluation of the entire program portfolio outlined in the ISP.

Updating the ISP: A full strategic planning exercise will be conducted every four years. During the intervening years, MOH and its partners, through the ISP working group, will prepare an annual update to determine if any changes to the strategic plan are required. The update will require the completion of three activities:

comparing the previous year’s actual versus planned results; these would be based on targets set in the strategic and operational plans;

conducting an environmental scan to determine if any significant changes are required to the assumptions that underpin the current plan (see Chapter Context and Challenges); and

adding one additional year to the plan.

By ensuring that the plan continues to cover at least three years beyond the planning year, the updated strategic plan can continue to inform the annual budget request, which also requires a three-year forecast. Most often, the vision, strategic goals and program goals do not change unless a major event, such as an unforeseen economic crisis, occurs. The updating exercise should be completed by May 30 each year, which allows time for the collection and analysis of results achieved from the previous year.

39

SEMI-ANNUAL RESULTS REVIEW: OUTPUT, PRODUCT

AND INPUT INDICATORS

QUARTERLY REVIEW: PROCESS / PRODUCT AND

INPUT INDICATORS


INPUT INDICATORS


INPUT INDICATORS


INPUT INDICATORS

ANNUAL RESULTS REVIEW: ALL INDICATORS

OCT.JULYAPRILJAN.

V. Financial resources

The ISP for the healthcare sector is made of three strategic objectives comprising nine budgetary programs. The measures, actions and activities included in the plan are assigned to multiple stakeholders, the most important of which are the MoH, the NHIH and their deconcentrated services, the NAHQM, the NIPH, the NADMD and the NSPHMTH. As a result, the ISP budget is made of the resources spent by two main credit officers – MoH and NHIH – and the subordinates.

The allocations forecast for ISP until 2020 are separated by source between the state budget, including the National Health Insurance Fund, non-reimbursable funds (from the European Union, Norwegian and European Economic Area financial mechanisms, Swiss-Romanian Cooperation Program etc.) and loans. The spending limits of the NHIF and MoH state budget components were taken from the Fiscal-Budgetary Strategy 2017-2019 (FBS)29. As such, the validity of the budgetary programs depends on the fulfilment of the underlying assumptions of the Strategy. The FBS also offers indicative limits for most of the non-reimbursable funding available to the MoH throughout 2014-2020 programming period.

Over the four-year life-cycle, the ISP strategic objectives and budgetary programs will add up to 160 bn. RON, with annual allocations rising from 34 bn. RON in 2017 to 45 bn. RON by 2020 (see Figure6). The breakdown by strategic objective reveals almost two-thirds of the funding being channeled through SO 2 “Cross-cutting measures”, where most of the health services and medicines are included. SO 1 “Improving the health of the population” which plans interventions against the major determinants of the health status accounts for 23% of the ISP. The remaining 14% is allocated through SO 3 “Institutional capacity” for recurrent spending and capacity development projects.

Figure 6. Annual ISP financing by strategic objective (bn. RON)

2017 2018 2019 2020 -

5,000,000,000

10,000,000,000

15,000,000,000

20,000,000,000

25,000,000,000

30,000,000,000

35,000,000,000

40,000,000,000

45,000,000,000

50,000,000,000

0

5,000,000,000

10,000,000,000

15,000,000,000

20,000,000,000

25,000,000,000

30,000,000,000

35,000,000,000

40,000,000,000

45,000,000,000

4,356,016,233.506,014,290,926.186,419,925,415.136,351,975,104.91

21,842,659,930.1723,294,231,196.68

26,388,235,389.4628,585,741,694.93

7,972,509,436.338,749,112,837.15

9,735,412,751.4010,042,741,566.3034,171,185,600.00

38,057,634,960.00

42,543,573,556.0044,980,458,366.15

3 Strategic objective: Develop the institutional capacity of management structures in the healthcare system2 Strategic objective: Cross-cutting measures to increase the performance of the healthcare system1 Strategic objective: Improving the health of the population through measures of morbidity prevention and controlTotal ISP

The main spending channel of the ISP is the National Health Insurance House, which will manage more than 80% of available funding (see Figure 7). This comes as no surprise, as NHIH is the single

29 Available of the MoF website at http://www.mfinante.gov.ro/strategbug2015.html?pagina=domenii.

40

http://www.mfinante.gov.ro/strategbug2015.html?pagina=domenii

payer in the social health insurance system and the biggest payer in the overall healthcare sector. The MoH and its subordinated institutions will spend 17% of the ISP resources, mostly on public health interventions, emergency transport and care, expensive hospital procedures and infrastructure.

Figure 7. Annual ISP financing by main credit officer (bn. RON)

2017 2018 2019 2020 -

5,000,000,000

10,000,000,000

15,000,000,000

20,000,000,000

25,000,000,000

30,000,000,000

35,000,000,000

40,000,000,000

45,000,000,000

50,000,000,000

0

5,000,000,000

10,000,000,000

15,000,000,000

20,000,000,000

25,000,000,000

30,000,000,000

35,000,000,000

40,000,000,000

45,000,000,000

28,822,581,000.0031,378,550,000.0034,862,350,000.0037,293,445,454.55

5,337,081,000.006,665,259,000.00

7,664,980,000.007,671,100,000.00

11,523,600.0013,825,960.00

16,243,556.0015,912,911.60

34,171,185,600.00

38,057,634,960.00

42,543,573,556.0044,980,458,366.15

NHIH MoH NAHQM Total ISP

The breakdown of the ISP by financing source reveals the overreliance on state budget funding, which accounts for 98% of total. The vast majority of state budget funding is directed towards recurrent health services via NHIF or the MoH budget. The remainder of the ISP is made of investment projects financed from non-reimbursable funds or loans.

Figure 8. Annual ISP financing by source of funding (bn. RON)

2017 2018 2019 2020 -

5,000,000,000

10,000,000,000

15,000,000,000

20,000,000,000

25,000,000,000

30,000,000,000

35,000,000,000

40,000,000,000

45,000,000,000

50,000,000,000

0

5,000,000,000

10,000,000,000

15,000,000,000

20,000,000,000

25,000,000,000

30,000,000,000

35,000,000,000

40,000,000,000

45,000,000,000

34,149,917,600.00 37,477,675,960.0041,566,943,556.00 44,188,883,366.15

17,920,000.00498,360,000.00

840,400,000.00687,000,000.00

3,348,000.0081,599,000.00

136,230,000.00104,575,000.00

34,171,185,600.0038,057,634,960.00

42,543,573,556.0044,980,458,366.15

state budget non-reimbursable funds (EU et al.)

cofinancing of non-reimbursable funds (EU et al.) Total ISP

As far as the budget management is concerned, a major institutional challenge is the stakeholders’ ability to implement the ISP, namely planning, executing and monitoring their budgets on defined

41

programs. From an organizational and managerial perspective, the transition and monitoring of more budgetary programs represents the main challenge throughout the ISP lifecycle.

42

Annex 1a: Budgetary Programs and Financial Resources by financing source 2017-2020 (thousand RON)

total ISP total ISP total ISP total ISP total ISP state budget

state budget

state budget

state budget

non-reimburs

able funds (EU

et al.)

non-reimburs

able funds (EU

et al.)

non-reimburs

able funds (EU

et al.)

non-reimburs

able funds (EU

et al.)

cofinancing of non-

reimbursable

funds (EU et al.)

cofinancing of non-

reimbursable

funds (EU et al.)

cofinancing of non-

reimbursable

funds (EU et al.)

cofinancing of non-

reimbursable

funds (EU et al.)

Strategic objective/ Budgetary program 2017-2020 2017 2018 2019 2020 2017 2018 2019 2020 2017 2018 2019 2020 2017 2018 2019 2020

1 Strategic objective: Improving the health of the population through

measures of morbidity prevention and control

36.499.777 7.972.509 8.749.113 9.735.413 10.042.742 7.970.209 8.544.213 9.497.263 9.871.392 2.000 176.400 203.000 149.000 300 28.500 35.150 22.350

Program 1.1: Prevention and control of non-communicable

diseases26.623.080 6.087.871 6.553.819 6.839.249 7.142.141 6.087.871 6.438.819 6.724.249 7.027.141 - 100.000 100.000 100.000 - 15.000 15.000 15.000

Program 1.2: Prevention and control of communicable diseases 9.643.546 1.850.795 2.134.166 2.799.135 2.859.451 1.848.495 2.069.766 2.734.735 2.803.101 2.000 56.000 56.000 49.000 300 8.400 8.400 7.350

Program 1.3: Improving mother and child health 140.369 32.006 33.606 36.055 38.703 32.006 33.606 36.055 38.703 - - - - - - - -

Program 1.4: Monitoring public health in connection with the

environment92.781 1.838 27.522 60.974 2.447 1.838 2.022 2.224 2.447 - 20.400 47.000 - - 5.100 11.750 -

2 Strategic objective: Cross-cutting measures to increase the

performance of the healthcare system

100.110.868 21.842.660 23.294.231 26.388.235 28.585.742 21.827.660 22.934.656 25.669.435 27.968.517 12.500 309.000 621.000 535.500 2.500 50.575 97.800 81.725

Program 2.1: Ensure the functional framework and the resources for

the healthcare system636.500 15.000 252.750 261.150 107.600 - - - - 12.500 216.500 223.500 93.000 2.500 36.250 37.650 14.600

Program 2.2: Improve the efficiency and quality of healthcare services 82.209.698 18.283.225 19.121.517 21.493.437 23.311.519 18.283.225 19.095.192 21.461.287 23.284.894 - 22.500 27.500 22.500 - 3.825 4.650 4.125

Program 2.3: Ensure patient access to medicine and medical devices 14.148.594 3.282.641 3.446.773 3.619.112 3.800.068 3.282.641 3.446.773 3.619.112 3.800.068 - - - - - - - -

Program 2.4: Upgrade the healthcare system infrastructure 3.116.076 261.794 473.191 1.014.537 1.366.555 261.794 392.691 589.037 883.555 - 70.000 370.000 420.000 - 10.500 55.500 63.000

3 Strategic objective: Develop the institutional capacity of

management structures in the healthcare system

23.142.208 4.356.016 6.014.291 6.419.925 6.351.975 4.352.048 5.998.807 6.400.245 6.348.975 3.420 12.960 16.400 2.500 548 2.524 3.280 500

Program 3.1: Improve the performance of strategic,

regulatory and administration institutions in the healthcare

system

23.142.208 4.356.016 6.014.291 6.419.925 6.351.975 4.352.048 5.998.807 6.400.245 6.348.975 3.420 12.960 16.400 2.500 548 2.524 3.280 500

Total ISP 159.752.852 34.171.186 38.057.635 42.543.574 44.980.458 34.149.918 37.477.676 41.566.944 44.188.883 17.920 498.360 840.400 687.000 3.348 81.599 136.230 104.575

43

Annex 1b: Budgetary Programs and Financial Resources by main credit officer 2017-2020 (thousand RON)

total ISP total ISP total ISP total ISP total ISP MoH MoH MoH MoH NHIH NHIH NHIH NHIH NAHQM NAHQM NAHQM NAHQMStrategic objective/ Budgetary program

2017-2020 2017 2018 2019 2020 2017 2018 2019 2020 2017 2018 2019 2020 2017 2018 2019 2020

1 Strategic objective: Improving the health of the population

through measures of morbidity prevention and control

36.499.777 7.972.509 8.749.113 9.735.413 10.042.742 643.645 1.058.602 1.137.864 1.119.240 7.328.864 7.690.510 8.597.549 8.923.502 - - - -

Program 1.1: Prevention and control of non-communicable

diseases26.623.080 6.087.871 6.553.819 6.839.249 7.142.141 49.854 168.199 171.835 175.281 6.038.017 6.385.621 6.667.414 6.966.861 - - - -

Program 1.2: Prevention and control of communicable

diseases9.643.546 1.850.795 2.134.166 2.799.135 2.859.451 559.947 829.276 869.001 902.810 1.290.848 1.304.890 1.930.134 1.956.641 - - - -

Program 1.3: Improving mother and child health 140.369 32.006 33.606 36.055 38.703 32.006 33.606 36.055 38.703 - - - - - - - -

Program 1.4: Monitoring public health in connection with the

environment92.781 1.838 27.522 60.974 2.447 1.838 27.522 60.974 2.447 - - - - - - - -

2 Strategic objective: Cross-cutting measures to increase the performance of the healthcare

system

100.110.868 21.842.660 23.294.231 26.388.235 28.585.742 2.642.613 3.182.811 3.860.303 4.268.798 19.200.047 20.110.270 22.525.632 24.316.369 - 1.150 2.300 575

Program 2.1: Ensure the functional framework and the resources for the healthcare

system

636.500 15.000 252.750 261.150 107.600 1.800 189.750 196.350 105.200 13.200 63.000 64.800 2.400 - - - -

Program 2.2: Improve the efficiency and quality of

healthcare services82.209.698 18.283.225 19.121.517 21.493.437 23.311.519 2.379.019 2.519.870 2.649.417 2.797.043 15.904.206 16.600.497 18.841.720 20.513.901 - 1.150 2.300 575

Program 2.3: Ensure patient access to medicine and medical

devices14.148.594 3.282.641 3.446.773 3.619.112 3.800.068 - - - - 3.282.641 3.446.773 3.619.112 3.800.068 - - - -

Program 2.4: Upgrade the healthcare system infrastructure 3.116.076 261.794 473.191 1.014.537 1.366.555 261.794 473.191 1.014.537 1.366.555 - - - - - - - -

3 Strategic objective: Develop the institutional capacity of

management structures in the healthcare system

23.142.208 4.356.016 6.014.291 6.419.925 6.351.975 2.050.823 2.423.846 2.666.812 2.283.062 2.293.670 3.577.769 3.739.169 4.053.575 11.524 12.676 13.944 15.338

Program 3.1: Improve the performance of strategic,

regulatory and administration institutions in the healthcare

system

23.142.208 4.356.016 6.014.291 6.419.925 6.351.975 2.050.823 2.423.846 2.666.812 2.283.062 2.293.670 3.577.769 3.739.169 4.053.575 11.524 12.676 13.944 15.338

Total ISP 159.752.852 34.171.186 38.057.635 42.543.574 44.980.458 5.337.081 6.665.259 7.664.980 7.671.100 28.822.581 31.378.550 34.862.350 37.293.445 11.524 13.826 16.244 15.913

44

Annex 1c: Measures and Financial Resources by financing source 2017-2020 (thousand RON)


state budget

state budget

state budget

non-reimbur

sable funds (EU et

al.)

non-reimbur

sable funds (EU et

al.)

non-reimbur

sable funds (EU et

al.)

non-reimbur

sable funds (EU et

al.)

cofinancing of non-

reimbursable funds (EU et al.)

cofinancing of non-


cofinancing of non-


cofinancing of non-


Budgetary program/ Measure 2017-2020 2017 2018 2019 2020 2017 2018 2019 2020 2017 2018 2019 2020 2017 2018 2019 2020Program 1.1: Prevention and control of

non-communicable diseases 26.623.080 6.087.871 6.553.819 6.839.249 7.142.141 6.087.871 6.438.819 6.724.249 7.027.141 - 100.000 100.000 100.000 - 15.000 15.000 15.000

Measure 1.1.1.1 Develop and implement mechanisms for prevention, diagnostic, treatment and control of cardiovascular

diseases

9.063.338 2.124.224 2.245.515 2.312.072 2.381.528 2.124.224 2.188.015 2.254.572 2.324.028 - 50.000 50.000 50.000 - 7.500 7.500 7.500

Measure 1.1.1.2 Develop and implement mechanisms for prevention, diagnostic,

treatment and control of oncologic diseases

10.128.148 2.257.819 2.488.619 2.621.085 2.760.624 2.257.819 2.465.619 2.598.085 2.737.624 - 20.000 20.000 20.000 - 3.000 3.000 3.000

Measure 1.1.1.3 Develop and implement mechanisms for prevention, diagnostic,

treatment and control of diabetes mellitus

4.652.339 1.055.300 1.142.620 1.198.087 1.256.332 1.055.300 1.108.120 1.163.587 1.221.832 - 30.000 30.000 30.000 - 4.500 4.500 4.500

Measure 1.1.1.4 Prevention and control of mental and behavior disorders 1.751.582 429.000 433.450 440.099 449.033 429.000 433.450 440.099 449.033 - - - - - - - -

Measure 1.1.1.5 Promote a healthy lifestyle and combat the main risk factors 6.959 1.499 1.649 1.814 1.996 1.499 1.649 1.814 1.996 - - - - - - - -

Measure 1.1.2.1 Develop medical services for patients with special pathologies 1.020.715 220.029 241.966 266.092 292.628 220.029 241.966 266.092 292.628 - - - - - - - -

Program 1.2: Prevention and control of communicable diseases 9.643.546 1.850.795 2.134.166 2.799.135 2.859.451 1.848.495 2.069.766 2.734.735 2.803.101 2.000 56.000 56.000 49.000 300 8.400 8.400 7.350

Measure 1.2.1.1 Strengthen the system of prevention, surveillance and control of

communicable diseases71.660 8.241 20.401 21.119 21.900 8.241 8.901 9.619 10.400 - 10.000 10.000 10.000 - 1.500 1.500 1.500

Measure 1.2.1.2 Strengthen the system of prevention, surveillance and control of

priority communicable diseases – tuberculosis

146.813 23.120 41.417 43.834 38.442 21.970 24.167 26.584 29.242 1.000 15.000 15.000 8.000 150 2.250 2.250 1.200

Measure 1.2.1.3 Strengthen the system of prevention, surveillance, detection,

diagnostic, treatment and monitoring of priority communicable diseases – viral

hepatitis

6.258.131 1.214.775 1.259.514 1.880.764 1.903.078 1.214.775 1.225.014 1.846.264 1.868.578 - 30.000 30.000 30.000 - 4.500 4.500 4.500

Measure 1.2.1.4 Strengthen the system of prevention, surveillance and control of priority communicable diseases - HIV/

AIDS

1.911.577 443.508 465.684 488.968 513.416 443.508 465.684 488.968 513.416 - - - - - - - -

Measure 1.2.2.1 Protect the population health against main communicable

1.255.365 161.150 347.150 364.450 382.615 160.000 346.000 363.300 381.465 1.000 1.000 1.000 1.000 150 150 150 150

46


state budget

state budget

state budget

non-reimbur

sable funds (EU et

al.)

non-reimbur

sable funds (EU et

al.)

non-reimbur

sable funds (EU et

al.)

non-reimbur

sable funds (EU et

al.)

cofinancing of non-


cofinancing of non-


cofinancing of non-


cofinancing of non-


Budgetary program/ Measure 2017-2020 2017 2018 2019 2020 2017 2018 2019 2020 2017 2018 2019 2020 2017 2018 2019 2020diseases that can be prevented through

vaccinationProgram 1.3: Improving mother and child

health 140.369 32.006 33.606 36.055 38.703 32.006 33.606 36.055 38.703 - - - - - - - -

Measure 1.3.1.1 Early detection and assessment of risks during pregnancy for

both mother and child29.260 6.538 6.865 7.551 8.306 6.538 6.865 7.551 8.306 - - - - - - - -

Measure 1.3.1.2 Measures of early detection and assessment of child

diseases with increasing incidence, such as autism spectrum disorders

36.267 8.103 8.509 9.359 10.295 8.103 8.509 9.359 10.295 - - - - - - - -

Measure 1.3.1.3 Measures aimed at improving child nutrition and other

measures for specific diseases74.843 17.364 18.233 19.144 20.101 17.364 18.233 19.144 20.101 - - - - - - - -

Program 1.4: Monitoring public health in connection with the environment 92.781 1.838 27.522 60.974 2.447 1.838 2.022 2.224 2.447 - 20.400 47.000 - - 5.100 11.750 -

Measure 1.4.1.1 Monitor and report on the determining factors from the living

and working environment8.531 1.838 2.022 2.224 2.447 1.838 2.022 2.224 2.447 - - - - - - - -

Measure 1.4.2.1 Consolidate monitoring services for the determining factors from

the living and working environment84.250 - 25.500 58.750 - - - - - - 20.400 47.000 - - 5.100 11.750 -

Program 2.1: Ensure the functional framework and the resources for the

healthcare system636.500 15.000 252.750 261.150 107.600 - - - - 12.500 216.500 223.500 93.000 2.500 36.250 37.650 14.600

Measure 2.1.1.1 Human resource Development Initiatives 414.000 - 161.000 161.000 92.000 - - - - - 140.000 140.000 80.000 - 21.000 21.000 12.000

Measure 2.1.2.1 Initiatives to improve the management of financial resources 11.400 1.800 5.400 4.200 - - - - - 1.500 4.500 3.500 - 300 900 700 -

Measure 2.1.3.1 Initiatives designed to improve information management 193.100 13.200 80.350 89.950 9.600 - - - - 11.000 67.000 75.000 8.000 2.200 13.350 14.950 1.600

Measure 2.1.4.1 Initiatives aimed at promoting research and innovation in the

health sector18.000 - 6.000 6.000 6.000 - - - - - 5.000 5.000 5.000 - 1.000 1.000 1.000

Program 2.2: Improve the efficiency and quality of healthcare services 82.209.698 18.283.225 19.121.517 21.493.437 23.311.519 18.283.225 19.095.192 21.461.287 23.284.894 - 22.500 27.500 22.500 - 3.825 4.650 4.125

Measure 2.2.1.1 Develop the community healthcare services 1.281.107 289.000 310.350 325.523 356.235 289.000 303.450 318.623 350.485 - 6.000 6.000 5.000 - 900 900 750

Measure 2.2.1.2 Extend the role of family medicine services 8.763.373 1.680.014 1.859.765 2.321.769 2.901.824 1.680.014 1.848.015 2.310.019 2.887.524 - 10.000 10.000 12.000 - 1.750 1.750 2.300

Measure 2.2.1.3 Develop the services in the specialty clinic and para-clinic

outpatient care12.772.163 2.776.652 2.952.068 3.312.104 3.731.339 2.776.652 2.951.493 3.310.379 3.731.339 - 500 1.500 - - 75 225 -

Measure 2.2.2.1 Increase the efficiency and performance of hospital services 50.420.754 11.474.801 11.827.463 13.228.620 13.889.871 11.474.801 11.823.863 13.225.020 13.886.271 - 3.000 3.000 3.000 - 600 600 600

Measure 2.2.2.2 Reinforcement of emergency healthcare services 6.945.901 1.610.000 1.691.700 1.778.025 1.866.176 1.610.000 1.690.500 1.775.025 1.863.776 - 1.000 2.500 2.000 - 200 500 400

47


state budget

state budget

state budget

non-reimbur

sable funds (EU et

al.)

non-reimbur

sable funds (EU et

al.)

non-reimbur

sable funds (EU et

al.)

non-reimbur

sable funds (EU et

al.)

cofinancing of non-


cofinancing of non-


cofinancing of non-


cofinancing of non-


Budgetary program/ Measure 2017-2020 2017 2018 2019 2020 2017 2018 2019 2020 2017 2018 2019 2020 2017 2018 2019 2020Measure 2.2.3.1 Develop the long-term

healthcare services, rehabilitation/medical recovery, home

caregiving, palliation

775.339 165.837 174.129 203.442 231.931 165.837 174.129 203.442 231.931 - - - - - - - -

Measure 2.2.4.1 Improve the quality of healthcare services 16.550 500 5.300 8.175 2.575 500 3.000 3.000 2.000 - 2.000 4.500 500 - 300 675 75

Measure 2.2.5.1 Strengthen services for organ, tissue and human cell transplant 729.876 169.340 177.807 186.697 196.032 169.340 177.807 186.697 196.032 - - - - - - - -

Measure 2.2.5.2 Ensure demand and security of blood products 504.635 117.081 122.935 129.082 135.536 117.081 122.935 129.082 135.536 - - - - - - - -

Program 2.3: Ensure patient access to medicine and medical devices 14.148.594 3.282.641 3.446.773 3.619.112 3.800.068 3.282.641 3.446.773 3.619.112 3.800.068 - - - - - - - -

Measure 2.3.1.1 Increase patient access to compensated medicines in financially

sustainable conditions12.703.836 2.947.440 3.094.812 3.249.553 3.412.030 2.947.440 3.094.812 3.249.553 3.412.030 - - - - - - - -

Measure 2.3.2.1 Increase patient access to medical devices 1.444.758 335.201 351.961 369.559 388.037 335.201 351.961 369.559 388.037 - - - - - - - -

Program 2.4: Upgrade the healthcare system infrastructure 3.116.076 261.794 473.191 1.014.537 1.366.555 261.794 392.691 589.037 883.555 - 70.000 370.000 420.000 - 10.500 55.500 63.000

Measure 2.4.1.1 Upgrade service provider infrastructure to the current standards of

healthcare services and the patients’ needs

3.116.076 261.794 473.191 1.014.537 1.366.555 261.794 392.691 589.037 883.555 - 70.000 370.000 420.000 - 10.500 55.500 63.000

Program 3.1: Improve the performance of strategic, regulatory and administration

institutions in the healthcare system23.142.208 4.356.016 6.014.291 6.419.925 6.351.975 4.352.048 5.998.807 6.400.245 6.348.975 3.420 12.960 16.400 2.500 548 2.524 3.280 500

Measure 3.1.2.1 Promote healthcare in all policies 720 240 480 - - - - - - 200 400 - - 40 80 - -

Measure 3.1.2.2 Promote evidence-based public policies 20.292 3.488 4.924 11.280 600 - - - - 3.020 4.160 9.400 500 468 764 1.880 100

Measure 3.1.3.1 Develop the human capital from the MoH, NHIF and other subordinated/coordinated institutions

21.120 240 10.080 8.400 2.400 - - - - 200 8.400 7.000 2.000 40 1.680 1.400 400

Measure 3.1.3.2 Ensure the optimum functioning of public institutions 23.100.076 4.352.048 5.998.807 6.400.245 6.348.975 4.352.048 5.998.807 6.400.245 6.348.975 - - - - - - - -

Total ISP 159.752.852 34.171.186 38.057.635 42.543.574 44.980.458 34.149.918 37.477.676 41.566.944 44.188.883 17.920 498.360 840.400 687.000 3.348 81.599 136.230 104.575

48

Annex 2: Institutional Strategic Plan (summary table)

Unit Reference value

Target 2019

Target 2020

Strategic objective 1: Improving the health of the population through measures of morbidity prevention and control

Impact indicator No. 1.1: The gap between the life expectancy and healthy life expectancy in men Years 12,4

(71,4-59) 12,3 12,2

Impact indicator No. 1.2: The gap between the life expectancy and healthy life expectancy in women Years 19,7

(78,7-59) 19,5 19,3


Result 1.1.1: Reduce the prevalence of risk factors for non-communicable diseasesOutcome indicator: Standardized rate of deaths caused by chronic diseases in persons aged below 65Outcome indicator: Suicide mortality rateOutcome indicator: Percentage of daily adult smokersOutcome indicator: Percentage of adults with harmful alcohol consumption

Cases/ 100,000Cases/ 100,000

%%

2199,5

20%69%

2179,3

19%67%

2179,3

18%66%

Result 1.1.2: Ensure access to early detection, diagnosis and / or treatment for specific diseases

Outcome indicator: Coverage of target group for cervical cancer screeningOutcome indicator: Cervical cancer incidenceOutcome indicator: Cervical cancer mortality

%Cases/ 100,000

Cases/ 100,000

9%34,24

14,75

10%34

13

10%34

12


Result 1.2.1: Reduce the incidence and prevalence of priority infectious diseases

49


Target 2019

Target 2020

Outcome indicator: Incidence of nosocomial infection with MDR microorganisms

Outcome indicator: Standardized TB incidenceOutcome indicator: Standardized HIV/AIDS incidenceOutcome indicator: Standardized hepatitis B incidence

%

Cases/ 100,000Cases/ 100,000Cases/ 100,000

ICUs - 5%&

Surgeries - 3%63

1,991,11

ICUs - 5%& Surgeries

- 3%601,91

ICUs - 5%&

Surgeries - 3%601,91

Result 1.2.2: Increase the compliance rate to the vaccinations included in the National Immunization Calendar

Outcome indicator: Vaccination coverage for children of 12 and 24 months as part of the national immunization calendarOutcome indicator: Incidence of selected diseases preventable by vaccination (rubella and poliomyelitis)

% of target group

Cases/ 100,000

80%

0.3/ 0

85%

0.3/ 0

85%

0.3/ 0

Program 1.3: Improve the health status of the mother and child

Result 1.3.1: Improve mother and child health

Outcome indicator: Mother mortality at birth (per 1000 live births)

Outcome indicator: Infant mortality rate (per 1000 live births)

Outcome indicator: Perinatal mortality rate (per 1000 live births)

Outcome indicator: Neonatal mortality rate 0-6 days (per 1000 live births)

Cases/ 1000 live births




0,1

7,97

7,08

3,17

0,1

7,9

6,8

3

0,1

7,9

6,8

2,9

50


Target 2019

Target 2020

Program 1.4: Monitoring public health in relation with the environment

Result 1.4.1: Reduction in diseases linked to environmental risk factorsOutcome indicator: Number of occupational diseases Cases 1025 820 800

Result 1.4.2: Reduction of the negative impacts of environmental catastrophes occurring at infrastructure sites exposed to environmental risks

Outcome indicator: Map of areas posing risks for human health (industrial facilities, large chemical plants, routes of transportation for chemical, radioactive or hazardous materials, areas with high risk of floods of earthquakes)

Yes/ no No Yes Yes

Strategic objective 2: Cross-cutting measures to increase the performance of the healthcare system

Impact indicator No.2.1:Territorial distribution of physicians (ratio between averages of quartile 4 and quartile 1 of county rates of physicians per 100,000 population)

Ratio q4/q1 2,9 2,7 2,6

Program 2.1: Ensure the functional framework and the resources for the healthcare systemResult 2.1.1: Ensure the human resources, in order to provide the healthcare services at an agreed quality level

Outcome indicator: Coverage with available medical staff at national level Physicians and nurses/ 100,000 280/ 583 285/ 590 287/ 595

Result 2.1.2: Ensure sustainable funding for the healthcare sectorOutcome indicator: Total healthcare expenditures (%GDP) % 5,1 5,2 5,3

Result 2.1.3: Develop the Health Integrated IT System, by implementing sustainable e-health solutions

51


Target 2019

Target 2020

Outcome indicator: Level of development of the IPSI (Information Platform of Social Insurance)

No of fully operational IPSI

components4 6 6

Result 2.1.4: Develop the research and innovation capacity in the health sectorOutcome indicator: Applications resulted from the research projects, transferred into medical practice (no) 0 4 5

Impact indicator No.2.2:Territorial coverage with primary care services

No of local government units

without family physician

No of local government units

without specialty care providers

165

2767

130

2650

100

2600

Impact indicator No.2.3:Rate of reimbursed hospital admissions for conditions treatable in outpatient care No of cases/ 100.000 1035 950 900


Result 2.2.1: Increase the provision of preventive services for the population through primary care

Outcome indicator: % of local government units (LGU) where there is at least one family doctor for every 2000 inhabitantsOutcome indicator: number of towns without specialist outpatient care providers

% of LGU

Number of LGU

50%

57

52%

0

53%

0Result 2.2.2: Rationalize and increase efficiency for hospital healthcare services

Outcome indicator: No of acute beds

Outcome indicator: Admission rate for acute cases

Beds per 1,000 inhabitants

4,2 4 4

52


Target 2019

Target 2020

Outcome indicator: Average response time to emergencies

Cases per 1,000 inhabitantsminutes

19

11

18

11

18

11Result 2.2.3: Develop the palliative assistance to be provided to terminal patients and for long-term recovery

Outcome indicator: Beds for long term care (per 1.000 inhabitants at least 65 years old)Outcome indicator: Beds for palliative care (per 100.000 inhabitants)Outcome indicator: Beds for long-term care (per 100.000 inhabitants)

Beds/ 1.000Beds/ 100.000Beds/ 100.000

518

160

620

166

620

166

Result 2.2.4: Increase the quality of healthcare services, irrespective of the level where they are supplied

Outcome indicator: Legal frame allowing the integration and/ or coordination of services providers approvedOutcome indicator: Centralized reports on patient satisfaction cover #% of the hospital services providers

Yes/ no

%

No

0%

Yes

100%

Yes

100%

Result 2.2.5: Improve the outcomes of blood transfusions and organ transplant services

Outcome indicator: Number of transplants per %0000 inhabitants

Outcome indicator: Ensure self-sufficiency for blood transfusions

Transplants/ 1000000Quantity of

transfused blood and plasma (liters)

65

180000

67

180000

68

180000

Program 2.3: Ensure patient access to medicines and medical devices

Result 2.3.1: Increase the number of patients who have access to medicines needed to control or treat chronic conditions

Outcome indicator: Updates to the reimbursed medicines listOutcome indicator: Share of generic drugs in total reimbursed drugs

No of pieces of legislation approved

%

327%

329%

330%

53


Target 2019

Target 2020

Result 2.3.2: Reduce waiting lists for medical devices

Outcome indicator: Standardize the information on the names and characteristics of medical devices and healthcare supplies

Medical devices registry operational No Yes Yes

Program 2.4: Modernization of the health infrastructure

Result 2.4.1: Decrease the inequity of access to healthcare services through the development of infrastructure

Outcome indicator: Population covered by newly-built regional hospitals (as % and number of regions)Outcome indicator: Density of operational radio-therapy equipment compliant with EU standards, per types of equipment

%, number of regions

Units/ 100,000

0%; 0

0,36

0%; 0

0,42

39%; 3

0,45

Strategic objective 3: Develop the institutional capacity of management structures in the healthcare system

Impact indicator 3.1: Percentage of Romanians who trust the HC system % 27%30 30% 30%Program 3.1: Improve the performance of strategic, regulatory and administration institutions in the healthcare systemResult 3.1.1: Implement and use best practice tools in the healthcare administration

Outcome indicator: Number of best practice tools used in the healthcare administration No of units 2 3 4

Result 3.1.2: Increase efficiency of the public policy formulation and implementation processes in the healthcare sector

Outcome indicator: Percentage of public policies with impact studies % of draft pieces of 10% 15% 15%

30 Eurobarometer no. 411, Patient Safety and Quality of Care, data for Romania, European Commission, 2014, available at http://ec.europa.eu/public_opinion/index_en.htm

54


Target 2019

Target 2020

legislationResult 3.1.3: Increase productivity of the human capital in the healthcare administration

Outcome indicator: Percentage of management personnel who must meet annual performance targets

% of approved positions 0% 15% 15%

55

Annex 3: Programs and related Measures (summary table)

Budgetary programMeasure description

Output indicator (unit) Baseline Target 2017 Target 2018 Target 2019 Target 2020


Measure 1.1.1.1 Develop and implement mechanisms for prevention, diagnostic, treatment and control of cardiovascular diseasesThe measure aims to design and implement an integrated approach of primary and secondary prevention services under the Institutional Strategic Plan. The program will focus more on the services provided by family physicians and specialized outpatient facilities. Emphasis will be given to interventions that counter the level of smoking and alcohol consumption, sedentary lifestyle and unhealthy eating habits. It will accomplish this by focusing on early detection of cardiovascular diseases risk and by reducing the risk of cardiovascular diseases in asymptomatic adults. These will be the objectives of the National Cardiovascular Diseases Control Plan.The interventions are aimed at both specific primary prevention as well as active early detection of cardiovascular diseases risk, diagnosis and treatment of cardiovascular diseases. The measure is financed from the state budget, European non-reimbursable funds (ENF) and National Health Insurance Fund (NHIF) and is to be implemented between 2017-2020.Implementing institutions: Ministry of Health (MoH), National

draft piece of legislation for Plan approval [pieces of legislation]

0 0 1 0 0

56



Health Insurance House (NHIH), county public health departments (CHDs), county health insurance houses (CHIH), family physicians, community nurses, hospitals, other providers.Measure 1.1.1.2 Develop and implement mechanisms for prevention, diagnostic, treatment and control of oncologic diseasesThis measure is aimed at lowering the cancer burden on the population through early detection of the disease and through reducing specific mortality over the medium and long term, through screening interventions organized at the national level, under the National Multiannual Integrated Plan for Cancer Control, with an emphasis on oncologic prevention. Emphasis is laid on implementing the national screening program for cervical cancer, on early detection interventions, through population screening for the other two eligible types of cancer (breast and colorectal cancer), and through patient monitoring and palliative community activities, by: 1. Infrastructure development; 2. Testing, diagnosis and treatment for the insured and non-insured; 3. providing human resources. The diagnosis and treatment of oncologic diseases will be conducted in an integrated manner.The measure is financed from the state budget, European non-reimbursable funds (ENF) and National Health Insurance Fund (NHIF) and is to be implemented between 2017-2020.Implementing institutions: MoH, NHIF, medical care units, outpatient care units, paraclinical service providers, family physicians, community nurses.

no of Babes-Papanicolau tests [tests]

200.000 200.000 200.000 200.000 200.000

draft piece of legislation for Plan approval [pieces of legislation]

0 0 1 0 0

no of cancer medication beneficiaries as part of the NHP [persons]

110.000 110.000 110.000 110.000 110.000

Measure 1.1.1.3 Develop and implement mechanisms for draft piece of 0 0 1 0 0

57



prevention, diagnostic, treatment and control of diabetes mellitusThe measure provides for the drafting of a National Plan for Diabetes Control. The plan will be aimed at lowering the prevalence of risk factors, at detecting new diabetes cases, most often asymptomatic, and at detecting chronic complications of diabetes, educating patients in an ongoing manner on changing their life style, ensuring compliance with the prescribed therapy and at preventing chronic complications and providing monitoring tests. Diabetes patients will benefit from services at all levels of care: case management in primary care; medicines, tests and devices through the NHIH’s Diabetes National Program; hospital services and medical devices for case with complications and comorbidities.The measure is financed from the state budget, European non-reimbursable funds (ENF) and National Health Insurance Fund (NHIF) and is to be implemented between 2017-2020.Implementing institutions: MoH, NHIF, medical care units, family physicians, community nurses.

legislation on the national diabetes plan [pieces of legislation]no of diabetes medication beneficiaries as part of the NHP [persons]

700.000 700.000 700.000 700.000 700.000

58



Measure 1.1.1.4 Prevention and control of mental and behavior disordersThe measure aims at (i) promoting and protecting mental health, (ii) preventing psychological morbidities and (iii) ensuring adequate access to diagnosis, treatment and follow-up services. At activity level, the measure will put emphasis on the implementation of the National Strategy for Mental Health of Children and Youths 2016-2020, mental health promotion projects, preventive interventions, diagnosis, treatment and monitoring of patients. A special focus will be given to the role of primary care providers, especially community care assistants and family physicians, who will be trained and encouraged to get involved in detecting and treating patients with mental and behavior disorders.The measure is financed from the state budget, European non-reimbursable funds (ENF) and National Health Insurance Fund (NHIF) and is to be implemented between 2017-2020.Implementing institutions: MoH, NHIF, National Public Health Institute regional departments, medical care units, outpatient care units, family physicians, community nurses.

hospital beds for metal health problems [beds/ 1,000]

0,8 0,8 0,8 0,8 0,8

schools in which preventive interventions are carried out [units]

600 600 600 600 600

national campaigns to promote mental health [campaigns]

1 1 1 1 1

Measure 1.1.1.5 Promote a healthy lifestyle and combat the main risk factorsThe actions are aimed at strengthening the capabilities of

information campaigns implemented

22 22 22 22 22

59



health promotion agencies and effective implementation of specific campaigns. As stated in the NHS, a national Plan for Health Promotion will be developed, which will provide reference for subsequent development and implementation of county health promotion plans. The NPHI will carry out studies of the health status and health determinants and will then adjust the existing awareness campaigns to their findings. The campaigns will focus on preventing and fighting alcohol consumption, smoking, as well as joint actions with the Ministry of Education and the Ministry of Youth and Sports, aimed at promoting healthy eating habits and a healthy life style.The measure is financed from the state budget, European non-reimbursable funds (ENF) and National Health Insurance Fund (NHIF) and is to be implemented between 2017-2020.Implementing institutions: MoH, ISPs, National Public Health Institute regional departments, outpatient care units, family physicians, community nurses.

[campaigns]number of educational units in which specific interventions are carried out [units]

2134 2134 2134 2134 2134

personnel trained in health promotion at regional and county level [persons]

120 120 120 120 120

draft piece of legislation for approval of the national Plan for Health Promotion [pieces of legislation]

0 0 1 0 0

Measure 1.1.2.1 Develop medical services for patients with special pathologiesThe measure concerns the early detection, diagnosis and treatment of rare diseases included in the NHIH’s national program for treatment of rare diseases, as well as hemophilia and thalassemia. It will seek to consolidate and extend the infrastructure for diagnosis and treatment by supporting the set up and the operations of centers of expertise for rare diseases, as envisaged by the order of MoH no 540/2016. Also,

draft regulation of the approval of National Plan for Rare Diseases [pieces of legislation]

0 0 1 0 0

no of rare disease medication beneficiaries as

3518 3518 3518 3518 3518

60



support will be given to reference labs authorized to perform diagnosis tests. Patients with rare disease will continue to have access to specific medicines and to services at all levels of care.The measure is financed from the state budget, European non-reimbursable funds (ENF) and National Health Insurance Fund (NHIF) and is to be implemented between 2017-2020.Implementing institutions: MoH, NHIF, National Public Health Institute regional departments, medical care units.

part of the NHP [persons]


Measure 1.2.1.1 Strengthen the system of prevention, surveillance and control of communicable diseasesThis measure is aimed at diseases preventable through vaccination, water-borne diseases, food-borne diseases and zoonoses, blood-borne infections, hospital-acquired infections, STI, HIV, TB and other priority diseases. The measure aims to support surveillance infrastructure, upgrade IT equipment and epidemiological software for implementing the electronic surveillance system, surveillance and control of hospital-acquired infections and monitor the use of antibiotics and the antibiotic resistance.The measure is financed from the state budget, European non-reimbursable funds (ENF) and is to be implemented between 2017-2020.Implementing institutions: MoH, National Public Health Institute (NPHI), National Public Health Institute regional departments, CHDs, family physicians, hospitals, other providers.

personnel trained under the National Plan for Intervention in Case of Epidemics and Pandemics [persons]

50 50 50 50 50

studies, reports, surveys [documents]

1 1 1 1 1

reports, surveys on the nosocomial infections [documents]

2 2 2 2 2

draft piece of 0 1 0 0 0

61



legislation for the approval of the National Strategic Plan on Nosocomial Infections [pieces of legislation]

Measure 1.2.1.2 Strengthen the system of prevention, surveillance and control of priority communicable diseases – tuberculosisThe measure includes activities for developing and implementing the Framework Action Plan for Countering Tuberculosis, the surveillance infrastructure, ensuring access to integrated services or patient-centered care and prevention: 1. Improving the programmatic management and intervention capacity for the prevention and control of TB, especially of MDR/XDR forms. 2. Increasing the diagnosis capacity for TB/MDR TB and ensuring universal access to high quality diagnosis, in compliance with international standards. 3. Improving treatment conditions and ensuring the access of all patients to first and second line TB drugs. Special emphasis will be laid on detecting tuberculosis in the passive form (in symptomatic patients, who see the physician on their own initiative) and the active, intensive form (through contacts control, and through the control of persons with TB risk), by mobilizing family physicians and community nurses.The measure is financed from the state budget, European non-reimbursable funds (ENF) and National Health Insurance Fund (NHIF) and is to be implemented between 2017-2020.

National Plan for TB Awareness developed [documents]

0 0 1 0 0

centralized procurement of TB medicines [tenders]

1 0 1 0 1

62



Implementing institutions: MoH, NHIF, health care units, family physicians, community nurses.Measure 1.2.1.3 Strengthen the system of prevention, surveillance, detection, diagnostic, treatment and monitoring of priority communicable diseases – viral hepatitisThe measure includes integrated activities aimed at reducing morbidity, invalidity and mortality determined by acute viral, protracted and chronic forms of hepatitis B, C and D, cirrhosis of the liver caused by these viruses through activities related to prevention, screening, treatment and follow-up.The measure is financed from the state budget, European non-reimbursable funds (ENF) and National Health Insurance Fund (NHIF) and is to be implemented between 2017-2020.Implementing institutions: MoH, NHIF, health care units, family physicians, community nurses.

hepatitis registry operational [yes/ no]

no yes yes yes yes

no of screened persons for HCV and HBV [persons]

13.000 13.000 13.000 13.000 13.000

Measure 1.2.1.4 Strengthen the system of prevention, surveillance and control of priority communicable diseases - HIV/ AIDSThis measure is aimed at implementing epidemiologic surveillance activities through clinical and lab examinations for the general population and for the population segments with a high risk of contracting sexually transmitted diseases and infections, as well as ensuring patient access to services of prevention, diagnosis, treatment and monitoring of the HIV/AIDS infection.The measure is financed from the state budget, European non-reimbursable funds (ENF) and National Health Insurance Fund (NHIF) and is to be implemented between 2017-2020.Implementing institutions: MoH, NHIF, health care units, family

no of screened persons [persons] 370.000 370.000 370.000 370.000 370.000

National Multiparty HIV Committee operational [yes/ no]

no no yes yes yes

no of antiretroviral treatment beneficiaries [persons]

10.551 10.551 10.551 10.551 10.551

63



physicians.Measure 1.2.2.1 Protect the population health against main communicable diseases that can be prevented through vaccinationThis measure is aimed at continuing the vaccination coverage for all vaccines and age groups provided in the national immunization calendar. It includes regulatory changes to improve compliance, a national awareness campaign on the benefits and safety of vaccination, the setup of the National Committee for Vaccination, training of personnel involved in vaccination and investment in the vaccination network infrastructure.A series of legislative measures are foreseen for the transfer of the Cantacuzino NIRDMI to the Ministry of Health and for financing it based on its status as provider of economic services of general interest to ensure the investments necessary for the resumption of vaccine production.The measure is financed from the state budget, European non-reimbursable funds (ENF) and is to be implemented between 2017-2020.Implementing institutions: MoH, NPHI, CHDs, NIRDMI Cantacuzino31, family physicians, community nurses.

National Vaccination Registry operational [yes/ no]

yes yes yes yes yes

draft piece of legislation on vaccination [pieces of legislation]

0 1 0 0 0

no of national campaigns implemented [campaigns]

1 1 1 1 1

% cases of vaccination adverse events investigated of total reported [%]

100% 100% 100% 100% 100%

counties in which vaccination rates are below optimal levels [counties]

30 30 30 30 30

draft piece of legislation of the

0 1 0 0 0

31 National Institute for Research and Development in Microbiology and Immunology (Institutul National de Cercetare, Dezvoltare pentru Microbiologie si Imunologie, in Romanian)

64



transfer of the institute to the MoH [pieces of legislation]

Program 1.3: Improving mother and child health

Measure 1.3.1.1 Early detection and assessment of risks during pregnancy for both mother and childThe measure is aimed at conducting prenatal investigations, improving medical care services and monitoring for pregnant women, women who have recently given birth, and newborns.The measure is financed from the state budget, European non-reimbursable funds (ENF) and National Health Insurance Fund (NHIF) and is to be implemented between 2017-2020.Implementing institutions: MoH, NHIF, CHDs, CHIHs, family physicians, community nurses, hospitals, other providers.

public policy proposal on the health state on children, including cross-sector activities [documents]

1 0 0 1 0

% of children benefiting from preventive iron supplements as per guidelines [%]

≥ 50% ≥ 50% ≥ 50% ≥ 50% ≥ 50%

report on reproduction health [documents]

1 1 1 1 1

no of maternity units included in "Child friendly hospital" initiative [persons]

10 10 10 10 10

Measure 1.3.1.2 Measures of early detection and assessment guidelines for 1 1 1 1 1

65



of child diseases with increasing incidence, such as autism spectrum disordersGiven the magnitude and the high costs entailed, both for the family and for the healthcare system, the measure initially provides conducting a national-level epidemiologic study and then designing interventions based on its findings. Such interventions might include the early detection and assessment of neurodevelopmental disorders, including: child autism, Asperger disorder, disintegrative childhood disorder, Rett syndrome and pervasive developmental disorders not otherwise specified (PDD-NOS), or typical autism.The measure is financed from the state budget, European non-reimbursable funds (ENF) and is to be implemented between 2017-2020.Implementing institutions: MoH, NHIH, health care units, family physicians.

pregnant women and children updated/ developed [documents]

Measure 1.3.1.3 Measures aimed at improving child nutrition and other measures for specific diseasesThe measure aims at the promotion of breastfeeding; the micronutrient diet supplementation of the pregnant woman and infant baby; the prophylaxis of malnutrition in low birth weight children; the healthy diet and the prevention of child obesity. It also envisages the development of studies and research concerning mother and child health and related determining factors. The measure is financed from the state budget, European non-reimbursable funds (ENF) and is to be implemented between 2017-2020.Implementing institutions: MoH, NHIF, health care units, family

pregnant women receiving advice given on breast feeding [%]

50% 50% 50% 50% 50%

66



physicians.

Program 1.4: Monitoring public health in connection with the environment

Measure 1.4.1.1 Monitor and report on the determining factors from the living and working environmentThis measure includes activities aimed at monitoring the quality of the drinking water and bathing water, correlating health indicators with various pollutants in the surrounding air, analyzing the impact of industrial and household waste on general health, monitoring the waste management system for waste generated by the medical activities, monitoring food quality, risk assessment. It will finance research studies of factors with a potentially negative impact on public health will be conducted under this measure. Based on the findings of all research and monitoring activities, accident/ catastrophe response guidelines and procedures will be updated/ developed.The measure is financed from the state budget, European non-reimbursable funds (ENF) and is to be implemented between 2017-2020.Implementing institutions: MoH, NPHI, National Public Health Institute regional departments, CHDs, family physicians, other providers.

annual report on the determining factors from the living and working environment released [documents]

1 1 1 1 1

67



Measure 1.4.2.1 Consolidate monitoring services for the determining factors from the living and working environmentThis measure is aimed at supporting the surveillance infrastructure through the national level mapping of risk factors that could impact human health (industrial facilities, large chemical plants, routes of transportation for chemical, radioactive or hazardous materials, facilities for poultry processing, areas with high risk of floods of earthquakes), consolidating and modernizing laboratory equipment in public institutes and public health directorates. All personnel involved in response to environmental emergencies will be trained in the guidelines, procedures and mapping results. In addition, based on the mapping and research, further measures to strengthen the response capacity and infrastructure will be designed.The measure is financed from the state budget, European non-reimbursable funds (ENF) and is to be implemented between 2017-2020.Implementing institutions: MoH, INSP, ISPs, CHDs.

no of risk maps [maps] 0 0 0 42 42

no of trained persons [persons] 42 42 42 42 42

no of laboratories upgraded [labs] 42 42 42 42 42

Program 2.1: Ensure the functional framework and the resources for the healthcare system

Measure 2.1.1.1 Human resource development initiativesThe measure aims at developing and implementing an integrated HR development policy for the healthcare sector. It entails the development of a plan for the human resources in healthcare, identification and implementation of sustainable strategies for attracting and retaining doctors and nurses in the Romanian health sector, especially in understaffed specialties

no of trained nurses [persons] 130.537 130.537 130.537 130.537 130.537

draft regulations and guidelines on human resources

2 2 2 2 2

68



and areas. The plan will put emphasis on increasing mobility with a view to improving the territorial distribution of medical staff. The measure also points to the development of unitary criteria for work norming, quality, evaluation and monitoring the activities conducted by medical staff. It includes actions designed to increase efficiency of training programs. The measure also foresees the development and implementation of a motivating payment system for the medical staff.The measure is financed from the state budget, European non-reimbursable funds (ENF) and National Health Insurance Fund (NHIF) and is to be implemented between 2017-2020.Implementing institutions: MoH, CHDs, NPHI and its network, College of Physicians.

developed [pieces of legislation]

number of graduates in deficient specialties [persons]

ICA 180Epidemiology 40Hygiene 25Emergency medicine 127Lab medicine 94Psychiatry 153Pediatric psychiatry 20





draft piece of legislation on the approval of a new remuneration system [pieces of legislation]

0 1 0 0 0

draft piece of legislation on the human resource strategy approval [pieces of legislation]

0 1 0 0 0

Measure 2.1.2.1 Initiatives to improve the management of financial resources

draft piece of legislation on the 0 0 0 1 0

69



The measure includes actions designed to develop the service contracting and payment systems, to improve the efficiency of spending in the national health programs. It foresees actions aimed at improving the reimbursement and reporting systems, as well as policies to increase the financial resources for healthcare services.The measure is financed from the state budget, European non-reimbursable funds (ENF) and National Health Insurance Fund (NHIF) and is to be implemented between 2017-2020.Implementing institutions: MoH, NHIF and service providers.

approval of new payment mechanisms for services within national health programs [pieces of legislation]number of public budgets developed based on program budgeting [budgets]

0 0 0 3 0

public policy on private health insurance [documents]

0 0 1 0 0

Measure 2.1.3.1 Initiatives designed to improve information managementThe Measure aims at ensuring the standardization, integration and interoperability of the healthcare information system, developing an integrated health IT system, i.e. the Information Platform of Social Insurance, strengthening or developing IT solutions for the healthcare services, under e-health projects, developing patient or disease registries, and improving the use of IT&C solutions in the emergency services. The measure is financed from the state budget, European non-reimbursable funds (ENF) and National Health Insurance Fund

draft piece of legislation on harmonization of service classification, codification and reporting [pieces of legislation]

0 0 1 0 0

ICD 10 classification system extended

0 0 1 0 0

70



(NHIF) and is to be implemented between 2017-2020.Implementing institutions: MoH, NHIF, CHDs, CHIHs, service providers.

to family medicine and specialist outpatient care [pieces of legislation]no of operational components of the IT platform [components]

4 4 4 5 6

no of new operational registries, complying with EU standards [registries]

4 4 4 4 4

regional cancer and cancer screening registries operational [yes/ no]

no no no no yes

Measure 2.1.4.1 Initiatives aimed at promoting research and innovation in the health sectorThe Measure aims at developing the research and innovation capacity for the health sector, including public health and healthcare services, to support evidence-based policies. It also focuses on improving the framework for clinical studies. The National Plan for Healthcare Research will be updated and will

draft piece of legislation on amending regulations for clinical studies [pieces of legislation]

0 1 0 0 0

71



include mechanisms for the transfer of research projects’ results into policies and clinical practice.The measure is financed from the state budget, European non-reimbursable funds (ENF) and is to be implemented between 2017-2020.Implementing institutions: MoH, NHIF, CHDs, CHIHs and health R&D units.

final report [documents] 0 0 1 0 0


Measure 2.2.1.1 Develop the community healthcare servicesThis measure is aimed at implementing and extending the community healthcare services with a view to providing primary prevention services and facilitating the access of vulnerable groups to basic healthcare services. It also seeks to ensure integration with other providers of healthcare service, education and social services.The activities under this measure will relate to employment and qualification of more community care assistants, the improvement of the legal framework, development of guidelines for community interventions, training of community assistants and other stakeholders, designing better mechanisms for monitoring and evaluation of community care assistants’ work.The beneficiaries are members of the community healthcare network and the population of the relevant local communities. This measure is financed from the budget of MoH, through the Swiss-Romanian cooperation program and has a permanent character/ shall apply until 2020.

no of community assistants and health mediators [persons]

1867 1867 1867 1867 1867

draft piece of legislation on the community care [pieces of legislation]

0 1 0 0 0

integrated community care teams [teams]

0 0 0 0 200

no of guidelines and methodologies developed and disseminated [documents]

1 1 1 1 1

72



Implementing institutions: Ministry of Health (MoH), National Health Insurance House (NHIH), county health departments (CHDs), county health insurance houses (CHIH), family physicians, community nurses, hospitals, other providers.Measure 2.2.1.2 Extend the role of family medicine services This measure seeks to increase the coverage and quality of family medicine services, extend the scope and frequency of preventive services, improve the management of chronic disease patients, integrate family medicine with other healthcare services.The activities under this measure will consist of identifying patients at risk of chronic conditions and patients with high risk of complications, inclusion of high risk patients in case management practices, offering physicians software for diagnosis and prescription support, designing and implementing pay-for-performance mechanisms, designing new incentives for attracting physicians in underserved areas, providing financial support to 24/7 centers and integration via telemedicine with hospitals’ emergency rooms. The measure will finance the ongoing medical services delivered by family physicians.Beneficiaries shall be family doctors and insured patients registered in their lists. The measure is financed from the state budget, European non-reimbursable funds (ENF), National Health Insurance Fund (NHIF) and World Bank loan and is to be implemented between 2017-2020.Implementing institutions: Ministry of Health (MoH), National

diagnostic and prescription support software purchased and operational [yes/ no]

no no no no yes

draft legislation on pay-for-performance mechanism for selected services provided by family physicians [pieces of legislation]

0 0 0 0 1

no of communes without family practitioner [communes]

165 165 165 165 165

draft piece of legislation on incentives for family physicians and resident physicians for

0 0 1 0 0

73



Health Insurance House (NHIH), county health insurance houses (CHIH), family physicians.

relocation in service deficient areas [pieces of legislation]no of operational permanence centers [centers]

1481 1481 1481 1481 1481

draft piece of legislation on allowing the residency program in the family care practice [pieces of legislation]

0 0 1 0 0

Measure 2.2.1.3 Develop the services in the specialty clinic and para-clinic outpatient care This measure is aimed at preparing and implementing a public policy dedicated to the expansion of specialty outpatient services with a view to improving coverage and facilitating patient access to high-quality outpatient diagnosis and treatment services. The measure will support the outpatient medical centers providing (a) imagery diagnosis services, (b) surgery and procedures performed without admission to a hospital (c) screening services for cancer and (d) specialized care for complications occurred in chronic diseases.Other activities within this measure will consist of designing and implementing new payment mechanisms, which will encourage the multidisciplinary approach for same-day

no of outpatient physicians in deficient specialties [persons]

Lab medicine - 105Radiology-medical imaging - 155Pneumology - 70





draft legislation on pay-for-performance mechanism for selected services provided by outpatient

0 0 0 0 1

74



diagnosis and treatment services, outpatient surgery, more numerous chronic disease management services. The measure will provide support to hospitals converted into outpatient clinics. It will finance the ongoing medical services delivered by specialist physicians, the outpatient paraclinical services and the dialysis national health program. The measure is financed from the state budget, European non-reimbursable funds (ENF), National Health Insurance Fund (NHIF) and World Bank loan and is to be implemented between 2017-2020.Implementing institutions: Ministry of Health (MoH), National Health Insurance House (NHIH), county health insurance houses (CHIH), service providers.

physicians [pieces of legislation]draft piece of legislation on the approval of the Strategy for outpatient care [pieces of legislation]

0 0 1 0 0

no of dialysis patients under treatment [persons]

12100 12100 12100 12100 12100

no of outpatient physicians in deficient specialties [persons]






Measure 2.2.2.1 Increase the efficiency and performance of hospital servicesThis measure is aimed at increasing the efficiency of expenditure and the quality of hospital services through rationalizing the network and pursuing integration at regional level, standardization of hospital organization and equipment, and improving the payment methods for services.This measure includes activities related to the provision of

report on the DRG system released [documents]

0 0 0 1 0

draft piece of legislation on the approval of standards for organization and

0 0 1 0 0

75



high-quality hospital services, based on the optimal combination of human and technological resources, rationalization of hospital network services, integration of hospital services with other healthcare providers, increasing the efficiency of financing and improvements to the classification, organization and operation of hospitals.The measure is financed from the state budget, European non-reimbursable funds (ENF), National Health Insurance Fund (NHIF) and World Bank loan and is to be implemented between 2017-2020.Implementing institutions: Ministry of Health (MoH), National Health Insurance House (NHIH), county health departments (CHDs), county health insurance houses (CHIH), hospitals.

endowment of hospitals based on level of competence [pieces of legislation]draft piece of legislation on the setup and functioning of centers of excellence [pieces of legislation]

0 0 0 1 0

draft piece of legislation on the coordination of hospital services by regional hospitals [pieces of legislation]

0 0 1 0 0

isolated communities connected to hospitals by telemedicine systems [l.g. units]

160 160 160 160 160

76



Measure 2.2.2.2 Reinforcement of emergency healthcare services This measure is aimed at ensuring the provision of emergency pre-hospital and hospital services, concurrently with the implementation of projects for the development of the network. This Measure includes actions to ensure the functionality of emergency pre-hospital services and to further develop the emergency hospital services through roll-out of integrated it systems, expanded telemedicine facilities and upgrade of emergency transport capabilities.The measure is financed from the state budget, European non-reimbursable funds (ENF), the World Bank loan and is to be implemented between 2017-2020.Implementing institutions: Ministry of Health (MoH), Ministry of Internal Affairs, county health departments (CHDs), hospitals, ambulance service.

no of integrated operations centers [centers]

41 41 41 41 41

paper-free communication system within emergency units and transport [yes/ no]

no no no yes yes

ambulances available [units] 1941 1941 1941 2858 2858

Measure 2.2.3.1 Develop the long-term healthcare services, rehabilitation/medical recovery, home caregiving, palliationThe measure foresees the implementation of specific services for palliative assistance provided to terminally ill patients and for long-term recovery. It consists of actions aimed at drawing up and approving national policies concerning specific services for palliative care provided to terminal patients and for long-term recovery, including financing sources and mechanisms, and at implementation of specific palliative services provided

draft piece of legislation on the approval of the National Plan for long term, rehabilitation , home and paliative care [pieces of

0 0 0 1 0

77



to terminally ill patients and for long-term recovery.The measure is financed from the state budget, European non-reimbursable funds (ENF) and National Health Insurance Fund (NHIF) and is to be implemented between 2017-2020.Implementing institutions: Ministry of Health (MoH), National Health Insurance House (NHIH), county health insurance houses (CHIH), long-term care and palliative services providers, family physicians, community nurses, hospitals.

legislation]

beneficiaries of home medical services [persons]

45.743 45.743 45.743 45.743 45.743

Measure 2.2.4.1 Improve the quality of healthcare servicesThe measure is aimed at creating the foundation for increasing the quality of medical services, through the expansion of the provider accreditation system, development of clinical audit capacity, development of clinical guidelines, integration of providers at various levels of care around patients with specific chronic diseases and the advancement of the interaction with patients.The measure includes actions intended to develop and implement accreditation standards, implement quality control mechanisms, update clinical guidelines, extend the supply of evidence-based services, promote the multi-disciplinary approaches to the patient and ensure the continuity of care, extend health technology assessment systems, integrate service providers, improve the mechanisms for the information of and communication with patients.The measure is financed from the state budget, European non-reimbursable funds (ENF), National Health Insurance Fund (NHIF), National Agency for Healthcare Quality Management budget and the World Bank loan and is to be implemented between 2017-2020.

no of clinical guidelines and protocols for improving service quality newly developed or amended, including clinical pathway [documents]

hospitalProcedures 142Protocols 72





diagnostic and prescription support software purchased and operational [yes/ no]

no no no no yes

draft piece of legislation on the rules for approval and update of clinical guidelines

0 0 1 0 0

78



Implementing institutions: MoH, NHIH, the National Agency for Healthcare Quality Management (NAHQM), specialist MoH advisory committees, services providers.

[pieces of legislation]no of providers evaluated [providers]

180 public and private hospitals





draft piece of legislation on the approval of accreditation standards for primary care providers [pieces of legislation]

0 0 0 1 0

draft piece of legislation on the amendment of accreditation standards for hospitals [pieces of legislation]

0 0 1 0 0

national registry for near-miss/ adverse events operational [yes/ no]

0 0 0 yes yes

no of trained persons in guideline

100 100 100 100 100

79



implementation [persons]draft piece of legislation on the HTA framework for services, devices, equipment and public health interventions [pieces of legislation]

0 0 0 1 0

no of integrated functional care networks at area/ county level [networks]

0 0 0 2 8

draft piece of legislation on the piloting of integrated functional care networks at area/ county level [pieces of legislation]

0 0 1 0 0

national health portal operational 0 0 0 yes yes

80



[yes/ no]draft piece of legislation on the approval of minimum standards for health providers’ webpages [pieces of legislation]

0 0 0 1 0

annual report on patient satisfaction released [documents]

0 1 1 1 1

Measure 2.2.5.1 Strengthen services for organ, tissue and human cell transplantThe measure seeks to ensure continuity and development of services for organ, tissue and cell transplant. It aims at improving budgetary efficiency and access to post-transplant medicines.The actions included in the measure concern the development of guidelines for each transplant phase, the actual implementation of transplant procedures and associated measures, developing proposals to reform financing mechanisms and prescription and dispensing medicine for post-transplant patients.The measure is financed from the state budget and National Health Insurance Fund (NHIF) and is to be implemented between 2017-2020.

draft piece of legislation on the approval of guidelines for organ transplant [pieces of legislation]

0 0 1 0 0

no of beneficiaries of post-transplant medicines [persons]

3278 3278 3278 3278 3278

draft legislation on the disbursements for organ

0 0 1 0 0

81



Implementing institutions: MoH, NHIH, National Agency for Transplant, services providers.

transplant services [pieces of legislation]

Measure 2.2.5.2 Ensure demand and security of blood productsThe measure aims at ensuring sufficient quantities of secure blood products and developing providers’ capacity.The actions envisaged by the measure center upon the operation of blood transfusion centers and investment in service infrastructure.The measure is financed from the state budget, European non-reimbursable funds (ENF).Implementing institutions: MoH, the National Institute for Transfusion Hematology and its subordinated centers, services providers.

no of donors [persons] 345.598 345.598 345.598 345.598 345.598

no of centers upgrades [centers] 41 41 41 41 41

Program 2.3: Ensure patient access to medicine and medical devices

Measure 2.3.1.1 Increase patient access to compensated medicines in financially sustainable conditionsThe measure aims at increasing the quality of decisions regarding medicines reimbursement, as well as the NHIH related expenditure. The measure includes actions intended to review the methodology for setting the price of prescription medicines, so as to ensure the adequate supply of the local market, to strengthen the administrative capacity of the staff in the unit for health technology assessment (HTA) within National Drugs and Medical Devices Agency (NDMDA), to review the HTA regulations by including cost-effectiveness criteria in decision-

draft piece of legislation on the mechanism for setting prescription medicines prices [pieces of legislation]

1 1 0 0 0

draft piece of legislation on amendments to the HTA system

0 1 0 1 0

82



making, to extend the managed entry agreements for expensive new medicines, to ensure access to medicines, with or without personal contribution, for patients with chronic or acute conditions and to monitor the physicians` prescription behavior.The measure is financed from the state budget, European non-reimbursable funds (ENF), National Health Insurance Fund (NHIF) and World Bank loan and is to be implemented between 2017-2020.Implementing institutions: regulatory bodies in the central administration (MoH, NHIF, NDMDA), CHIHs.

[pieces of legislation]

no of MEAs concluded [contracts]

4 4 4 4 4

Measure 2.3.2.1 Increase patient access to medical devicesThe measure aims at improving the quality of life for patients with organic or functional deficiencies and at standardizing the medical devices and supplies used in Romania. The measure includes actions intended to ensure patients` access to medical devices designed for the recovery of organic or functional deficiencies, in line with the basic medical services package or the national health programs, and to set up and implement a Nomenclature of medical devices and healthcare supplies.The measure is financed from the state budget, European non-reimbursable funds (ENF) and National Health Insurance Fund (NHIF) and is to be implemented between 2017-2020.Implementing institutions: Ministry of Health (MoH), National Health Insurance House (NHIH), county health insurance houses (CHIH), medical devices providers.

no of beneficiaries of medical devices [persons]

266.000 266.000 266.000 266.000 266.000

registry operational [yes/ no]

no no no yes yes

83



Program 2.4: Upgrade the healthcare system infrastructure

Measure 2.4.1.1 Upgrade service provider infrastructure to the current standards of healthcare services and the patients’ needs This measure is aimed at achieving rationalization and conversion of local hospitals, the development and rationalization of county hospitals (rehabilitated for increasing their energy efficiency, upgrading to improve physical access for the disabled and the provision of equipment), rationalization and/ or building of regional hospitals, increasing the efficiency of integrated outpatient services in the treatment of complex pathologies requiring multi-disciplinary approaches. It also seeks to upgrade the infrastructure of radio-therapy and oncology services.The measure will provide support for setting up/ refurbishing/ building integrated community care centers, integrated health centers and family practices in remote areas. Similar support is intended for primary care permanence centers set up with the aim of providing services round the clock for the population in designated areas.The measure is financed from the state budget, European non-reimbursable funds (ENF), National Health Insurance Fund (NHIF) and World Bank loan and is to be implemented between 2017-2020.Implementing institutions: Ministry of Health (MoH), National Health Insurance House (NHIH), county health departments (CHDs), county health insurance houses (CHIH), hospitals.

number of regional hospitals in construction [hospitals]

0 0 3 3 3

no of upgraded hospitals [projects]

14 14 14 14 14

integrated community centers upgraded/ built, equipped and staffed [projects]

45 45 45 45 45

radiotherapy centers upgraded/ built [projects]

1 1 1 1 1

outpatient clinics upgraded/ built/ equipped [projects]

87 87 87 87 87

84



Measure 2.4.1.2 Development of public health infrastructureThis measure is aimed at improving the infrastructure of public health laboratories, to perform investments in infrastructure, technology and the equipment and to provide the adequate infrastructure to manage medical waste.The measure is financed from the state budget, European non-reimbursable funds (ENF) and is to be implemented between 2017-2020.Implementing institutions: Ministry of Health (MoH), county health departments (CHDs), NIPH, National Public Health Institute regional departments.

no of upgrade projects [projects]

42 PHD labs DSP + 17 LIR - DSP + 17 labs RPHC





Measure 2.4.1.3 Development of the infrastructure for emergency servicesThe measure consists of upgrading and extending emergency rooms in emergency hospitals, providing the appropriate specific equipment for ambulance and SMURD services and of extending the coverage of SMURD services at national level.The measure is financed from the state budget, European non-reimbursable funds (ENF) and World Bank loan and is to be implemented between 2017-2020.Implementing institutions: Ministry of Health (MoH), Ministry of Internal Affairs, county health departments (CHDs), ambulance services, hospitals.

upgraded emergency rooms [projects]

29 29 29 29 29


85



Measure 3.1.1.1 Develop integrity, transparency and professional ethicsThe measure is aimed at strengthening and extending the integrity and control structures of the Ministry of Health; reviewing patient feedback mechanisms; preventing and identifying situations that may create conflicts of interest among clinical and management personnel of public health providers; developing a new mechanism of financial support for life-long medical education; improving mechanisms of accountability for managers and other representatives of the decision-making apparatus in hospitals; transparent use and publication of public funds.The measure is financed from the state budget, European non-reimbursable funds (ENF) and National Health Insurance Fund (NHIF) and is to be implemented between 2017-2020.Implementing institutions: MoH, NHIH, National Integrity Agency, CHDs, CHIHs, public hospitals, other providers.

personnel trained in inspection and control topics [persons]

90 90 90 90 90

annual report for national health programs [documents]

1 1 1 1 1

analyses, reports, evaluations to substantiate public policies [documents]

1 1 1 1 1

Measure 3.1.1.2 Develop the administrative capacity of centralized public procurementThis measure aims at implementing the strategic planning for medical technologies procurement and related implementation activities for every type of selected medical technology. Another objective is to develop the MoH administrative capacity to perform centralized public procurement procedures efficiently and effectively.The measure is financed from the state budget, European non-reimbursable funds (ENF) and World Bank loan and is to be implemented between 2017-2020.Implementing institutions: Ministry of Health (MoH), public

institutional framework for RHSPs operational (committees at national and regional level) [committees]

0 1/ 8 1/ 8 1/ 8 1/ 8

no of trained persons in public procurement [persons]

0 0 10 10 10

86



hospitals.Measure 3.1.1.3 Increase institutional performance by improving the management systems The measure aims at strengthening the methodological coordination of the audit compartments from the healthcare units subordinated to the MoH, developing the managerial internal control system, developing IT instruments for internal procedures, strengthening the state sanitary inspection, and improving the management capacity for managed entry agreements. The measure also seeks to establish a mechanism for prioritizing budgetary allocations and making evidence-based decisions at MoH and NHIH level. Additional activities relate to the establishment within the MoH and NHIH of a joint mechanism for monitoring and control of suppliers in the health insurance system and of a mechanism for tracking medicines on the Romanian market.The measure is financed from the state budget, European non-reimbursable funds (ENF) and National Health Insurance Fund (NHIF) and is to be implemented between 2017-2020.Implementing institutions: Ministry of Health (MoH), National Health Insurance House (NHIH), county health departments (CHDs)32, county health insurance houses (CHIH)33, NDMDA.

no of new IT systems, management systems and trained persons [persons]

0 1 2 2 2

Measure 3.1.2.1 Promote healthcare in all policiesThe measure aims at improving the MoH capacity for policy formulation and the strategic planning cycle in the healthcare sector. It also seeks to ensure enough staff capable to

draft piece of legislation on the amendment of public policy

0 0 1 0 0

32 Directorate for Public Health (Directia de Sanatate Publica, in Romanian)33 County Health Insurance Agency (Casa Judeteana de Asigurari de Sanatate, in Romanian)

87



formulate healthcare policies, develop strategies and coordinate the programs and measures from the Institutional Strategic Plan. The measure includes activities to develop procedures and instruments for the formulation of public policies and strategies, for monitoring, evaluating and reviewing the ISP and the National Healthcare Strategy; for development of impact studies. The measure also points to the development of partnerships and joint programs with the stakeholders from associated fields (local public authorities, social, education, environment, police, emergency situations, transportation); to the drafting and implementation of the legal framework for consultations with the social stakeholders and other NGOs.The measure is financed from the state budget, European non-reimbursable funds (ENF) and is to be implemented between 2017-2020.Implementing institutions: Ministry of Health (MoH), National Health Insurance House (NHIH), other stakeholders from associated fields (social services, education, environment, internal affairs, transportation etc.).

proposal format and content [pieces of legislation]no of joint projects [projects] 1 1 1 1 1

no of trained persons [persons] 0 3 3 3 3

Measure 3.1.2.2 Promote evidence-based public policiesThe measure is aimed at conducting studies on the usage of health services, the performance of the health system, the financing of health services, the management and leadership capacity of the health system. It seeks to implement monitoring & evaluation system for the National Health Strategy 2014-2020. It also refers to implementation of research projects, studies or surveys on the determinants of health and disease burden in the population. The measure

draft piece of legislation developed and debated [pieces of legislation]

0 0 1 0 0

report of the health survey [documents]

0 0 0 1 0

annual evaluation 1 1 1 1 1

88



includes the development and implementation of a public policy and related regulations regarding investments in healthcare infrastructure, as well as a multiannual plan for investment in public hospitals.The measure is financed from the state budget, European non-reimbursable funds (ENF) and World Bank loan and is to be implemented between 2017-2020.Implementing institutions: Ministry of Health (MoH), National Health Insurance House (NHIH), other stakeholders from associated fields (social services, education, environment, internal affairs, transportation etc.).

report [documents]

Measure 3.1.3.1 Develop the human capital from the MoH, NHIF and other subordinated/coordinated institutionsThe measure aims at developing the human capital of healthcare regulatory bodies, by introducing modern HR management tools, conducting needs assessment and planning interventions to close the gaps, improving the staff’s recruitment and motivational factors, introducing performance-based incentives, promoting life-long learning practices, implementing specialized training programs and developing the organizational culture.The measure is financed from the state budget, European non-reimbursable funds (ENF) and National Health Insurance Fund (NHIF) and is to be implemented between 2017-2020.Implementing institutions: Ministry of Health (MoH), National Health Insurance House (NHIH), county health departments (CHDs), county health insurance houses (CHIH), other subordinated institutions.

final report [documents] 0 0 0 1 0

89

Annex 4: Institutional profile, internal and external assessment

Main determinants of the health status

At the sub-national level, there are major differences in the determinants of the health status (socio-economic, behavioral factors, factors deriving from the physical life and work environment or individual characteristics). The strategies meant to influence their distribution and amplitude place significant emphasis on health promotion and primary care professionals.

a. Socio-economic factors (directly or indirectly) play a significant role in shaping public health status, including in the broader meaning of health as defined by WHO, particularly on access to healthcare services. Healthcare is an important pillar in the multi-dimensional approach to mitigate poverty and social exclusion34, a significant goal of the European growth strategy by 202035.

Romania has one of the highest levels of poverty in the EU. Approximately 37% of the population live on the edge of poverty and social exclusion risk, a level that is exceeded in the EU-28 only by Bulgaria36.

b. Environmental factors. Traditional environmental determinants contribute 17% to the burden of disease in Romania, or the equivalent of 30 DALY/1,000 inhabitants per annum 37. Recent studies reveal that four out of the top 15 risk factors, depending on the disease, pertain directly to the environment38. The main pathologies known to have environmental components are: respiratory, cardio-vascular, neurologic diseases, but also some forms of cancer.

c. Individual behavioral factors. The behaviors with well-known impact on health status - smoking, alcohol abuse, diet/obesity and physical inactivity - weigh heavily on the health status of the overall population but with notable differences in impact by gender.

Tobacco abuse. Smoking is the third cause of disease for men and fifth for women. The estimated percentage of daily smokers in Romania is 19.6% in 2015, slightly lower than in 2013. Compared to other European countries, Romania is labelled as an average risk country in relation to tobacco abuse.

Alcohol abuse among Romanians continues to be the highest in Europe (RO: 16.3 l/adult/year39, EU27: 12.45 l/adult/year in 2012), exceeding by 30% the European average40. Available health data –

34 EHMA, The role of health care sector in tackling poverty and social exclusion in Europe, 200435 Regulation (EU) No 282/2014 of the European Parliament and of the Council of 11 March 2014 on the establishment of a third Programme for the Union's action in the field of health (2014-2020) and repealing Decision No 1350/2007/EC (1) Health for Growth 2014-2020 programme, European Commission36 Eurostat, 2015.37 WHO, Country profiles of Environmental Burden of Disease-Romania, Public Health and the Environment, Geneva 2009 . Accessed on 15 October 2013 la http://www.who.int/ quantifying_ehimpacts/national/countryprofile/romania.pdf38 Exposure to suspension powder, the quality of home air, occupational risks and lead exposure.39 Out of which 3 liters is consumption not registered in official records.40 Anderson P, Alcohol in the European Union Consumption, harm and policy approaches, WHO & EC, 2012.

91

http://www.who.int/%20quantifying_ehimpacts/national/countryprofile/romania.pdf

http://www.who.int/%20quantifying_ehimpacts/national/countryprofile/romania.pdf

e.g., number of hospital admissions attributed to alcohol, the overall and average hospital stay etc. – point to a significant public health concern.41

Physical inactivity is the fourth most significant cause of disease amongst Romanian women. In absolute terms men are even more impacted by physical inactivity than women. Recent MoH data on physical activity expect a worsening trend from 37% in 2013 to 33% in 201542.

Inappropriate diet . In accordance to NPHSA, a large percentage of Romanians eat too much salt (53%), saturated fats (32%) and/or red meat (27%)43.

Overweight/obesity . The prevalence of obesity in adults is relatively low in Romania (~8%), for the time being, the lowest in the EU-28 and one-third the European maximum figures (26% in Hungary and UK).44,45 As for the overweight population, the results of NPHSA reveal that 54% of persons assessed by family doctors had excess weight46.

High blood pressure in Romanian adults reaches 40%, according to the SEPHAR I and II surveys 47 and even 49.5%, based on intermediate data of SEPHAR III. The population group with the highest HBP risk are middle-aged women in urban areas, from the Southern region, with secondary education (high-school) and low income, non-smoking and with a sedentary lifestyle.

Institutional arrangements and capabilities referring to sector development

Apart from the health indicators described above, which are influenced by determinants inside and outside the health sector, the performance of the health system may also be assessed by:

• Ability to respond to the beneficiary’s needs (responsiveness),

• Equity and financial protection

• Efficiency and sustainability

The ability to respond to beneficiaries’ needs is a key concern of the health system. It is captured both by systematic measurements in relation to the satisfaction and perception of users, and by its reflection in public debate and mass-media. A 2014 Eurobarometer on the satisfaction of EU citizens with healthcare revealed that Romanians were the most discontented, with 73% of respondents describing service quality as “bad”48.

41 Romanian Association for the Promotion of Health, Study on the economic impact of harmful alcohol consumption on the Romanian health system, 2012.42 MoH, Report on the evaluation of the NHS 2014-2020, Bucharest, 2015, available at www.ms.ro. 43 National Healthcare Strategy 2014-2020, p. 16, Government Decision no 1028/2014.44 Eurostat, Overweight and obesity - BMI statistics, November 2011. Accessed on 4 November 2013 on http://epp.eurostat.ec.europa.eu/statistics_explained/index.php/Overweight_and_obesity_-_BMI_statistics . 45 OECD, Health at a Glance: Europe 2012, Accessed on 4 November 2013 la http://www.oecd-ilibrary.org . 46 National Healthcare Strategy 2014-2020, p. 16, Government Decision no 1028/2014.47 Romanian Hyper-Tension Society, Studiul de Prevalență a Hipertensiunii Arteriale și evaluare a riscului cardiovascular în România (SEPHAR), Copiilor si Tinerilor din Romania, 2011. Accessed on 4 November 2013 at http://www.sephar.ro/; Dorobantu M et co., Profile of the Romanian Hypertensive Patient, Data from SEPHAR II Study, ROM. J. INTERN. MED., 2012, 50, 4, 285–29648 Eurobarometer no. 411, Patient Safety and Quality of Care, data for Romania, European Commission, 2014, available at http://ec.europa.eu/public_opinion/index_en.htm

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http://www.sephar.ro/

http://www.oecd-ilibrary.org/

http://epp.eurostat.ec.europa.eu/statistics_explained/index.php/Overweight_and_obesity_-_BMI_statistics

http://www.ms.ro/

http://ec.europa.eu/public_opinion/index_en.htm

Corruption in healthcare is addressed at two levels: higher level corruption – in public procurement – and petty corruption in the form of informal payments for medical services. Projects in both areas have been pursued in 2014. As a first step towards attempting to curb informal payments, a feedback mechanism for patients is now being tested. Ethical Councils in hospitals are not yet functional, but a methodology for their operation is now being developed. They will be tasked with the analysis of patients' reports of possible ethical breaches and deeds of corruption.

Equity and financial protection. Social health insurance coverage has been fluctuating in recent years: from 87.8% of the population in 2008 to 95.9% in 2010 and then down to 85.3% in 2012. Throughout this period, a 20 p.p. gap existed between the coverage of population in urban and rural areas.

In terms of medical service coverage, urban areas are clearly better than rural areas for all categories of medical services. At the national level, the density of family doctors is 0.5/1,000 inhabitants in rural areas, as compared to 0.6/1,000 inhabitants in urban, while other specialist clinical services are virtually absent in rural areas. The urban-rural gaps and geographic inequalities are reflected in the health status indicators, like infant mortality49.

The level of financial protection. Based on the 2013 Family Budget Survey of the National Statistical Institute, the healthcare expenses of households ranked fourth highest, amounting to 4.8% of total. According to the World Bank50, there are major differences in access to healthcare between people by income. In the case of chronic diseases, approximately 40% of individuals in the lowest quintile did not seek care, as compared to only 17% in the highest quintile.

Efficiency and financial sustainability. The inefficiencies of Romania’s public spending on healthcare have been repeatedly pointed out by reports of the World Bank, the International Monetary Fund and the European Union. They all emphasize the overreliance on hospital spending, also shown in Figure 2 above, and the small share of outpatient care. NICE International’s 2012 report also stated that: “there is relative under-financing in the primary and outpatient healthcare sector” and this is associated with structural and financing abnormalities which seem to have resulted in “apparent under-use of primary healthcare”, an “apparent over-use of hospital healthcare” and, as a consequence, to an extended transfer of costs entailing perverse incentives51.

Romania has undergone a multi-year effort to reduce the size of the hospital sector, marked with the reduction of the number of beds contracted with the NHIH, the closure of 60 hospitals and the stimulation of day admissions. As a result, the number of continuous acute admissions reimbursed by the NHIH went down by 20% in the four years to 2015. However, NHIH reports and NSPHTIH data from Figure 3 and 4 point to the continuation of some hospital spending inefficiencies: (i) half of hospital admissions are emergencies; (ii) hospitals admit significantly more patients than they get paid for and, (iii) the number of high severity cases increased significantly since 2010, leading to a higher cost per patient, despite no visible change in the general morbidity.

49 NIS, Tempo database, accessed in December 2016.50 World Bank, Functional Analysis of the Healthcare System in Romania, 201151 NICE International, Romania: Final Report, January 2012

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Figure 9. Hospital cases classified under the DRG system

2010 2011 2012 2013 20140

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

4,000,000

4,500,000

5,000,000

70%

75%

80%

85%

90%

95%

100%

75%

79%

85%87% 88%

3,560,412 3,392,852 3,471,612 3,557,413 3,404,422

4,717,9044,319,314

4,107,954 4,108,8693,889,924

reimbursed cases (NHIH) vs DRG reports - acute casesNHIH reimbursed acute casesDRG registered acute cases

Source: NSPHTIH

Figure 10. Multiannual trend of acute cases by complexity (2010=100%)

2,010 2,011 2,012 2,013 2,014 2,015

100%

88%80% 78%

73% 69%

100%

116% 113% 116% 113% 112%

ordinary severe catastrophic

Source: NSPHTIH

Institutional profile

MoH subordinated institutions

1. Institutions financed from the state budget (up to 17,496 positions)

42 deconcentrated services in counties and the city of Bucharest

Institutul Naţional de Sănătate Publică; Institutul Naţional de Medicină Sportivă; Institutul Naţional de Hematologie Transfuzională "Prof. Dr. C.T. Nicolau"; Agenţia Naţională de Transplant; Oficiul Central de Stocare pentru Situaţii Speciale; Registrul Naţional al Donatorilor Voluntari de Celule Stem Hematopoietice;

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Agenţia Naţională a Medicamentului şi a Dispozitivelor Medicale; Spitalul Tichileşti (leprozerie); serviciile de ambulanţă judeţene şi Serviciul de Ambulanţă Bucureşti - Ilfov.

2. Self-financed institutions (own revenues) (up to 45,850 positions)

58 public hospitals

3. Institutions financed both from the state budget and own revenues (up to 380 positions)

Institutul Naţional de Medicină Legală "Mina Minovici" Bucureşti; Institutul de Medicină Legală Iaşi; Institutul de Medicină Legală Cluj-Napoca; Institutul de Medicină Legală Timişoara; Institutul de Medicină Legală Craiova; Institutul de Medicină Legală Târgu Mureş; Centrul Naţional de Sănătate Mintală şi Luptă Antidrog Bucureşti; Academia de Ştiinţe Medicale.

4. Organizations under the authority of the MoH

Compania Naţională "Unifarm" - S.A. Bucureşti; Societatea Comercială "Antibiotice" - S.A. Iaşi.

5. Institutions under the coordination of the MoH (up to 75 positions)

Şcoala Naţională de Sănătate Publică, Management şi Perfecţionare în Domeniul Sanitar Bucureşti

NHIH subordinated institutions

42 county health insurance houses and of the city of BucharestCASAOPSNAJ (Health Insurance House For Employees In The Army, Public Safety, National Security And Justice)

Pieces of legislation to be developed and approved in 2017

The following pieces of legislation will be developed and enacted in 2017. The listing and timing are the result of the ISP action plan, which included NHS action plan and Government Program 2017-2020 provisions.

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Table 13. Pieces of legislation to be enacted in the healthcare sector in 2017

type piece of legislation

recurrent by-law for 2017 to the GD on the approval of the Framework contract on the regime of medical services, medicines and devices within the social health insurance system 2016-2017 (joint MoH-NHIH order)

recurrent Government decision on the approval of national health programs for 2017-2018

recurrent by-law to the GD on the approval of national health programs for 2017-2018 on the programs implemented by the NHIH (NHIH order)

recurrent by-law to the GD on the approval of national health programs for 2017-2018 on the programs implemented by the MoH (MoH order)

new adopt a draft healthcare law

new draft piece of legislation on the amendment of public policy proposal format and content (health in all policies initiative)

new draft piece of legislation for approval of the national Plan for Health Promotion

new draft piece of legislation on the human resource strategy approval

new draft piece of legislation on the approval of the consolidated service plan

new draft piece of legislation on the coordination of hospital services by regional hospitals

new draft piece of legislation on the approval of standards for organization and endowment of hospitals based on level of competence

new draft pieces of legislation for the multiannual investment plan in hospitals, procedures to authorize investments in public hospitals and endowment standards based on hospital competency level

new draft piece of legislation on harmonization of service classification, codification and reporting

new draft piece of legislation on the rules for approval and update of clinical guidelines

new draft piece of legislation on the approval of integrated care pathways for the 20 most frequent diseases

new draft piece of legislation on the setup and functioning of centers of excellence

new draft piece of legislation on the mechanism for setting prescription medicines prices

new draft piece of legislation on amendments to the HTA system

new draft piece of legislation on amending regulations for clinical studies

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Main pieces of legislation in the health sector

Legea nr. 95/2006 privind reforma în domeniul sănătăţii, cu modificările și completările ulterioare

Hotărârea Guvernului nr. 1028/2014 privind aprobarea Strategiei naţionale de sănătate 2014-2020 şi a Planului de acţiuni pe perioada 2014-2020 pentru implementarea Strategiei naţionale

ORDIN nr. 1.410 din 12 decembrie 2016 privind aprobarea Normelor de aplicare a Legii drepturilor pacientului nr. 46/2003

Ordinul ministrului sănătăţii şi al preşedintelui Casei Naţionale de Asigurări de Sănătate nr. 763/377/2016 privind aprobarea Normelor metodologice de aplicare în anul 2016 a Hotărârii Guvernului nr. 161/2016 pentru aprobarea pachetelor de servicii şi a Contractului-cadru care reglementează condiţiile acordării asistenţei medicale, a medicamentelor şi a dispozitivelor medicale în cadrul sistemului de asigurări sociale de sănătate pentru anii 2016-2017

ORDIN nr. 1.355 din 28 noiembrie 2016 privind componenţa, atribuţiile, regulamentul de organizare şi funcţionare al comisiilor de specialitate ale Ministerului Sănătăţii

ORDIN nr. 1.376 din 6 decembrie 2016 pentru aprobarea Planurilor regionale de servicii de sănătate

ORDIN nr. 1.365 din 29 noiembrie 2016 pentru modificarea şi completarea Ordinului ministrului sănătăţii nr. 867/2015privind aprobarea modului de administrare, finanţare şi implementare a acţiunilor prioritare pentru tratamentul endovascular al pacienţilor critici cu leziuni periferice acute

Ordinul ministrului sănătăţii nr. 477/2009 privind înfiinţarea Registrului Naţional de Transplant, desemnarea persoanelor responsabile cu gestionarea datelor din Registrul Naţional de Transplant din cadrul unităţilor sanitare acreditate pentru efectuarea de transplant de organe şi stabilirea datelor necesare înregistrării unei persoane pentru atribuirea codului unic de înregistrare la Agenţia Naţională de Transplant

Ordinul ministrului sănătăţii şi al preşedintelui Casei Naţionale de Asigurări de Sănătate nr. 674/252/2012 privind aprobarea formularului de prescripţie medicală electronică pentru medicamente cu şi fără contribuţie personală în tratamentul ambulatoriu şi a Normelor metodologice privind utilizarea şi modul de completare a formularului de prescripţie medicală electronică pentru medicamente cu şi fără contribuţie personală în tratamentul ambulatoriu

Ordinul ministrului sănătăţii şi al preşedintelui Casei Naţionale de Asigurări de Sănătate nr. 1.605/875/2014 privind aprobarea modului de calcul, a listei denumirilor comerciale şi a preţurilor de decontare ale medicamentelor care se acordă bolnavilor în cadrul programelor naţionale de sănătate şi a metodologiei de calcul al acestora

Hotărârra Guvernului nr. 161/2016 pentru aprobarea pachetelor de servicii şi a Contractului-cadru care reglementează condiţiile acordării asistenţei medicale, a medicamentelor şi a dispozitivelor medicale în cadrul sistemului de asigurări sociale de sănătate pentru anii 2016-2017

Ordinul ministrului sănătăţii şi al preşedintelui Casei Naţionale de Asigurări de Sănătate nr. 3/1/2015privind modelul de contract, metodologia de negociere, încheiere şi monitorizare a modului de implementare şi derulare a contractelor de tip cost-volum/cost-volum-rezultat

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Hotărârea Guvernului nr. 800/2016 pentru aprobarea Metodologiei privind modul de calcul şi procedura de avizare şi aprobare a preţurilor maximale ale medicamentelor de uz uman cu autorizaţie de punere pe piaţă în România

ORDIN nr. 1.114 din 10 octombrie 2016 privind aprobarea Metodologiei pentru desfăşurarea concursului de rezidenţiat pe loc şi pe post în medicină, medicină dentară şi farmacie, sesiunea 20 noiembrie 2016

Ordinul ministrului sănătăţii publice şi al preşedintelui Casei Naţionale de Asigurări de Sănătate nr. 1.782/576/2006 privind înregistrarea şi raportarea statistică a pacienţilor care primesc servicii medicale în regim de spitalizare continuă şi spitalizare de zi

ORDIN nr. 1.116 din 10 octombrie 2016 privind stabilirea specialităţilor deficitare pentru care se organizează rezidenţiat pe post în spitale clinice cu secţii clinice universitare, institute sau centre medicale clinice în sesiunea 20 noiembrie 2016

ORDIN nr. 1.123 din 12 octombrie 2016 pentru aprobarea datelor, informaţiilor şi procedurilor operaţionale necesare utilizării şi funcţionării dosarului electronic de sănătate (DES) al pacientului

ORDIN nr. 1.096 din 30 septembrie 2016 privind modificarea şi completarea Ordinului ministrului sănătăţii nr. 914/2006pentru aprobarea normelor privind condiţiile pe care trebuie să le îndeplinească un spital în vederea obţinerii autorizaţiei sanitare de funcţionare

ORDIN nr. 1.101 din 30 septembrie 2016 privind aprobarea Normelor de supraveghere, prevenire şi limitare a infecţiilor asociate asistenţei medicale în unităţile sanitare

ORDIN nr. 658 din 2013 privind Lista medicamentelor, materialelor sanitare, echipamentelor medicale, echipamentelor de protecţie, a serviciilor, combustibililor şi lubrifianţilor pentru parcul auto, pentru care se organizează proceduri de achiziţie centralizate la nivel naţional

ORDIN nr. 1.009 din 6 septembrie 2016 privind înregistrarea dispozitivelor medicale în baza naţională de date

Ordinul ministrului sănătăţii nr. 867/2015 privind aprobarea modului de administrare, finanţare şi implementare a acţiunilor prioritare pentru tratamentul endovascular al pacienţilor critici cu leziuni periferice acute

Ordinul ministrului sănătăţii nr. 449/2015 privind aprobarea modului de administrare, finanţare şi implementare a acţiunilor prioritare pentru tratamentul pacienţilor cu infarct miocardic acut

Ordinul ministrului sănătăţii nr. 447/2015 privind aprobarea modului de administrare, finanţare şi implementare a acţiunilor prioritare pentru monitorizarea, tratamentul şi îngrijirea pacienţilor critici din secţiile ATI adulţi/copii şi terapie intensivă nou-născuţi

ORDIN nr. 961 din 19 august 2016 pentru aprobarea Normelor tehnice privind curăţarea, dezinfecţia şi sterilizarea în unităţile sanitare publice şi private, tehnicii de lucru şi interpretare pentru testele de evaluare a eficienţei procedurii de curăţenie şi dezinfecţie, procedurilor recomandate pentru dezinfecţia mâinilor, în funcţie de nivelul de risc, metodelor de aplicare a dezinfectantelor chimice în funcţie de suportul care urmează să fie tratat şi a metodelor de evaluare a derulării şi eficienţei procesului de sterilizare

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ORDIN nr. 936 din 10 august 2016 pentru modificarea şi completarea Metodologiei de elaborare a programului de investiţii publice al Ministerului Sănătăţii şi de alocare de fonduri pentru cheltuieli de investiţii unităţilor publice din reţeaua Ministerului Sănătăţii, aprobată prin Ordinul ministrului sănătăţii nr. 512/2014

ORDIN nr. 931 din 5 august 2016 privind modificarea şi completarea Normelor tehnice de realizare a programelor naţionale de sănătate publică pentru anii 2015 şi 2016, aprobate prin Ordinul ministrului sănătăţii nr. 386/2015

Ordinul ministrului sănătăţii nr. 446/2015 privind aprobarea modului de administrare, finanţare şi implementare a acţiunilor prioritare pentru tratamentul pacienţilor critici cu leziuni traumatice acute

ORDIN nr. 871 din 19 iulie 2016 pentru aprobarea Procedurilor, standardelor şi metodologiei de evaluare şi acreditare a spitalelor

Ordin nr. 27 privind modificarea Normelor tehnice de realizare a programelor naționale de sănătate curative pentru anii 2015 și 2016 2017-02-01

HG nr. 853/2016 Norme metodologice privind asistenta medicala transfrontaliera

Ordin 185/2015 privind aprobarea Normelor tehnice de realizare a programelor naționale de sănătate curative pentru anii 2015 și 2016

Hotărârea nr. 629/2015 privind componenţa, atribuţiile, modul de organizare şi funcţionare ale Autorităţii Naţionale de Management al Calităţii în Sănătate

ORDIN Nr. 861 din 23 iulie 2014 pentru aprobarea criteriilor şi metodologiei de evaluare a tehnologiilor medicale, a documentaţiei care trebuie depusă de solicitanţi, a instrumentelor metodologice utilizate în procesul de evaluare privind includerea, extinderea indicaţiilor, neincluderea sau excluderea medicamentelor în/din Lista cuprinzând denumirile comune internaţionale corespunzătoare medicamentelor de care beneficiază asiguraţii, cu sau fără contribuţie personală, pe bază de prescripţie medicală, în sistemul de asigurări sociale de sănătate, precum şi denumirile comune internaţionale corespunzătoare medicamentelor care se acordă în cadrul programelor naţionale de sănătate, precum şi a căilor de atac

Hotărârea Guvernului nr. 720/2008 pentru aprobarea Listei cuprinzând denumirile comune internaţionale corespunzătoare medicamentelor de care beneficiază asiguraţii, cu sau fără contribuţie personală, pe bază de prescripţie medicală, în sistemul de asigurări sociale de sănătate

ORDIN Nr. 1384 din 4 noiembrie 2010 privind aprobarea modelului-cadru al contractului de management şi a listei indicatorilor de performanţă a activităţii managerului spitalului public

ORDONANŢĂ DE URGENŢĂ Nr. 71 din 20 noiembrie 2012 privind desemnarea Ministerului Sănătăţii ca unitate de achiziţii publice centralizată

ORDONANŢĂ DE URGENŢĂ Nr. 77 din 21 septembrie 2011 privind stabilirea unei contribuţii pentru finanţarea unor cheltuieli în domeniul sănătăţii

ORDIN Nr. 1199 din 26 iulie 2011 privind introducerea şi utilizarea clasificării RO DRG v.1

ORDIN Nr. 1144 din 7 iulie 2011 pentru aprobarea Normelor metodologice de organizare şi funcţionare a centrelor de sănătate multifuncţionale

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ORDIN Nr. 323 din 18 aprilie 2011 privind aprobarea metodologiei şi a criteriilor minime obligatorii pentru clasificarea spitalelor în funcţie de competenţă

HOTĂRÂRE Nr. 346 din 31 martie 2011 privind desfiinţarea unor unităţi sanitare publice cu paturi din subordinea autorităţilor administraţiei publice locale

HOTĂRÂRE Nr. 345 din 31 martie 2011 privind aprobarea pentru anul 2011 a Raportului comisiei de selecţie a unităţilor sanitare cu paturi care nu pot încheia contracte cu casele de asigurări de sănătate, precum şi a listei acestor unităţi sanitare

HOTĂRÂRE Nr. 303 din 23 martie 2011 pentru aprobarea Strategiei naţionale de raţionalizare a spitalelor

HOTĂRÂRE Nr. 151 din 23 februarie 2011 privind aprobarea Planului naţional de paturi pentru perioada 2011 - 2013

HOTĂRÂRE Nr. 144 din 23 februarie 2010 privind organizarea şi funcţionarea Ministerului Sănătăţii

ORDIN Nr. 75 din 3 februarie 2010 pentru aprobarea Regulilor de bună practică farmaceutică

LEGE Nr. 266 din 7 noiembrie 2008 *** Republicată - Legea farmaciei

ORDONANŢĂ DE URGENŢĂ Nr. 68 din 28 mai 2008 privind vânzarea spaţiilor proprietate privată a statului sau a unităţilor administrativ-teritoriale cu destinaţia de cabinete medicale, precum şi a spaţiilor în care se desfăşoară activităţi conexe actului medical

ORDIN Nr. 365/1 din 22 februarie 2007 pentru aprobarea Normelor metodologice privind asigurările voluntare de sănătate

ORDIN Nr. 886 din 19 iulie 2006 privind externalizarea serviciilor medicale şi nemedicale din unităţile sanitare

ORDIN Nr. 824 din 5 iulie 2006 pentru aprobarea Normelor privind organizarea şi funcţionarea Inspecţiei Sanitare de Stat

LEGE Nr. 263 din 16 iunie 2004 privind asigurarea continuităţii asistenţei medicale primare prin centrele de permanenţă

HOTĂRÂRE Nr. 884 din 3 iunie 2004 privind concesionarea unor spaţii cu destinaţia de cabinete medicale

LEGE Nr. 46 din 21 ianuarie 2003 Legea drepturilor pacientului

ORDONANŢĂ Nr. 53 din 30 ianuarie 2000 privind obligativitatea raportării bolilor şi a efectuării vaccinărilor

ORDONANŢĂ Nr. 124 din 29 august 1998 *** Republicată privind organizarea şi funcţionarea cabinetelor medicale

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Competența face diferența!Proiect selectat în cadrul Programului Operațional Capacitate Administrativă, cofinanțat de Uniunea

Europeană din Fondul Social European

Competence makes a difference!Project selected under the Administrative Capacity Operational Programme, co-financed by the

European Union from the European Social Fund

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